Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains

Domains of effective teaching process students perspectives in two medical schools

BACKGROUND

There has been little systematic investigation of student belief about the characteristics of the optimum process for clinical bedside teaching.

AIMS

The intent was to identify the most important characteristics of the bedside teaching experience from the perspective of two groups of students, one from Oman and the other from Canada.

METHOD

Students were asked to complete a questionnaire about their concept of the ideal process of bedside teaching. Their answers were analyzed using factor analysis.

RESULTS

Answers provided by the students was consistent with the presence of six domains. These corresponded to Preparation, Introduction, Experience, Summary, Explanation, and Conclusion. 'Preparation' involves consideration of the patient and the knowledge level of the learners, 'Introduction' involves effective communication, and 'Experience' means the need for the students to be actively involved in the history and physical examination. The remaining three domains deal with the need to provide a summary and elaboration as well as advice and feedback. These 6 factors explained 60% of the total variance.

CONCLUSIONS

While these areas still need to be defined more closely, the application of these six domains to the structure of the bedside teaching experience is likely to result in improved student learning.

Conceptual frameworks to illuminate and magnify

CONTEXT

In a recent study of the quality of reporting experimental studies in medical education, barely half the articles examined contained an explicit statement of the conceptual framework used. Conceptual frameworks represent ways of thinking about a problem or a study, or ways of representing how complex things work. They can come from theories, models or best practices. Conceptual frameworks illuminate and magnify one's work. Different frameworks will emphasise different variables and outcomes, and their inter-relatedness. Educators and researchers constantly use conceptual frameworks to guide their work, even if they themselves are not consciously aware of the frameworks.

METHODS

Three examples are provided on how conceptual frameworks can be used to cast development and research projects in medical education. The examples are accompanied by commentaries and a total of 13 key points about the nature and use of conceptual frameworks.

CONCLUSIONS

Ultimately, scholars are responsible for making explicit the assumptions and principles contained in the conceptual framework(s) they use in their development and research projects.

Virtual patients: a critical literature review and proposed next steps

CONTEXT

The opposing forces of increased training expectations and reduced training resources have greatly impacted health professions education. Virtual patients (VPs), which take the form of interactive computer-based clinical scenarios, may help to reconcile this paradox.

METHODS

We summarise research on VPs, highlight the spectrum of potential variation and identify an agenda for future research. We also critically consider the role of VPs in the educational armamentarium.

RESULTS

We propose that VPs' most unique and cost-effective function is to facilitate and assess the development of clinical reasoning. Clinical reasoning in experts involves a non-analytical process that matures through deliberate practice with multiple and varied clinical cases. Virtual patients are ideally suited to this task. Virtual patients can also be used in learner assessment, but scoring rubrics should emphasise non-analytical clinical reasoning rather than completeness of information or algorithmic approaches. Potential variations in VP design are practically limitless, yet few studies have rigorously explored design issues. More research is needed to inform instructional design and curricular integration.

CONCLUSIONS

Virtual patients should be designed and used to promote clinical reasoning skills. More research is needed to inform how to effectively use VPs.

How student models of expertise and innovation impact the development of adaptive expertise in medicine

OBJECTIVES

The ability to innovate new solutions in response to daily workplace challenges is an important component of adaptive expertise. Exploring how to optimally develop this skill is therefore of paramount importance to education researchers. This is certainly no less true in health care, where optimal patient care is contingent on the continuous efforts of doctors and other health care workers to provide the best care to their patients through the development and incorporation of new knowledge. Medical education programmes must therefore foster the skills and attitudes necessary to engage future doctors in the systematic development of innovative problem solving. The aim of this paper is to describe the perceptions and experiences of medical students in their third and fourth years of training, and to explore their understanding of their development as adaptive experts.

METHODS

A sample of 25 medical students participated in individual 45-60-minute semi-structured interviews. Interviews were audiotaped, transcribed and entered into NVivo qualitative data analysis software to facilitate a thematic analysis. The analysis was both inductive, in that themes were generated from the data, and deductive, in that our data were meaningful when interpreted in the context of theories of adaptive expertise.

RESULTS

Participants expressed a general belief that, as learners in the health care system, exerting any effort to be innovative was beyond the scope of their responsibilities. Generally, students suggested that innovative practice was the prerogative of experts and an outcome of expert development centred on the acquisition of knowledge and experience.

CONCLUSIONS

Students' perceptions of themselves as having no responsibility to be innovative in their learning process have implications for their learning trajectories as adaptive experts.

Can hospital rankings measure clinical and educational quality?

BACKGROUND

A relative dearth of relevant data hampers efforts to demonstrate a link between educational and clinical quality and may preclude residency applicants from identifying programs with the best clinical outcomes. Existing clinical rankings could fill this gap if they are based on sound judgments about quality.

METHOD

To explore the potential of the U.S. News & World Report "America's Best Hospitals" clinical rankings in measuring the quality of clinical and learning environments, the author systematically reviewed the U.S. and Canadian literature for 1975 through 2007 regarding quality indicators and teaching hospitals. Individual data elements of the rankings were examined to assess the extent to which they included accepted measures of clinical performance.

RESULTS

A total of 187 articles met the inclusion criteria of addressing clinical quality criteria relevant to the rankings and quality assessment in teaching hospitals. Statistical examination of the data underlying the rankings and their relationship with measures of educational and clinical quality showed the rankings are largely based on institutional "prestige." Ranked clinical programs and institutions consistently outperform counterparts on available indices, suggesting that the data elements underlying the rankings may provide valid assessments about the quality of care in educational settings.

CONCLUSIONS

Data elements in the rankings can be used to assess clinical and, to a lesser extent, educational quality, but the number of specialties and ranked institutions is too small to have a significant effect on widespread clinical or educational quality, unless ranked institutions serve as sites for the development, study, and dissemination of best practices.

Professionalism and communication in the intensive care unit: reliability and validity of a simulated family conference

OBJECTIVE

An Objective Structured Clinical Exam was designed to assess physician's ability to discuss end-of-life (EOL) and disclose iatrogenic complications (DOC) with family members of intensive care unit patients. The study explores reliability and validity based on scores from contrasting rater groups (clinicians, SPs, and examinees).

METHODS

Two 20-minute stations were administered to 17 surgical residents and 2 critical fellows at a university-based training program. The exam was conducted, videotaped, and scored in a standardized setting by 8 clinical raters (MD and RN) and 8 standardized families using separate rating tools (EOL and DOC). Examinees assessed themselves using the same tools. We analyzed the internal consistency, inter-rater agreement, and discriminant validity of both cases using data from each rater group. Cross-rater group comparisons were also made.

RESULTS

The internal consistency reliability correlations were above 0.90 regardless of case or rater group. Within rater groups, raters were within 1 point of agreement (5-pt and 6-pt scales) on 81% of the DOC and between 74% and 79% of the EOL items. Family raters were more favorable than clinical raters in scoring DOC, but not EOL cases. Large raw differences in performance by training level favored more experienced trainees (3rd year residents and fellows). These differences were statistically significant when based on residents own self-ratings, but not when they were based on clinical or family ratings.

DISCUSSION

The Family Conference Objective Structured Clinical Exam is a reliable exam with high content validity. It seems unique in the literature for assessing surgical trainees' ability to discuss "bad news" with family members in intensive care.

Part-time clinical anesthesia practice: a review of the economic, quality, and safety issues

Part-time clinical practice in anesthesia is increasing due to the feminization and the aging of the medical workforce, as well as the arrival of generations X and Y to the health care workforce. Recruiting the best and brightest physicians requires accommodating their needs and interests, as well as retaining older workers who wish to reduce their hours as they approach retirement. This article discusses steps to help departments or groups optimally manage the part-time anesthesia workforce.

Patient safety, competency, and the future of surgical simulation

Despite its relatively short track record, simulation has been successfully introduced into the surgical arena in an effort to augment training. Initially a fringe endeavor at isolated centers, simulation has now become a mainstream component of surgical education. The surgical community is now aware that the old adage, "see one, do one, and teach one" is no longer acceptable from the ethical standpoint of practicing procedures on patients. Moreover, financial and time constraints have made teaching outside of the operating room an attractive proposition. Coupled with the growing body of validation, new procedures can now be practiced and proficiency can be acquired on a multitude of simulation platforms. Importantly, simulation standards are being established and there is an unprecedented national acceptance and endorsement of simulation as an invaluable educational tool; in fact, simulation is being mandated for surgical residency programs. Team training will likely expand the impact of surgical simulation considerably and help assure multidimensional competency verification. For both surgery residents and surgeons in practice, simulation holds great promise as a safe, effective, and efficient means of acquiring new skills.

Linking process to outcome: are we training pediatricians to meet evolving health care needs?

The Residency Review and Redesign in Pediatrics (R(3)P) Project began in 2005 and will have been completed in 2009. The purpose was to conduct a comprehensive reassessment of general pediatric residency education. The project convened 3 major colloquia supplemented by numerous meetings of an R(3)P committee and by surveys of residents, subspecialty fellows, and generalist and subspecialty practitioners. A principal conclusion was that resident learning opportunities should be more flexibly directed toward the variety of career choices available to pediatricians. Another conclusion was that reasonable expectations for residency education are most likely if learning is regarded as an integrated continuum, beginning in medical school and continuing throughout a career in practice. The R(3)P Committee declined to create a list of recommendations for immediate changes in residency education; instead, it recommends that changes be based on evidence of education outcomes that are important to improving the health of children, adolescents, and young adults.

Evaluating training for a simulated team in complex whole procedure simulations in the endovascular suite

INTRODUCTION

Simulators supporting the development of technical skills for complex procedures are gaining prominence. Safe performance of complex procedures requires effective team interactions. Our research group creates 'whole' procedure simulations to produce the psychological fidelity of clinical settings. Recruitment of real interventional team (IT) members has proved challenging. Actors as a simulated team are expensive. We hypothesised that medical students and trainees in a vascular unit could authentically portray members of the endovascular suite for carotid stenting.

METHODS

This paper describes the evaluation of a training programme for a simulated IT. Participants rated the extent to which programmes objectives were met and realism of simulations. Researchers' field notes provided insight into strengths and weaknesses of the programme.

RESULTS

Seven members from the vascular unit undertook training. Learning objectives were largely met. Nineteen simulations with 13 interventionalists were performed. Realism levels were at least moderate. Simulated IT members reported increased understanding of teamwork and roles in the endovascular suite.

DISCUSSION

A simulated IT proved feasible. Authentic psychological fidelity complemented the physical fidelity of the simulated suite. Although there were areas for development in training, this approach might contribute considerably to interventionalist training and increase knowledge and skills of vascular trainees and medical students.

Cognitive and learning sciences in biomedical and health instructional design: A review with lessons for biomedical informatics education

Theoretical and methodological advances in the cognitive and learning sciences can greatly inform curriculum and instruction in biomedicine and also educational programs in biomedical informatics. It does so by addressing issues such as the processes related to comprehension of medical information, clinical problem-solving and decision-making, and the role of technology. This paper reviews these theories and methods from the cognitive and learning sciences and their role in addressing current and future needs in designing curricula, largely using illustrative examples drawn from medical education. The lessons of this past work are also applicable, however, to biomedical and health professional curricula in general, and to biomedical informatics training, in particular. We summarize empirical studies conducted over two decades on the role of memory, knowledge organization and reasoning as well as studies of problem-solving and decision-making in medical areas that inform curricular design. The results of this research contribute to the design of more informed curricula based on empirical findings about how people learn and think, and more specifically, how expertise is developed. Similarly, the study of practice can also help to shape theories of human performance, technology-based learning, and scientific and professional collaboration that extend beyond the domain of medicine. Just as biomedical science has revolutionized health care practice, research in the cognitive and learning sciences provides a scientific foundation for education in biomedicine, the health professions, and biomedical informatics.

Using simulation to isolate physician variation in intensive care unit admission decision making for critically ill elders with end-stage cancer: a pilot feasibility study

OBJECTIVE

To determine the feasibility of high-fidelity simulation for studying variation in intensive care unit admission decision making for critically ill elders with end-stage cancer.

DESIGN

Mixed qualitative and quantitative analysis of physician subjects participating in a simulation scenario using hospital set, actors, medical chart, and vital signs tracings. The simulation depicted a 78-yr-old man with metastatic gastric cancer, life-threatening hypoxia most likely attributable to cancer progression, and stable preferences to avoid intensive care unit admission and intubation. Two independent raters assessed the simulations and subjects completed a postsimulation web-based survey and debriefing interview.

SETTING

Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh.

SUBJECTS

Twenty-seven hospital-based attending physicians, including 6 emergency physicians, 13 hospitalists, and 8 intensivists.

MEASUREMENTS AND MAIN RESULTS

Outcomes included qualitative report of clinical verisimilitude during the debriefing interview, survey-reported diagnosis and prognosis, and observed treatment decisions. Independent variables included physician demographics, risk attitude, and reactions to uncertainty. All (100%) reported that the case and simulation were highly realistic, and their diagnostic and prognostic assessments were consistent with our intent. Eight physicians (29.6%) admitted the patient to the intensive care unit. Among the eight physicians who admitted the patient to the intensive care unit, three (37%) initiated palliation, two (25%) documented the patient's code status (do not intubate/do not resuscitate), and one intubated the patient. Among the 19 physicians who did not admit the patient to the intensive care unit, 13 (68%) initiated palliation and 5 (42%) documented code status. Intensivists and emergency physicians (p = 0.048) were more likely to admit the patient to the intensive care unit. Years since medical school graduation were inversely associated with the initiation of palliative care (p = 0.043).

CONCLUSIONS

Simulation can reproduce the decision context of intensive care unit triage for a critically ill patient with terminal illness. When faced with an identical patient, hospital-based physicians from the same institution vary significantly in their treatment decisions.

How much work is enough work? Results of a survey of US and Australian anesthesiologists' perceptions of part-time practice and part-time training

This article reports the results of a written survey administered to anesthesiologists in Australia and the United States regarding their opinions toward part-time practice and training. Although type of work and case volume were acknowledged to be important, most respondents reported a need for guidelines regarding levels of minimum acceptable clinical activity. A major recurring theme was that interindividual variation in competence is so great that no one set of rules can encompass each individual's circumstances with regard to minimum hours to stay competent and need to re-train after more than 6 months away from routine clinical practice. Guidelines regarding volume and variety of clinical work to acquire and maintain competence while practicing part-time may deserve further study to maintain quality and safety.

Deliberate practice and acquisition of expert performance: a general overview

Traditionally, professional expertise has been judged by length of experience, reputation, and perceived mastery of knowledge and skill. Unfortunately, recent research demonstrates only a weak relationship between these indicators of expertise and actual, observed performance. In fact, observed performance does not necessarily correlate with greater professional experience. Expert performance can, however, be traced to active engagement in deliberate practice (DP), where training (often designed and arranged by their teachers and coaches) is focused on improving particular tasks. DP also involves the provision of immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance to refine behavior. In this article, we draw upon the principles of DP established in other domains, such as chess, music, typing, and sports to provide insight into developing expert performance in medicine.

The use of simulation in the development of individual cognitive expertise in emergency medicine

This consensus group from the 2008 Academic Emergency Medicine Consensus Conference, "The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise," held in Washington, DC, May 28, 2008, focused on the use of simulation for the development of individual expertise in emergency medicine (EM). Methodologically sound qualitative and quantitative research will be needed to illuminate, refine, and test hypotheses in this area. The discussion focused around six primary topics: the use of simulation to study the behavior of experts, improving the overall competence of clinicians in the shortest time possible, optimizing teaching strategies within the simulation environment, using simulation to diagnose and remediate performance problems, and transferring learning to the real-world environment. Continued collaboration between academic communities that include medicine, cognitive psychology, and education will be required to answer these questions.

Developing technical expertise in emergency medicine--the role of simulation in procedural skill acquisition

Developing technical expertise in medical procedures is an integral component of emergency medicine (EM) practice and training. This article is the work of an expert panel composed of members from the Society for Academic Emergency Medicine (SAEM) Interest Group, the SAEM Technology in Medical Education Committee, and opinions derived from the May 2008 Academic Emergency Medicine Consensus Conference, "The Science of Simulation in Healthcare." The writing group reviewed the simulation literature on procedures germane to EM training, virtual reality training, and instructional learning theory as it pertains to skill acquisition and procedural skills decay. The authors discuss the role of simulation in teaching technical expertise, identify training conditions that lead to effective learning, and provide recommendations for future foci of research.

Research opportunities in simulation-based medical education using deliberate practice

There are many opportunities for the academic emergency medicine (EM) community to engage in simulation-based educational research using deliberate practice (DP). This article begins by defining and giving examples of two key concepts: deliberate practice and mastery learning. The article proceeds to report six lessons learned from a research legacy in simulation-based medical education (SBME). It concludes by listing and amplifying 10 DP research opportunities in academic EM. A coda states that the research agenda is rich and ambitious and should focus on the goal of educating superb, expert clinicians.

To the point: medical education review of the role of simulators in surgical training

Simulation-based training (SBT) is becoming widely used in medical education to help residents and medical students develop good technical skills before they practice on real patients. SBT seems ideal because it provides a nonthreatening controlled environment for practice with immediate feedback and can include objective performance assessment. However, various forms of SBT and assessment often are being used with limited evidence-based data to support their validity and reliability. In addition, although SBT with high-tech simulators is more sophisticated and attractive, this is not necessarily superior to SBT with low-tech (and lower cost) simulators. Therefore, understanding the types of surgical simulators and appropriate applications can help to ensure that this teaching and assessment modality is applied most effectively. This article summarizes the key concepts that are needed to use surgical simulators effectively for teaching and assessment.

Pediatric resident confidence in resuscitation skills relates to mock code experience

To assess confidence in resuscitation skills among pediatric residents and its relationship to training and experience, all pediatric residents at one institution were surveyed regarding their confidence in technical and leadership resuscitation skills and their prior experience with real and mock codes. Respondents (61/82, 74%) reported participation in 4.9 +/- 3.6 mock and 3.9 +/- 5.0 real codes. Confidence score for all skills was 2.7 +/- 0.6 (scale 1-5). Senior residents were more confident than interns (2.8 +/- 0.5 vs 2.3 +/- 0.5). Residents were more confident in basic (3.9 +/- 0.6) than in advanced (2.6 +/- 0.6) or expert resuscitation skills (1.6 +/- 0.7). Confidence correlated with mock codes (r = 0.52) and to a lesser degree with real codes attended (r = 0.36). Performance of active roles and debriefing occurred more commonly with mock than with real codes. The data indicate that pediatric residents have limited confidence in resuscitation skills and that mock code training with active participation and debriefing may be an effective educational tool.

The history of medical simulation

The historical roots of simulation might be described with the broadest definition of medical simulation: "an imitation of some real thing, state of affairs, or process" for the practice of skills, problem solving, and judgment. From the first "blue box" flight simulator to the military's impetus in the transfer of modeling and simulation technology to medicine, worldwide acceptance of simulation training is growing. Large collaborative simulation centers support the expectation of increases in multidisciplinary, interprofessional, and multimodal simulation training. Virtual worlds, both immersive and Web-based, are at the frontier of innovation in medical education.

Introducing resident doctors to complexity in ambulatory medicine

OBJECTIVES

Medical education instructional methods typically imply one 'best' management approach. Our objectives were to develop and evaluate an intervention to enhance residents' appreciation for the diversity of acceptable approaches when managing complex patients.

METHODS

A total of 124 internal medicine residents enrolled in a randomised, crossover trial. Residents completed four web-based modules in ambulatory medicine during continuity clinic. For each module we developed three 'complex cases'. Cases were intended to be complex (numerous variables, including psychosocial and economic barriers) and to suggest multiple acceptable management strategies. Several experienced faculty members described how they would manage each case. Residents reviewed each case, answered the same questions, and compared their responses with expert responses. Participants were randomly assigned to complete two modules with, and two modules without complex cases.

RESULTS

A total of 76 residents completed 279 complex cases. Residents agreed that complex cases enhanced their appreciation for the diversity of 'correct' options (mean +/- standard error of the mean 4.6 +/- 0.2 [1 = strongly disagree, 6 = strongly agree]; P < 0.001). Mean preference score was neutral (3.4 +/- 0.2 [1 = strongly favour no cases, 6 = strongly favour cases]; P = 0.72). Knowledge post-test scores were similar between modules with (76.0 +/- 0.9) and without (77.8 +/- 0.9) complex cases (95% confidence interval for difference - 4.0 to 0.3; P = 0.09). Resident comments suggested that lack of time and cognitive overload impeded learning.

CONCLUSIONS

Residents felt complex cases made a valuable contribution to their learning, although preference was neutral and knowledge scores were not affected. Methods to facilitate trainee comfort in managing medically complex patients should be further explored.

From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills

The Accreditation Council for Graduate Medical Education Outcome Project has shifted the focus of residents' education to competency-based outcomes of learning. The challenge of meaningful assessment of learner competence has stimulated interest in the Dreyfus and Dreyfus Model, a framework for assessing skill acquisition that describes developmental stages beginning with novice and progressing through advanced beginner, competent, proficient, expert, and master. Many educators have adopted this model, but no consensus about its adaptation to clinical medicine has been documented. In this article, the authors seek to integrate generally accepted knowledge and beliefs about how one learns to practice clinical medicine into a coherent developmental framework using the Dreyfus and Dreyfus model of skill acquisition. Using the general domain of patient care, the characteristics and skills of learners at each stage of development are translated into typical behaviors. A tangible picture of this model in real-world practice is provided through snapshots of typical learner performance at discrete moments in time along the developmental continuum. The Dreyfus and Dreyfus model is discussed in the context of other developmental models of assessment of learner competence. The limitations of the model, in particular the controversy around the behaviors of "experts," are discussed in light of other interpretations of expertise in the literature. Support for descriptive developmental models of assessment is presented in the context of a discussion of the deconstructing versus reconstructing of competencies.

Resuscitation education: narrowing the gap between evidence-based resuscitation guidelines and performance using best educational practices

Recent data from in- and out-of-hospital cardiopulmonary arrests reveal that health care teams frequently deviate from American Heart Association guidelines during resuscitation efforts. These discrepancies between the current state of evidence-based resuscitation guidelines and the quality of basic and advanced life support actually delivered represent a missed opportunity and provide a significant target for optimizing patient outcomes through improved educational effectiveness. This article presents discussion of the quality of resuscitation delivered to patients, a brief history of the development of cardiopulmonary resuscitation and attempts to translate the science of resuscitation to the bedside through effective educational strategies, a review of educational best practices that relate to resuscitation education, and discussion of the role of medical simulation in resuscitation training.

Unintentional failure to assess for experience in senior undergraduate OSCE scoring

CONTEXT

One goal of undergraduate assessment is to test students' (future) performance. In the area of skills testing, the objective structured clinical examination (OSCE) has been of great value as a tool with which to test a number of skills in a limited time, with bias reduction and improved reliability. But can OSCEs measure undergraduate internship expertise in basic clinical skills?

METHODS

Undergraduate students (n = 32) were given a questionnaire listing 182 basic clinical skills. We asked them to score the number of times they had performed each skill during their internships (a 12-month period in Year 6). We assessed the students at the end of Year 5 (before the start of their internships) and again at the start of Year 7 (undergraduate training takes 7 years in Belgium, with internships during Year 6), using a 14-station OSCE assessing basic clinical skills. Global ratings were used to score performance. The relationship between internship experience and the OSCE Year 7 score was analysed using a linear regression model, controlling for variation in OSCE scores from Year 5. A multi-level analysis was performed considering students as level-1 units and stations as level-2 units.

RESULTS

Year 7 OSCE scores (post-internships) were not affected by the number of times that students practised basic medical skills during their internships.

DISCUSSION

Scores on OSCEs do not seem to reflect clinical expertise acquired during internships. Other more integrated assessment methods may prove to be more valid for testing final undergraduate skills levels.

Support for simulation-based surgical education through American College of Surgeons--accredited education institutes

The American College of Surgeons (ACS) recently launched a new program to provide regional support for simulation-based surgical education through the establishment of a consortium of accredited education institutes. The goals of the program are to enhance surgical patient safety, support efforts of surgeons to meet the requirements for Maintenance of Certification, address the core competencies that all surgeons and surgical residents need to achieve and demonstrate, and enhance access to contemporary surgical education. The ACS-accredited institutes will comprehensively address the needs of a broad spectrum of learners and advance the science of simulation-based surgical education. Accreditation is being offered at two levels--Level I (Comprehensive) and Level II (Basic)--based on three standards that focus on the learners served, the curricula offered, and the technological support and resources available. Initial plans of the consortium of ACS-accredited Education Institutes include development and dissemination of innovative curricula, peer review of new educational programs and products, sharing of limited educational resources, and pursuit of collaborative research and development. This program should be of great value in supporting the professional activities of surgeons, surgical residents, medical students, and members of the surgical team, and in delivering surgical care of the highest quality.

The role of expertise research and human factors in capturing, explaining, and producing superior performance

OBJECTIVES

The goal of this article is to identify some of the major trends and findings in expertise research and their connections to human factors.

BACKGROUND

Progress in the study of superior human performance has come from improved methods of measuring expertise and the development of better tools for revealing the mechanisms that support expert performance, such as protocol analysis and eye tracking.

METHODS

We review some of the challenges of capturing superior human performance in the laboratory and the means by which the expert performance approach may overcome such challenges. We then discuss applications of the expert performance approach to a handful of domains that have long been of interest to human factors researchers.

RESULTS

Experts depend heavily on domain-specific knowledge for superior performance, and such knowledge enables the expert to anticipate and prepare for future actions more efficiently. Training programs designed to focus learners' attention on task-related knowledge and skills critical to expert performance have shown promise in facilitating skill acquisition among nonexperts and in reducing errors by experts on representative tasks.

CONCLUSIONS

Although significant challenges remain, there is encouraging progress in domains such as sports, aviation, and medicine in understanding some of the mechanisms underlying human expertise and in structuring training and tools to improve skilled performance.

APPLICATIONS

Knowledge engineering techniques can capture expert knowledge and preserve it for organizations and for the development of expert systems. Understanding the mechanisms that underlie expert performance may provide insights into the structuring of better training programs for improvingskill and in designing systems to support professional expertise.

The use of medical cognition in medical curriculum reform in Taiwan

Medical cognition studies have generated a great deal of knowledge that can be used to improve the quality of medical education. This review summarizes medical cognition research, the trends in medical education, and how the results of cognitive research can be applied to medical curriculum reform in Taiwan. The current trend in medical education is to develop a student-centered, outcome-oriented curriculum that integrates basic and clinical science, introduces students to patients at an early stage, reduces redundancy, and promotes active learning. To help students to develop and maintain their expertise in medicine, extensive supervised training with evaluation and feedback should be provided. The curriculum should also be designed to provide a learning context in which students are helped to develop a knowledge structure and diagnostic strategies similar to those used by experts. Finally, the curriculum should be flexible and responsive to the needs of students to train them to be excellent physicians in the future.

Effects of reflective practice on the accuracy of medical diagnoses

CONTEXT

Reflective practice has been suggested to be an important instrument in improving clinical judgement and developing medical expertise. Empirical evidence supporting this suggestion, however, is absent. This paper reports on an experiment conducted to study the effects of reflective practice on diagnostic accuracy.

METHODS

Participants were 42 internal medicine residents in hospitals in 2 states in the northeast of Brazil. They diagnosed 16 clinical cases. The experiment employed a repeated measures design, with 2 independent variables: the complexity of clinical cases (simple or complex), and the reasoning approach induced to diagnose the case (participants were instructed to diagnose each case either through pattern recognition or reflective reasoning). The dependent variable was the accuracy of the diagnosis provided for each case. All participants participated in each of the 2 levels of both independent variables.

RESULTS

A main effect of case complexity emerged. There was no statistically significant main effect of reflective practice. However, a significant interaction effect was found between case complexity and mode of processing (F[1,41] = 4.48, P < 0.05), indicating that although reflective practice did not make a difference to accuracy of diagnosis in simple cases, it had a positive effect when diagnosing complex cases.

CONCLUSIONS

Reflective practice had a positive effect on diagnosis of complex, unusual cases. Non-analytical reasoning was shown to be as effective as reflective reasoning for diagnosing routine clinical cases. Findings support the idea that reflective practice may particularly improve diagnoses in situations of uncertainty and uniqueness, reducing diagnostic errors.

Expertise and aging: maintaining skills through the lifespan

As lifespan continues to increase in many developed countries, so too does the age at which we see extraordinary achievements from older adults. Examples from running, golf, and other domains continue to redefine what is possible as we age. Evidence suggests, however, that progression through adulthood is associated with a dramatic decline in all manner of physical and cognitive abilities, from physiological capacities (e.g., VO2 max) to cognitive and perceptual functions (e.g., IQ scores, reaction time). In the face of such precipitous decline in specific abilities, how do we account for maintenance of skilled performance and expertise amongst those supposedly well along the age-decline curve? Expert performers are seemingly able to sustain high levels of achievement in the face of an overall deterioration in general capacities. Moreover, experts maintain this performance in spite of reduced involvement in their field. There are three primary explanations for the ability of experts to maintain superior performance in spite of an overall decline in abilities: (a) preserved differentiation, (b) compensation, and (c) selective maintenance. Overall, research into the high achievements of older adults may reveal a great deal with respect to skill preservation and how to best counter age-related decline.