Practice Perfect 809
How Important Is Experience?
Part 2 - Maintaining Expertise

In last week’s Practice Perfect, I posited the potentially controversial question about the importance of experience in expertise. My research for the blog revealed that, according to experts in this field of research, the simple equation increasing years of experience equals increased expertise is not true. Simply doing something repetitively over many years does not necessarily equate with improved outcomes in medicine. In fact, in some medical fields, it appears younger physicians in their first few years of practice may have better outcomes than doctors with many years of practice. This is generally attributed to these physicians’ recent graduation from training where they are exposed to more updated information. For surgeons, a somewhat different trend has been reported as a concave distribution. Surgeons of middle age appear to have the best outcomes with younger and much older surgeons demonstrating poorer outcomes. This is hypothesized to be due to younger doctors having less experience and much older surgeons more likely to have physical impairments that decreases their surgical effectiveness.

Surgeons of middle age appear to have the best outcomes with younger and much older surgeons demonstrating poorer outcomes.

Obviously, these reported trends oversimplify the question of experience, and I continue to assert that the manner in which a physician or surgeon practices medicine and maintains their skills is the determinant of what level of expertise they will attain. And that brings us to today’s issue, where I’d like to discuss some thoughts about how each of us can maintain and grow our skills over time.

Deliberate Practice to Maintain and Grow Your Skills 

I believe there’s one primary way for physicians and surgeons to maintain and grow their skills: deliberate practice. This term was coined by the researcher Anders Ericsson who has spent his entire career studying how experts at the top of their fields become experts. He has studied a variety of top performers, from pianists and dancers to athletes and surgeons, among others, and he has contributed significantly to the published research in this field. In fact, he is an expert about experts. He published an excellent book with coauthor Robert Pool called Peak: The Secrets from the New Science of Expertise in 2017. I highly recommend this engaging and thought-provoking book in which he discusses the components of deliberate practice and how it can be used to attain expertise. Without going into too much detail, I’ll list the primary characteristics and then recommend some ways we can use deliberate practice to continue to grow in our chosen professions.

The Characteristics of Deliberate Practice

  1. Learners develop skills that have already been figured out, with education designed by and overseen by a coach or teacher.
  2. Learning takes place outside of one’s comfort zone, just beyond one’s abilities and is generally not considered enjoyable.
  3. The focus is on well-defined, specific goals.
  4. It requires full attention while concentrating on that specific goal.
  5. It involves feedback and modification of efforts, and with time the learner should be able to self-monitor and adjust their performance accordingly.
  6. A major focus is on improving mental representations which become increasingly detailed over time.
  7. One builds and modifies previously acquired skills by focusing on specific aspects of those skills and working to improve them.

With those characteristics in mind, I’ll make a comment about Ericsson’s mental representations, which are a key component in becoming truly expert at something. Think of a mental representation as a picture in your mind of a concept or skill. As we become expert at something, we develop increasingly complex representations of that topic. Take, for example, the diagnosis of a disorder such as Morton’s neuroma. A podiatry student may have a mental image of this disease as “numbness in a couple of toes of one foot.” However, a more experienced student will have a more complex mental representation, for example, “numbness or paresthesias of the 3rd and 4th toes with a sensation of something under the ball of the foot.” A more experienced podiatrist will have a yet more nuanced representation that may include the above characteristics but also incorporate “rare presentation in intermetatarsal spaces other than the 3rd, no evidence of MTP joint pathology, occasional radiation to the midfoot, pain with palpation of the 3rd intermetatarsal space and a positive Mulder’s click.” You can see with this simple example the power of the expert’s more detailed mental representation. This is the reason why attending physicians often astound students with very rapid diagnoses when the students took much longer to figure things out.

A more detailed mental representation is the reason why attending physicians often astound students with very rapid diagnoses when the students took much longer to figure things out.

So, how can we apply these principles to our own maintenance of expertise? Ericsson strongly asserts that doctors do not gain expertise from experience alone. Clearly, it is important that we continue to see a variety of patients and see pathology in all its intricacies. Without that experience, we can’t modify our mental representations. The same is true for surgery; we have to continue to gain experience to create the opportunities to hone our skill.

Ericsson suggests certain methods for physician continuing education based on deliberate practice, including those with some interactive component such as role play, discussion groups, case solving, and hands-on training and moving away from straight lectures, adding in those activities that allow feedback, chances to try something new, with opportunities to make mistakes and correct them, gradually developing new skills. I would comment that, although effective, these methods are very difficult and expensive to scale up for physician conferences.

Now, laying the responsibility for maintaining and growing our expertise on the laps of conferences is neither fair nor likely to provide the results we need. Thus, it’s our individual responsibilities as doctors to make the effort. Here are some ideas to consider when growing your expertise. 

  1. Fight against ego - In the excellent book, Ego Is the Enemy, Ryan Holiday makes the strong argument that we need to get rid of our egos to grow. This is definitely not an easy thing to do, especially for those of us with large egos (yours truly included). But to move outside our individual comfort zones and accept feedback, we have to lose the ego.
  2. Go outside your comfort zone - Endeavoring to look for those aspects of your professional life that you do not know or feel uncertain of can be very uncomfortable. Remember, that although uncomfortable, these situations and topics are the areas where you are most likely to grow your expertise. Keep in mind, though, not to go too far outside that comfort zone into areas where you have absolutely no expertise, at least, not without someone else who has that expertise. We must balance our individual learning with patient safety.
  3. Use the opportunities you have - As physicians and surgeons, we are surrounded daily by things we don’t know. For example, just in the last week I’ve been confronted by pathologies such as Achilles tendon ruptures with large deficits, Charcot arthropathy of a lesser metatarsophalangeal joint, and congenital hyperkeratotic disorders of skin. Each of these requires a little extra research to learn more than my current level of knowledge. Similarly, every patient encounter, whether clinical or surgical, creates a new opportunity to learn something new. We just have to be open to those experiences.
  4. Look for a coach or mentor - An important aspect of deliberate practice is working with someone with the highest level of expertise. Residents obviously benefit from this system as they spend 3-4 years working with a variety of mentors in the form of their attendings. But when we graduate, private practice can be very isolating. Personally, I’m very lucky to be in an academic institution surrounded by smart people who are better physicians and surgeons than me. I learn so much every day by picking others’ brains, discussing cases, and sometimes having them scrub cases with me. For those in practice, a good way to find a mentor is to attend your local county or state podiatry association meeting or network at conferences. Remember, you must give up the ego to admit someone has more expertise than you and then learn from them.
  5. Analyze your own cases - I keep track of my own surgical cases using a program called Airtable. This is basically an online spreadsheet to which you can upload information and images, customized to your preferences. For each case, I look back at different intervals (immediately, at various times during the postoperative recovery, and at 6-month intervals for certain cases). It’s amazing what you can learn by examining your own work later down the line. I try to focus on things I feel I can improve upon rather than admiring my work (there’s always something you could have done better). Focusing on your deficiencies, errors, and poor outcomes are the only way to learn and improve.
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As a final note, for those of you interested in a good read, I suggest SKILL: 40 Principles that Surgeons, Athletes, and Other Elite Performers Use to Achieve Mastery by Dr Christopher Ahmad, a successful orthopedic surgeon. He reviews a variety of methods he has used to improve his own work and continue to build his expertise. It goes far beyond the five points I discussed above but incorporates all of the same principles of deliberate practice. With the right attitude, maintaining and improving expertise can be an interesting and enlightening journey and, dare I say it, an enjoyable one.

Best wishes on your journey to mastery.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor

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