Page 34 - JSOM Fall 2022

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a negative effect on skill transfer. 55,68,69 The extraneous load et al. Deliberate practice is a very specific, effortful type of
is determined by how the information is explained or deliv­ practice defined by several practices (Table 1). 98
ered. For example, if a concept is explained using confusing
diagrams and with unnecessary information, the extraneous TABLE 1 Deliberate Practice Concepts
load increases. If the material is presented clearly, with little Develops skills that other people have already figured out how
distracting information and in an easily understood manner, to do and for which effective training techniques have been
the extraneous load on a learner’s cognitive capacity is min­ established
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imized. This adds to the argument of why adding stressors Involves well­defined, specific goals and often involves improving
for novices is likely unhelpful. Gunfire, noise­flash, distrac­ some aspect of the target performance
tion devices, and screaming all probably add to the extraneous Takes place outside one’s comfort zone and requires a student to
load for novices. Even seemingly innocuous distractions, such constantly try things that are just beyond his or her current abilities
as interesting but only tangentially related anecdotes (e.g., war Occurs regularly and extends longitudinally
stories), might add to the extraneous load. 68,69,71 Involves building or modifying previously acquired skills by
focusing on particular aspects of those skills and working to
Some educational strategies seem to benefit virtually all groups, improve
from novices to experts. First, activities that force learners to Involves quantitative and qualitative feedback and modification of
recall and apply information, such as practice tests, 72­76 answer­ efforts in response to that feedback
ing questions about material just learned, 77,78 or even reciting Produces and depends on comprehensive mental representations of
the target task
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material, have demonstrated effectiveness. It also may be ben­
eficial for instructors to carefully customize training based on Is deliberate, which is to say that it requires one’s full attention and
conscious effort
novices’ needs; if they are struggling, additional guidance and
structure can be provided. If a learner breezes through the ba­ Adapted from Ericsson KA, Pool R. Peak: Secrets from the New Sci-
ence of Expertise. New York, NY: Houghton Mifflin Harcourt; 2016.
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sics, further challenges may be provided. This adaptive tech­
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nique may facilitate positive near and far transfer. Partial task This deep, intense, and deliberate practice can be enjoyable and
training is a technique whereby a multi­step, often complex or even personally all­consuming, 99,100 but it can also be challeng­
high­risk technical skill (e.g., cricothyrotomy) is broken down ing and frustrating. A trainee who completes a scenario and
into its individual competent steps for separate training and states, “That was awesome!” or “That was a crazy scenario!”
then combined so that the entire procedure can be performed. has not necessarily walked away with skills or knowledge. This
This technique may also reduce the intrinsic load of more is not to say that training shouldn’t be engaging, but rather
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complex skills. When a skill is broken down and practiced that attention should be paid to ensure it includes fundamen­
with variable emphasis or focus as part of a comprehensive se­ tal evidence­based teaching techniques and also is entertain­
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quence, a positive effect on transfer occurs. Also, the tempo­ ing. Training that is fun or easy does not necessarily equate to
rality of training is important. Spaced repetition over multiple effective training. This concept is known as training­transfer
sessions 84­87 and increasing intervals between practice demon­ dissociation. Several variables in training that make it easier
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strate better skills acquisition and retention. or more entertaining don’t necessarily facilitate transfer of skill
and information. Many learners often make this assumption
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An adage in the Special Operations community is, “Don’t train and conflate ease and enjoyment with quality and effective­
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until you get it right. Train until you can’t get it wrong.” This ness. The instructor should be aware of how students may
statement has some truth to it. Initially, when learning a new interpret scenarios in regard to efficacy and learning.
skill, novices are simply trying to understand the task. Their
experience revolves primarily around doing a task “correctly” The Role of the Prehospital Medical Instructor
and avoiding mistakes. Before long, mistakes become increas­ The instruction, guidance, coaching, and feedback provided
ingly less common, task completion becomes smoother, and by seasoned, experienced instructors and teachers are para­
learners no longer need to expend significant mental resources mount to successful learning. Such instruction begins with
focusing on the task. 88,89 In fact, often fewer than 50 hours of understanding students’ capabilities and limitations. Evidence
practice are required for a number of simple motor skills and suggests that there is a direct impact on education when in­
recreational activities before an “acceptable standard” of per­ structors understand the knowledge and beliefs that learners
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formance is achieved. However, the point at which learners bring to the encounter. 102–104 Instructors should understand the
feel things start to get easy and gross errors become rare is level of experience of trainees, their individual frames of refer­
far from mastery. Although rates in error commission don’t ence when it comes to key concepts and skills regarding tacti­
noticeably change, task performance continues to improve cal medicine, and how these frames of reference have come to
over weeks, months, and years. 90,91 In particular, there are two be. 105,106 Do the students have a significant amount of medical
primary measurable changes as practice continues: the speed experience treating patients in the prehospital trauma setting?
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of task performance increases, and the attentional cogni­ Have they learned habits from previous courses or their own
tive resources required to perform decrease. 93,94 Some authors experiences that may not be in accordance with best practice
have referred to this as “overlearning.” 19,95 The temptation is for the course? Such awareness can drive effective, adaptive,
to stop when competence is achieved or even when an indi­ and timely training that best meets the needs of the students.
vidual can complete error­free task performance. Incremental
improvements persist beyond this point, and the salient “I feel Aside from developing curricula and using evidence­based
like I got this . . .” is not a good marker to terminate learning, techniques, perhaps the most important role of an instructor
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especially when it comes to high­risk emergency procedures. 97 is to provide feedback. Feedback has been well studied 107–109
and is integral to both deliberate practice and learning across
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A concept that encapsulates these various aspects of effective disciplines. The timing of feedback and direction is vital.
training is that of deliberate practice, proposed by Ericsson Authors have examined feedback during task execution (i.e.,

32 | JSOM Volume 22, Edition 3 / Fall 2022