This podcast discusses deliberate practice, a concept developed by renowned cognitive psychologist Anders Ericsson, PhD. Deliberate practice is the kind of practice that top performers employ in order to reach the very highest levels of excellence across domains. Ericsson studied countless musicians, athletes, dancers, chess players, medical professionals and others to uncover the secrets and power of deliberate practice.
Malcolm Gladwell popularized some of Ericsson’s work in his 2008 book, Outliers, as the 10,000-hour rule to expertise, stating that on average, it takes about 10,000 hours to develop as an expert. But it’s not as easy as that. It’s not that simple. It’s not just about being on the job for 10,000 hours. And you know what I’m talking about. You’ve worked with people who are very experienced yet not the best – not even great – perhaps even mediocre, at their jobs. What Ericsson saw is that it takes top performers around 10,000 hours of deliberate practice – a concentrated, effortful, focused kind of practice, with feedback from a coach, to achieve the top level in any field.
Check out the podcast and links in the show notes for a quick break down and some examples of how to harness deliberate practice to improve your anesthesia career.
Resources:
Ericsson, K. A. (2008). Deliberate practice and acquisition of expert performance: a general overview. Academic emergency medicine, 15(11), 988-994.
Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine, 79(10), S70-S81.
Ericsson, K. A. (2015). Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert – Performance Approach With Deliberate Practice. Academic Medicine, 90(11), 1471. doi:10.1097/ACM.0000000000000939
Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.
Young, J. 5 May 2020. Researcher Behind ‘10,000-Hour Rule’ Says Good Teaching Matters, Not Just Practice. (podcast). EdSurg Podcast. Retrieved from https://www.edsurge.com/news/2020-05-05-researcher-behind-10-000-hour-rule-says-good-teaching-matters-not-just-practice.
This episode originally released on From the Head of the Bed in February of 2017.
Denham Ward, MD, PhD joined me to talk about expertise in anesthesia. At the time of this recording, Dr Ward was the director of the Academy at Maine Medical Center Institute for Teaching Excellence and professor of anesthesiology at Tufts University School of Medicine. He is Emeritus Professor and Chair of Anesthesiology and Emeritus Professor of Biomedical Engineering at the University of Rochester.
This podcast focuses on developing and maintaining expertise over a career in anesthesia. Highlights range from defining expertise, specialization in anesthesia, types of problem solving and clinical decision making, deliberate practice, grit and how to teach and coach the development of expertise in trainees as well as experienced clinicians. We touch on Ericsson’s ideas on deliberate practice and the 10,000 hour rule for expertise, Dreyfus’ conceptions of skill acquisition from novice-advanced beginner-competent-proficient-expert, Kahneman’s System 1 and System 2 ways of thinking, Moulton’s “when to slow down,” Gawande’s ideas on the benefit of getting coached to improve our performance even well into our careers and more.
“The difference between medicine and music is… musicians practice, practice, practice and then they go to Carnegie Hall for one evening… We’re essentially at Carnegie Hall every day.” Denham Ward, MD, PhD
“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.” Anders Ericsson
Duckworth, A. (2016). Grit: The power of passion and perseverance (Vol. 124). New York, NY: Scribner. Retrieved from http://www.simonandschuster.com/books/Grit/Angela-Duckworth/9781501111105. Screen shot by author.
Dweck, C. S. (2008). Mindset: The new psychology of success. Random House Digital, Inc.. Retreived from https://www.penguinrandomhouse.com/books/44330/mindset-by-carol-s-dweck-phd/9780345472328/. Screen shot by author.
Ericsson, K. A. (2015). Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert – Performance Approach With Deliberate Practice. Academic Medicine, 90(11), 1471. doi:10.1097/ACM.0000000000000939
Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine, 79(10), S70-S81.
Gawande, A. (2011). Personal best. The New Yorker, (30). 44. Retrieved from http://www.newyorker.com/magazine/2011/10/03/personal-best.
Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux.
Kaminski, J. (Fall, 2010). Theory applied to informatics – Novice to Expert. CJNI: Canadian Journal of Nursing Informatics, 5 (4), Editorial. Retrieved from http://cjni.net/journal/?p=967.
Moulton, C. E., Regehr, G., Mylopoulos, M., & MacRae, H. M. (2007). Slowing down when you should: a new model of expert judgment. Academic Medicine: Journal Of The Association Of American Medical Colleges, 82(10 Suppl), S109-S116.
In this episode Dr Cynthia Farina and I talk about the mid-to-late phase of your career as a CRNA. Every stage of your career has unique challenges & opportunities. There’s so much attention focused on getting into CRNA school, the SRNA/resident/training phase and becoming a new CRNA… this conversation is for the part of your career farther down the road.
Dr Farina is a CRNA from Michigan whom, at the time of this recording (December 2019), served as the chair of the American Association of Nurse Anesthetists’ (AANA) Health and Wellness Committee and the Michigan Association of Nurse Anesthetists Wellness Committee.
Dr Farina completed her Bachelor of Science in Nursing at the University of Michigan, Ann Arbor and then her Master of Science in Nursing in the anesthesia track from Oakland University in 1996. She then returned to the University of Michigan to complete her Doctor of Nursing Practice degree.
Cindy practiced full-time at a large suburban teaching hospital, where she also served as a clinical and didactic instructor in the Oakland University-Beaumont Graduate Program of Nurse Anesthesia.
Cindy has a strong interest in creating and sharing educational material on personal and workplace wellness for CRNAs and SRNAs. In her most recent work, she has explored the topic of career phases and transitions for nurse anesthetists.
This is a distillation of 10 key tips to help folks who are learning airway management improve their skills. This show gets straight to the point: 10 tips for airway management in 10 minutes.
10 Tips for Airway Management
1. Develop a growth mindset and practice deliberately
2. Do a good airway assessment
3. Develop and follow a plan
4. Control your environment
5. Position the patient and yourself for success
6. Preoxygenate adequately
7. Communicate effectively
8. Choose meds appropriately and let them work
9. Take your time with laryngoscopy
10. Recognize when you need to change your plan and do so deliberately
Chong, J. (2016). Airway management in obese patients. EMNote. Retrieved from http://www.emnote.org/emnotes/airway-management-in-obese-patients This is my personal ramp preference – a stack of blankets wrapped with one blanket (which helps when removing the ramp after intubation) and either a pillow or foam shay on top.
Resources:
Achar, S. K., Pai, A. J., & Shenoy, U. K. (2014). Apneic oxygenation during simulated prolonged difficult laryngoscopy: comparison of nasal prongs versus nasopharyngeal catheter: a prospective randomized controlled study. Anesthesia, essays and researches, 8(1), 63.
Booth, A. W. G., Vidhani, K., Lee, P. K., & Thomsett, C. M. (2017). SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal oxygen (STRIVE Hi) maintains oxygenation and airway patency during management of the obstructed airway: an observational study. BJA: British Journal of Anaesthesia, 118(3), 444-451
Caputo, N., Azan, B., Domingues, R., Donner, L., Fenig, M., Fields, D., … & McCarty, M. (2017). Emergency Department use of Apneic Oxygenation versus usual care during rapid sequence intubation: A randomized controlled trial (The ENDAO Trial). Academic Emergency Medicine, 24(11), 1387-1394.
Chong, J. (2016). Airway management in obese patients. EMNote. Retrieved from http://www.emnote.org/emnotes/airway-management-in-obese-patients
Dearani, J. A., Gold, M., Leibovich, B. C., Ericsson, K. A., Khabbaz, K. R., Foley, T. A., … & Daly, R. C. (2017). The role of imaging, deliberate practice, structure, and improvisation in approaching surgical perfection. The Journal of thoracic and cardiovascular surgery, 154(4), 1329-1336.
Ericsson, K. A. (2015). Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert – Performance Approach With Deliberate Practice. Academic Medicine, 90(11), 1471. doi:10.1097/ACM.0000000000000939
Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.
Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine, 79(10), S70-S81.
e Silva, L. O. J., Cabrera, D., Barrionuevo, P., Johnson, R. L., Erwin, P. J., Murad, M. H., & Bellolio, M. F. (2017). Effectiveness of apneic oxygenation during intubation: a systematic review and meta-analysis. Annals of emergency medicine, 70(4), 483-494.
Heard, A., Toner, A. J., Evans, J. R., Palacios, A. M. A., & Lauer, S. (2017). Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of buccal RAE tube oxygen administration. Anesthesia & Analgesia, 124(4), 1162-1167.
Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux.
Lee, P. K., Booth, A. W. G., Vidhani, K., & Bath, J. M. (2017). Spontaneous Breathing For the Difficult Airway: STRIVE Hi Demonstrates Its Versatility. Anesthesiology News.
Moulton, C. E., Regehr, G., Mylopoulos, M., & MacRae, H. M. (2007). Slowing down when you should: a new model of expert judgment. Academic Medicine: Journal Of The Association Of American Medical Colleges, 82(10 Suppl), S109-S116.
Myatra, S. N., Kalkundre, R. S., & Divatia, J. V. (2017). Optimizing education in difficult airway management: meeting the challenge. Current Opinion in Anesthesiology, 30(6), 748-754.
Nørskov, A. K., Rosenstock, C. V., Wetterslev, J., Astrup, G., Afshari, A., & Lundstrøm, L. H. (2015). Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia, 70(3), 272-281. [THIS IS THE STUDY SHOWING 93% OF DIFFICULT INTUBATIONS AND 94% OF DIFFICULT MASK VENTILATION CASES WERE NOT ANTICIPATED.]
Patel, A., & Nouraei, S. A. R. (2015). Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia, 70(3), 323-329.
Pratt, M. (2017). A Practical Approach to Apneic Oxygenation during Endotracheal Intubation. J Anesth Clin Res, 8(696), 2.
Pratt, M., & Miller, A. B. (2016). Apneic Oxygenation: A Method to Prolong the Period of Safe Apnea. AANA Journal, 84(5), 322-328.
Ramachandran, S. K., Cosnowski, A., Shanks, A., & Turner, C. R. (2010). Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. Journal of clinical anesthesia, 22(3), 164-168.
Weingart, S. D., & Levitan, R. M. (2012). Preoxygenation and prevention of desaturation during emergency airway management. Annals of emergency medicine, 59(3), 165-175.
