Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains

Abstract

The factors that cause large individual differences in professional achievement are only partially understood. Nobody becomes an outstanding professional without experience, but extensive experience does not invariably lead people to become experts. When individuals are first introduced to a professional domain after completing their education, they are often overwhelmed and rely on help from others to accomplish their responsibilities. After months or years of experience, they attain an acceptable level of proficiency and are able to work independently. Although everyone in a given domain tends to improve with experience initially, some develop faster than others and continue to improve during ensuing years. These individuals are eventually recognized as experts and masters. In contrast, most professionals reach a stable, average level of performance within a relatively short time frame and maintain this mediocre status for the rest of their careers. The nature of the individual differences that cause the large variability in attained performance is still debated. The most common explanation is that achievement in a given domain is limited by innate factors that cannot be changed through experience and training; hence, limits of attainable performance are determined by one's basic endowments, such as abilities, mental capacities, and innate talents. Educators with this widely held view of professional development have focused on identifying and selecting students who possess the necessary innate talents that would allow them to reach expert levels with adequate experience. Therefore, the best schools and professional organizations nearly always rely on extensive testing and interviews to find the most talented applicants. This general view also explains age-related declines in professional achievement in terms of the inevitable reductions in general abilities and capacities believed to result from aging. In this article, I propose an alternative framework to account for individual differences in attained professional development, as well as many aspects of age-related decline. This framework is based on the assumption that acquisition of expert performance requires engagement in deliberate practice and that continued deliberate practice is necessary for maintenance of many types of professional performance. In order to contrast this alternative framework with the traditional view, I first describe the account based on innate talent. I then provide a brief review of the evidence on deliberate practice in the acquisition of expert performance in several performance domains, including music, chess, and sports. Finally, I review evidence from the acquisition and maintenance of expert performance in medicine and examine the role of deliberate practice in this domain. The Traditional View of Skill Acquisition and Professional Development: History and Some Recent Criticisms The traditional view of skill acquisition is based on the assumption that innate biological capacities limit the level of achievement that a person can attain. Sir Francis Galton is generally recognized for developing the scientific basis for this view in the 19th century. In his pioneering book, Hereditary Genius,1 he presented evidence that height and body size was determined genetically, and most importantly, he argued that similar innate mechanisms must determine mental capacities, stating: Now, if this be the case with stature, then it will be true too as regards every other physical feature—as circumference of head, size of brain, weight of grey matter, number of brain fibres, &c.; and thence, a step on which no physiologist will hesitate, as regards mental capacity [italics added].1, pp. 31–2 At the same time, Galton clearly acknowledged the effects of practice and the need for training to reach high levels of performance in any domain. However, he argued that improvements are rapid only in the beginning of training and that subsequent increases become increasingly smaller, until “Maximal performance becomes a rigidly determinate quantity.”1, p. 15 According to the capacities the for an physical and mental and of the training have attained through then the limit for performance is that of p. According to the that limit performance cannot be through they must have for the of innate factors in performance have a on view of and of skill are with general and with the on the of professional When individuals are first introduced to an such as a or their is to reach a level of that will allow them to an acceptable level or to in with their the first of to the and on experience in the of become increasingly performance and no need to as to an acceptable After a limited of training and than for most such as and a acceptable of performance is individuals to a domain and their performance become they are able to and without a of of the of performance a with no which is with assumption of a performance The acquisition of and professional development to be a in time proficiency in is attained professional development the is only after years or of experience. In their and argued that in order to attain an level of performance in chess, an individual must maintain in the for years. on for that the some or and they the this performance level and a with large and a of experts and to in as a of their continued experience in the domain. on the that most people are able to their first after many years of experience without the that experience years of lead to in a performance domain. some of experience in a domain as a of the have that evidence for the traditional the development of through experience is and most the performance of who are by their based on their extensive experience and is for from their domain of performance on is not always to that of and from not always to students on the level of training and experience only to of performance in a domain. the of training and professional experience of is not to their and in and extensive experience with is not with proficiency on presented are to and of a without of the on the their performance is only than by of that and on in have that does not improve with experience. have in several other of In the of this article, I will review evidence on with as performance to their if I will the of that such the traditional of professional development and skill acquisition that people will reach a level of performance after experience. This assumption is with the of individuals to continue to improve their performance through that and professionals are they are able to improve their Finally, many have to and basic capacities, such as and as well as and to the innate limits of their attainable performance. to capacities to professional achievement have and to innate individual that are to expert performance are to by extensive training have not The only such innate for which the people and the mechanisms are well are body size and height an in height performance in These the view of determined limits that attainable performance. that individuals be able to their attained performance levels to a than is The of this are presented on attain expert levels of achievement in domains, including music, and is on the role of deliberate practice and training in improvements in levels of performance. the with on deliberate is to on in from the of in other provide for and attained levels of performance in the domain. The of and Acquisition In the to this article, several given such as and to on such as in and can no that individuals to be experts based on their experience will the achievement of in a domain. and of that for differences by and that on performance in a domain and any individual who they are recognized as expert or The first step is to that the of in the domain the can their performance in a and The on scientific evidence on performance a framework for the of and When the scientific evidence for the most is most of cannot be by and the only of are the their as In other the individuals the have a a to a it is often that they of their However, have during and are to the same to in The of that the of their is than that of the of the are by factors the is in large to for the best a of need to the scientific evidence to aspects of that can be and such as the expert variability in of from an would the of achievement in the it can be and In many domains, it is to expert performance by as they their achievement types of performance by experts are in who the in than can their In is a of by for The same is true for in music, and In of domains, individuals their have to be able to their performance in it is during and and it is to that the of in a given domain. in his pioneering work on argued that the for expert of selecting the best for during from and a he a time to an individual The to they the best for the presented to the best is with for of that the performance of domain experts in chess, and by and of by is in the of expert performance in that in to any of can the same and them to it as as The given in a common to the of that experts can a that individuals are to In the of for are with the that the expert of that are too for to to to or of and then them to their in as as When to experts can their with from their than can their performance. In can be to several for of a of of and can be to several for of many on a In it is to a of that the of in most domains, and can be to and In the of this article, I will that the for the in a in such as and The Acquisition of to performance that can be it is to several the acquisition of that of performance that performance increases and that is no evidence for increases from to the the performance of in and are by the increases in achievement are to be and many years. the which experts reach their performance is the to for many and or in the and for as well as the and This often development that the best individuals are able to in practice that lead to improvements in performance after physical is Finally, including the most or need a of years of they reach an level in and the in to reach that This of engagement in is the most evidence for the of experience to attain high levels of performance. interviews with in several domains, and his that are nearly always introduced to their of as in a as they for the and to their they help in a or and to on argued that to training during development is necessary to reach the The best evidence for the of training and of practice from The most improvements in the level of performance are in and are with and of performance is to the of the In some performance can be with or are as as a the of training be through and such as the role of practice in expert levels of and to training that most with improvements in performance and to them as deliberate a review of of and skill evidence for of performance the the to improve some of performance for a they able to on their performance. 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According to the traditional of skill people need to on they are to in order to as in the of experience, their become increasingly their performance and they no need to as to an acceptable After some limited training and than for most such as and a acceptable of performance is attained without need for are to the performance and become increasingly they and are no able to of the the of of expert performance and of The for is to reach as as a level that is and After individuals through the and they can their performance with a of the the of the In contrast, expert by developing increasingly mental to attain levels of of their performance and will within the and Some experts some in their their to and engagement in deliberate practice to improve which in of their performance. from scientific of expert levels of general for and by in p. by for contrast, expert performance to improve as a of experience, with deliberate The for expert is to the development with and to to their continued and The expert the by and mechanisms to continued and as in the of The experts and training in which the their level of performance. mechanisms that are to their and to performance in from the domain of a to during the of the of alternative for a In are able to without the in the and are able to of time to their The rapid of expert are not to of their but on their to and by to expert are able to a and will the the of deliberate practice lead experts to their and mechanisms that their is not an who can other in the can improve in this is it to improve one's to and to the best in a given this by the best in the through the a time to determine if their will the by the masters. the from their this would that their and must have some of the and the expert is generally able to the for the as as every in this of a time the of for a can the of their individuals their and can or the same on some of the best of performance can be through deliberate practice that the The is that individuals can their by as as they can maintain which is only for to a faster faster than their to to by their The faster also to in which the experts are and can their average and practice a that is still faster then the average The general of to performance if that performance can be only for short the for identifying and and that will improve performance. of expert performance as by of for the and of it becomes that acquisition requires an and deliberate practice is to improve aspects of performance in a that that attained can be performance. practice performance cannot be or of the for the performance. individuals in the professional and will an role in the experts to performance in a and In the to expert performance in the and have the mechanisms that this level of These mechanisms are not the result of experience. their development requires engagement in deliberate practice that of for the and of When expert in deliberate their to become and development of is the of In the I will to this framework to examine the and maintenance of performance in in In most professional domains, including it a relatively time for students to the and for the is also a of training professionals on for the in the such as after a is to practice is often continued training and experience to become a and eventually as an In is general one's level of attained as well as which individuals are experts. on have and students based on their recognized levels of and of experience. is common to of as a of and experience, a to through they are of the as an is generally that would to performance on that the of in In this I will examine evidence for and this level of and performance in the to on in The first step of the that the of the domain. The of medicine are the of and the of and who the most by be recognized as expert in nearly to the for based on their practice in The of often on many factors of the such as the of the the of the and individual differences in and it would not be to in by the of it is that a is for and are by a of a of the in is to other and the of general The would that experts and students would the same of is not for several to the same independently. 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