The old saying that says “practice makes perfect” is a basic rule taught to every resident starting their training. The follow-up questions that pose themselves: Is it true? How much time does it need to become perfect? What type of practice?
Time was answered partially by the journalist Malcolm Gladwell and his famous 10,000 hours rule; if one dedicates 10,000 hours for a skill, one will become an expert. If you do the math, you can more or less deduce that three years of medical residency gives a typical resident the right amount of time to become an expert, and if one combines it with the rule practice makes perfect, then the result must be a resident being an expert attending ready to practice independently.
In the current era of medical training, where various teaching models exist in a residency training program, this theory mentioned earlier makes sense. It generates a sense of security for junior trainees, especially at the beginning of their careers. Having said that, reality can be surprisingly different. Many junior attendings admit that their security level of independent practice is not what one thought to be before.
To solve this difference between expectations and reality, one must realize the different types of learning, namely passive and active learning, where passive learning is the absorption of knowledge and skills from direct observation of others and subconscious retention of information which typically takes a long time to increase, and active learning where one individually analyzes problems as they arise and practice critical thinking to come across different possible solutions tailored to that particular problem. One can view passive learning through lectures and bedside rounds and active learning through individual reading and analysis of evidence-based medicine at an individual or a group level.
More emphasis has indeed been put forward toward active learning in the past decades as it is thought to increase the amount of retained knowledge and nourishes the critical thinking mind, which is needed more so than ever, especially in medical practice. Still, active learning per se does not seem to be the foreseen solution for this dilemma between expectations to reality.
When starting medical training, the junior doctor is faced with many challenges; the major ones are knowing what needs to be done daily, how to assess patients, how to diagnose, and how to treat. It seems very natural to follow senior physicians’ orders and copy them. As the junior physician grows in this complex field of medicine, one will realize the different approaches each physician might take; they are very different and variable. This variability is the inescapable norm of reality.
Even in this advanced time of evidence-based medicine where complex diseases have management algorithms verified by experts and large randomized trials, individualized educated actions are practiced in many daily medical decisions. In most cases, it will take the junior doctor a year or two or even more to “figure it out,” and then the hours start to tick, marking the 10,000 hours journey to perfection.
It seems critical in this era of medical education to integrate both learning methods and get the maximum benefit of both. It is a continuum that starts with passive learning and matures to active learning and critical thinking. Juniors will learn from seniors, will absorb different scenarios and situations that will build the hands-on experience, the experience that written materials will not teach, they will read and listen to educational materials and when this experience starts to accumulate that the critical thinking will be powerful. Critical thinking is based on knowledge and experience, not speculation. By this will the individual physician be able to analyze situations, criticize medical research and individualize the treatment to suit that particular patient. It is the “perfect practice that makes perfect,” not any practice.
Salim Yaghi is an internal medicine chief resident.
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