Deliberate Practice

Written By John Hagen
 
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The differences between expert performers and normal adults are not immutable, that is, due to genetically prescribed talent. Instead, these differences reflect a life-long period of deliberate effort to improve performance.

- K. Anders Ericsson, cognitive psychologist whose work formed the basis for the 10,000 hour rule, and “the expert on experts.”


I can accept failure, everyone fails at something. But I can’t accept not trying.

- Michael Jordan, NBA star, GOAT


It was always felt like a competition in the pediatric heart room. Who would get the opportunity to steal the procedure from the other? Would I struggle with the central line, and defeated, turn it the over to my attending? Or would I finish first and also have time to try for the arterial line?

Its been almost a decade, but I remember it like it was yesterday. Those days always felt a little unnerving, like a challenge, as if doing a Norwood procedure wasn’t challenge enough. I had to focus because every movement, every step, every second counted. While I can’t say I was always able to get both lines, I can say I never gave my central line away. I also discovered I was much more successful when I used ultrasound for arterial access, should I get the opportunity to try. While it was a novelty, it built upon my burgeoning ultrasound skills honed by placing central lines and blocks. When I became an attending, I decided this was a skill I wanted to try and master. Rather than just break out the ultrasound when I struggled, I broke it out every time I planned on placing an arterial line. A 3-day-old for TEF repair. The 6-month-old for the first stage of their craniosynostosis repair. A 2 year old for ASD closure. Even the 18-year-old with an artery I could visibly see pulsating under the skin. I used it for everyone. For months. And months. The more I did it, the better I got. A twinkle of the needle tip here, a small displacement of tissue there, even in the short axis where you can sometimes feel like you’re flying blind, I became very facile at recognizing where I was and, more importantly, where I needed to be. Though I only recently discovered this term, I was doing deliberate practice.

For those of you who are unaware, deliberate practice is not like regular practice. Going to the driving range and mindlessly hitting your requisite 200 golf balls this is not.

Deliberate practice is about mindful intention. It is about setting a specific goal and methodically working on mastering each small step until you have mastered the larger, summed goal. While Tiger Woods makes it look effortless hitting his ball out of a sand trap during a competition, this is not innate skill or luck. Tiger would intentionally spend hours taking a ball, squashing it into the sand with his foot, and hitting it back onto the green, deliberately practicing for just this extraordinarily rare scenario. While you may only see one case of malignant hyperthermia in your entire career, we routinely revisit the information every so often to make sure it remains clear.

But why do we need deliberate practice? In order to reach expert-level performance, overcome plateaus in our skill level, or improve at a skill much faster than through regular practice, this is the way to do it.

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The 4 Components of Deliberate Practice

  1. Motivation—You have to be motivated to improve, to try something novel, to stretch outside of your comfort zone.

  2. Focus—Break your task into small, manageable parts.

  3. Feedback—Ideally, you should have immediate informative feedback and knowledge of results of your performance.

  4. Repetition- You should repeatedly perform the same or similar tasks.

Deliberate practice is designed specifically to improve performance. To benefit from practice and reach your potential, you have to constantly challenge yourself. This doesn’t mean repeatedly doing what you already know how to do. This means understanding your weaknesses and inventing specific tasks in your practice to address those deficiencies.

For me, initially it was ultrasound-guided arterial lines in children. For you, it may be doing in-plane popliteal blocks with the patient supine. Maybe it is doing a deep parasternal block for your cardiac kids. Perhaps it is performing a gastric ultrasound to evaluate the NPO status of the 4 year old tonsillectomy patient at the ambulatory center who may have snuck a cookie when no one was looking. Or perhaps it is using the ultrasound to place an IV in that impossible stick no one can seem to get access on. No matter the case, you won’t get better unless you pick up a probe and practice.

 
 

The Learning Zone

 
The Learning Zone Model
 
 

For many of us, we routinely live in our comfort zone. We like our comfort zone. It is always warm and cozy. There is never anything to worry about. We always look good in our comfort zone. However, in order to grow, you have to be OK with periodically stepping outside of that comfort zone and into the learning zone.

The learning zone exists just beyond, but not too far beyond your limits.

To be in your learning zone is to feel challenged, engaged, a sense of excitement, maybe even a little uncomfortable. It should require focused effort and attention. Think back to residency. Remember the first time you took care of an infant? BP of 60/30, HR in the 150’s (which not so coincidentally matched your own), perhaps not so silently praying the attending wouldn’t wander too far. That is the place you want to inhabit. Just make sure you’ve haven’t gone too far and ended up in your panic zone. Being engaged is ideal; being so stressed that you can no longer think clearly is going a bit too far.

Daniel Coyle writes in The Little Book of Talent:

There is a place, right on the edge of your ability, where you learn best and fastest. It’s called the sweet spot.…The underlying pattern is the same: Seek out ways to stretch yourself. Play on the edges of your competence. As Albert Einstein said, “One must develop an instinct for what one can just barely achieve through one’s greatest efforts.”

The key word is ‘barely.’

If you have people you work with who are skilled with an ultrasound, ask them to spot you, to teach you their tricks. It’s always good to have a mentor, as they may notice things in your technique you might not recognize yourself. Also, while it is ideal to have a mentor, if you are relatively facile with an ultrasound, depending on what you are trying to learn, you may or may not need a teacher. After graduating residency, the 5-6 blocks I was taught has not so gradually evolved into dozens of novel blocks. Rather than sit idly by waiting for a new hire to join the faculty to teach me new tricks, I have self-taught nearly every novel block technique around using articles and videos as guides. The ultrasound gave me immediate feedback, what was working, and what was not.

Although deliberate practice tends to result in much faster progress than normal practice, truly mastering a skill is a lifelong process. Making a breakthrough takes time. If you want to master a skill, you need to commit to working on it for a lengthy period of time, likely with few rewards. While there are no assurances that with struggle will come reward, without it the odds are undeniably lower.

Deliberate practice should not be boring. Frustrating, yes. Maddening, yes. Annoying, even. But never boring. As soon as practicing a skill gets comfortable, it’s time to up the stakes. Challenging yourself is about more than trying to work harder—it means doing new things.

While you may be intimidated by some the techniques on this site, don’t worry. Start small. Stay just outside of your comfort zone. Work on your Plan A blocks. Over time, incorporate new techniques when you’re ready and the opportunity presents itself. While it won’t happen overnight, you will make steady progress. Who knows, perhaps one day you’ll be doing both a transverse and a parasagittal paravertebral block in the same patient so there is no need to reposition.

All you need is a bit more practice. Deliberate practice.

If you’d like to learn more about the art and science of deliberate practice, check out any of these books:

John Hagen
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