Deliberate Practice and Proposed Limits on the Effects of Practice on the Acquisition of Expert Performance: Why the Original Definition Matters and Recommendations for Future Research

The meta-analyses of deliberate practice underestimate the effect size because they neglect the core characteristic of individualization—an analysis and empirical evidence

Influential meta-analyses have concluded that only a small to medium proportion of variance in performance can be explained by deliberate practice. We argue that the authors have neglected the most important characteristic of deliberate practice: individualization of practice. Many of the analyzed effect sizes derived from measures that did not assess individualized practice and, therefore, should not have been included in meta-analyses of deliberate practice. We present empirical evidence which suggests that the level of individualization and quality of practice (indicated by didactic educational capital) substantially influences the predictive strength of practice measures. In our study of 178 chess players, we found that at a high level of individualization and quality of practice, the effect size of structured practice was more than three times higher than that found at the average level. Our theoretical analysis, along with empirical results, support the claim that the explanatory power of deliberate practice has been considerably underestimated in the meta-analyses. The question of how important deliberate practice is for individual differences in performance remains an open question.

Three-Dimensionally Printed Surgical Simulation Tool for Brain Mapping Training and Preoperative Planning

BACKGROUND

Brain mapping is the most reliable intraoperative tool for identifying surrounding functional cortical and subcortical brain parenchyma. Brain mapping procedures are nuanced and require a multidisciplinary team and a well-trained neurosurgeon. Current training methodology involves real-time observation and operation, without widely available surgical simulation.

OBJECTIVE

To develop a patient-specific, anatomically accurate, and electrically responsive biomimetic 3D-printed model for simulating brain mapping.

METHODS

Imaging data were converted into a 2-piece inverse 3D-rendered polyvinyl acetate shell forming an anatomically accurate brain mold. Functional and diffusion tensor imaging data were used to guide wire placement to approximate the projection fibers from the arm and leg areas in the motor homunculus. Electrical parameters were generated, and data were collected and processed to differentiate between the 2 tracts. For validation, the relationship between the electrical signal and the distance between the probe and the tract was quantified. Neurosurgeons and trainees were interviewed to assess the validity of the model.

RESULTS

Material testing of the brain component showed an elasticity modulus of 55 kPa (compared to 140 kPa of cadaveric brain), closely resembling the tactile feedback a live brain. The simulator's electrical properties approximated that of a live brain with a voltage-to-distance correlation coefficient of r2 = 0.86. Following 32 neurosurgeon interviews, ∼96% considered the model to be useful for training.

CONCLUSION

The realistic neural properties of the simulator greatly improve representation of a live surgical environment. This proof-of-concept model can be further developed to contain more complicated tractography, blood and cerebrospinal fluid circulation, and more in-depth feedback mechanisms.

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle

Background

Errors in reasoning are a common cause of diagnostic error. However, it is difficult to improve performance partly because providers receive little feedback on diagnostic performance. Examining means of providing consistent feedback and enabling continuous improvement may provide novel insights for diagnostic performance.

Methods

We developed a model for improving diagnostic performance through feedback using a six-step qualitative research process, including a review of existing models from within and outside of medicine, a survey, semistructured interviews with individuals working in and outside of medicine, the development of the new model, an interdisciplinary consensus meeting, and a refinement of the model.

Results

We applied theory and knowledge from other fields to help us conceptualise learning and comparison and translate that knowledge into an applied diagnostic context. This helped us develop a model, the Diagnosis Learning Cycle, which illustrates the need for clinicians to be given feedback about both their confidence and reasoning in a diagnosis and to be able to seamlessly compare diagnostic hypotheses and outcomes. This information would be stored in a repository to allow accessibility. Such a process would standardise diagnostic feedback and help providers learn from their practice and improve diagnostic performance. This model adds to existing models in diagnosis by including a detailed picture of diagnostic reasoning and the elements required to improve outcomes and calibration.

Conclusion

A consistent, standard programme of feedback that includes representations of clinicians’ confidence and reasoning is a common element in non-medical fields that could be applied to medicine. Adapting this approach to diagnosis in healthcare is a promising next step. This information must be stored reliably and accessed consistently. The next steps include testing the Diagnosis Learning Cycle in clinical settings.

Defining “elite” status in sport: from chaos to clarity

The past two decades have seen a rapid rise in attention towards talent identification, athlete development and skill acquisition. However, there are important limitations to the evidentiary foundations of this field of research. For instance, variability in describing the performance levels of individuals has made it challenging to draw inferences about inter- and intrapopulation differences. More specifically, recent reviews on high performers in sport have noted considerable variation in how terms such as “elite” are used. This may be particularly concerning for researchers in high-performance disciplines, since they regularly struggle with small sample sizes and rely on research synthesis approaches (i.e. meta-analyses and systematic reviews) to inform evidence-based decisions. In this discussion piece, we (a) highlight issues with the application of current terminology, (b) discuss challenges in conceptualizing an improved framework and (c) provide several recommendations for researchers and practitioners working in this area.

The S-Shaped Performance Curve Prevails in Practicing Juggling

The development of performance, such as learning a new motor skill, can be represented in a performance curve. The shape of the performance curve is both of theoretical and practical relevance. Here, the author studied the interday performance of juggling over a period of 17 days in 112 college students. The results showed that 60% of participants followed an S-shaped performance curve with the inflection date on the 11th day, followed by a decelerated (20%), accelerated (14%), and linear curve (6%). As expected, except on Day 1, male participants performed at least 33% better than female participants on each practice day. Also as expected, learning performance was found to depend on the type of performance curve with the best learning performance exhibited by the linear group. The results further revealed that pooling all participants’ performance together without considering the percentage of each underlying type of performance curve would lead to biased, nonrepresentative results. Given the variety of the observed performance curves and the dominance of the S-shaped performance curve among them, coaches should continuously monitor the shape of an individual’s performance curve.

Evolving robotic surgery training and improving patient safety, with the integration of novel technologies

INTRODUCTION

Robot-assisted surgery is becoming increasingly adopted by multiple surgical specialties. There is evidence of inherent risks of utilising new technologies that are unfamiliar early in the learning curve. The development of standardised and validated training programmes is crucial to deliver safe introduction. In this review, we aim to evaluate the current evidence and opportunities to integrate novel technologies into modern digitalised robotic training curricula.

METHODS

A systematic literature review of the current evidence for novel technologies in surgical training was conducted online and relevant publications and information were identified. Evaluation was made on how these technologies could further enable digitalisation of training.

RESULTS

Overall, the quality of available studies was found to be low with current available evidence consisting largely of expert opinion, consensus statements and small qualitative studies. The review identified that there are several novel technologies already being utilised in robotic surgery training. There is also a trend towards standardised validated robotic training curricula. Currently, the majority of the validated curricula do not incorporate novel technologies and training is delivered with more traditional methods that includes centralisation of training services with wet laboratories that have access to cadavers and dedicated training robots.

CONCLUSIONS

Improvements to training standards and understanding performance data have good potential to significantly lower complications in patients. Digitalisation automates data collection and brings data together for analysis. Machine learning has potential to develop automated performance feedback for trainees. Digitalised training aims to build on the current gold standards and to further improve the 'continuum of training' by integrating PBP training, 3D-printed models, telementoring, telemetry and machine learning.

Effective Large Group Teaching for General Surgery

Large group settings display no signs of disappearing. Most surgeons charged with this education have received no formal training. Lecturing remains the most common method of educating large groups. Even though factors required for an excellent lecture are known, their inconsistent application results in variation of effectiveness. Long-standing principles of rhetoric and recent advances in neuroscience, cognitive science, learning models, and teaching theory play a role in achieving effectiveness. This article makes recommendations for creating and delivering lectures, including active learning opportunities and modern innovations in information technology supporting teaching methods. Effective lecturing skills are acquired by persistent deliberate practice.

Description and Validation of an Innovative and Effective Hand-Shaped Suture-Training Model for Medical Students

During medical education, medical students are often frustrated by difficulties in translating theoretical anatomical knowledge and basic surgical skills (suturing, tissue and instrument handling, and local anesthetic administration) into practice. A common etiological factor for this difficulty, among others, is lack of a low-cost and easy-to-assemble low fidelity suturing model. The purpose of this study is the demonstration of a validated, practical, inexpensive, hand-shaped anatomy training model. It is addressed to medical students and graduates that wish to get acquainted with neurovascular anatomy of the hand and improve their basic surgical skills. The model requires only two latex gloves, cotton, and two different color markers per trainee to draw the course of large nerve and vessels. Construction requires less than 15 minutes. For validation, 80 students participated as volunteers in the demonstration course. They evaluated course usefulness and their own confidence after the course. According to the 5-point Likert scale, the participants' confidence increased in a statistically significant way ( p < 0.05). All participants (100%) stated that their skills were "significantly improved" in terms of instrument handling, anatomy studying, performing digital anesthesia, and suturing technique. Overall experience was rated as "satisfactory" or above. The proposed model enables safe gentle soft-tissue handling, and it resembles a realistic human tissue. Low cost, availability, and fast construction are the most important characteristics, making this validated training model appropriate for acquiring fundamental local anesthesia, respect for hand neurovascular anatomy, and suturing skills.

Deliberate Practice in Simulation-Based Surgical Skills Training: A Scoping Review

BACKGROUND

In recent years there has been a shift from traditional Halstedian methods toward more simulation-based medical education (SBME) for developing surgical skills. Questions remain about the role and value of SBME, although feedback and engagement in repetitive practice have been associated with positive learning outcomes. Regardless of approach, the principles of deliberate practice align with both the Halstedian traditions and ways of implementing SBME. Whilst deliberate practice is well described in the wider literature, the extent to which it is an effective instructional approach in surgical training remains unknown.

OBJECTIVE

To explore the effectiveness of deliberate practice as an instructional design for developing surgical skills through SBME interventions, as assessed by improvements in trainee performance and/or patient outcomes.

METHODS

A combined search was conducted in PUBMED, CINAHL, EMBASE, MEDLINE, PSYCHINFO, and Google Scholar. Three hundred one articles were screened and 17 met the inclusion criteria for analysis.

RESULTS

There was heterogeneity of study methods with 6 randomized control trials, 7 pretest/post-test design, 2 nonrandomized comparisons and 2 observational studies. All articles demonstrated positive learner outcomes following SBME with deliberate practice, although there was no direct comparison to another instructional method. Two studies demonstrated skill transfer to the clinical environment and 1 demonstrated improved patient outcomes.

CONCLUSION

Deliberate practice informed SBME interventions appeared effective for developing surgical skills among trainee surgeons, however the reliability of these conclusions was limited by the modest quality of the research studies and the design elements of deliberate practice were inconsistently applied. There was little evidence that deliberate practice led to skills retention beyond 30 days, although participant numbers were low and the quality of studies was modest.

Deliberate practice and mastery learning in resuscitation education: A scoping review

STUDY AIM

To summarize the current state of knowledge of deliberate practice and mastery learning (DP and/or ML) as teaching methods for resuscitation education.

METHODS

A scoping review of PubMed, Scopus, and Embase was conducted through March 1, 2021. Studies examining the effect of the incorporation of either deliberate practice and/or mastery learning during resuscitation education were eligible for inclusion. Included studies were dichotomized into studies comparing deliberate practice and/or mastery learning to other training methods (randomized controlled trials) and studies examining before and after impact of deliberate practice and/or mastery learning alone (observational studies). Studies and findings were tabulated and summarized using the scoping review methodology published by Arksey and O'Malley.

RESULTS

63 published studies were screened; sixteen studies met all inclusion criteria (4 randomized controlled trials and 12 observational studies). One randomized controlled trial and eleven observational studies demonstrated improvement in skill and/or knowledge following educational interventions using deliberate practice and/or mastery learning. Significant variability between studies with regard to research designs, learner groups, comparators, and outcomes of interest made quantitative summarization of findings difficult.

CONCLUSIONS

The incorporation of deliberate practice and/or mastery learning in resuscitation education may be associated with improved educational outcomes and less skill decay than other educational methods. Current literature on DP and ML suffers from a lack of consistency in research methodology, subjects, and outcomes. Future research should employ uniform definitions for deliberate practice and mastery learning, follow research design that isolates its effect, and examine generalizable and translatable outcomes.

Skull Base Training and Mentorship

OBJECTIVE

To review teaching and mentoring techniques of experienced skull base surgeons and educators STUDY DESIGN:: Expert commentary.

SETTING

8th Quadrennial International Conference on vestibular schwannoma and other CPA tumors, panel on teaching, and mentoring.

MAIN OUTCOME MEASURES

Experiences and opinions of experienced skull base surgeons, both neurosurgeons and neurotologists, presented and discussed at the conference.

CONCLUSIONS

Obtaining surgical mastery is essential for the teachers of skull base surgery. Hard work and practice with immediate and constant feedback on performance is an essential component to success. Creating a patient-centered culture that encourages academic achievement is an accelerator for success of a training program. Both the mentor and the mentee must play an intentional and active role to maximize learning.

Reducing orthopaedic theatre exposure during the COVID-19 lockdown: does a shift towards virtual reality-based training offer a solution?

PerspectiveOrthopaedic training in the United Kingdom has changed little from the Halstedian apprenticeship model of graduated responsibility, with the mantra "see one, do one, teach one". Whilst still relevant in surgical teaching, the current and ongoing disruption to surgical training secondary to the coronavirus disease 2019 (COVID-19) outbreak highlights the need for alternative methods of experiential surgical learning, which allow for the development of the knowledge, skills, and attitudes of orthopaedic surgeons, to be sought.

Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study

OBJECTIVES

Diagnostic errors are pervasive in medicine and most often caused by clinical reasoning failures. Clinical presentations characterized by nonspecific symptoms with broad differential diagnoses (e.g., dizziness) are especially prone to such errors.

METHODS

We hypothesized that novice clinicians could achieve proficiency diagnosing dizziness by training with virtual patients (VPs). This was a prospective, quasi-experimental, pretest-posttest study (2019) at a single academic medical center. Internal medicine interns (intervention group) were compared to second/third year residents (control group). A case library of VPs with dizziness was developed from a clinical trial (AVERT-NCT02483429). The approach (VIPER - Virtual Interactive Practice to build Expertise using Real cases) consisted of brief lectures combined with 9 h of supervised deliberate practice. Residents were provided dizziness-related reading and teaching modules. Both groups completed pretests and posttests.

RESULTS

For interns (n=22) vs. residents (n=18), pretest median diagnostic accuracy did not differ (33% [IQR 18-46] vs. 31% [IQR 13-50], p=0.61) between groups, while posttest accuracy did (50% [IQR 42-67] vs. 20% [IQR 17-33], p=0.001). Pretest median appropriate imaging did not differ (33% [IQR 17-38] vs. 31% [IQR 13-38], p=0.89) between groups, while posttest appropriateness did (65% [IQR 52-74] vs. 25% [IQR 17-36], p<0.001).

CONCLUSIONS

Just 9 h of deliberate practice increased diagnostic skills (both accuracy and testing appropriateness) of medicine interns evaluating real-world dizziness 'in silico' more than ∼1.7 years of residency training. Applying condensed educational experiences such as VIPER across a broad range of common presentations could significantly enhance diagnostic education and translate to improved patient care.

A Minimal Theory of Creative Ability

Despite decades of extensive research on creativity, the field still combats psychometric problems when measuring individual differences in creative ability and people's potential to achieve real-world outcomes that are both original and useful. We think these seemingly technical issues have a conceptual origin. We therefore propose a minimal theory of creative ability (MTCA) to create a consistent conceptual theory to guide investigations of individual differences in creative ability. Building on robust theories and findings in creativity and individual differences research, our theory argues that creative ability, at a minimum, must include two facets: intelligence and expertise. So, the MTCA simply claims that whenever we do something creative, we use most of our cognitive abilities combined with relevant expertise to be creative. MTCA has important implications for creativity theory, measurement, and practice. However, the MTCA isn't necessarily true; it is a minimal theory. We discuss and reject several objections to the MTCA.

Competition-Based Success Factors During the Talent Pathway of Elite Male Swimmers

Marginal differences in race results between top swimmers have evoked the interest in competition-based success factors of long-term athlete development. To identify novel factors for the multi-dimensional model of talent development, the aim of the study was to investigate annual variation in competition performance (ACV), number of races per year, and age. Therefore, 45,398 race results of all male participants (n = 353) competing in individual events, i.e., butterfly, backstroke, breaststroke, freestyle, and individual medley, at the 2018 European Long-Course Swimming Championships (2018EC) were analyzed retrospectively for all 10 years prior to the championships with Pearson's correlation coefficient and multiple linear regression analysis. Higher ranked swimmers at the 2018EC showed significant medium correlations with a greater number of races per year and small but significant correlations with higher ACV in 10 and nine consecutive years, respectively, prior to the championships. Additionally, better swimmers were older than their lower ranked peers (r = −0.21, p < 0.001). Regression model explained a significant proportion of 2018EC ranking for 50 m (47%), 100 m (45%), 200 m (31%), and 400 m races (29%) but not for 800 and 1,500 m races with number of races having the largest effect followed by age and ACV. In conclusion, higher performance variation with results off the personal best in some races did not impair success at the season's main event and young competitors at international championships may benefit from success chances that increase with age. The higher number of races swum per year throughout the career of higher ranked swimmers may have provided learning opportunities and specific adaptations. Future studies should quantify these success factors in a multi-dimensional talent development model.

Variation in competition performance, number of races, and age: Long-term athlete development in elite female swimmers

While talent development and the contributing factors to success are hardly discussed among the experts in the field, the aim of the study was to investigate annual variation in competition performance (AVCP), number of races per year, and age, as potential success factors for international swimming competitions. Data from 40’277 long-course races, performed by all individual female starters (n = 253) at the 2018 European Swimming Championships (2018EC) for all 10 years prior to these championships, were analyzed. Relationships between 2018EC ranking and potential success factors, i.e., AVCP, number of races per year, and age, were determined using Pearson’s correlation coefficient and multiple linear regression analysis. While AVCP was not related to ranking, higher ranked swimmers at the 2018EC swam more races during each of the ten years prior to the championships (P < 0.001). Additionally, older athletes were more successful (r = -0.42, P < 0.001). The regression model explained highly significant proportions (P < 0.001) and 43%, 34%, 35%, 49% of total variance in the 2018EC ranking for 50m, 100m, 200m, and 400m races, respectively. As number of races per year (β = -0.29 –-0.40) had a significant effect on ranking of 50-400m races, and age (β = -0.40 –-0.61) showed a significant effect on ranking over all race distances, number of races per year and age may serve as success factors for international swimming competitions. The larger number of races swum by higher ranked female swimmers may have aided long-term athlete development regarding technical, physiological, and mental skill acquisitions. As older athletes were more successful, female swimmers under the age of peak performance, who did not reach semi-finals or finals, may increase their chances of success in following championships with increased experience.

Utilising an Accelerated Delphi Process to Develop Guidance and Protocols for Telepresence Applications in Remote Robotic Surgery Training

Context

The role of robot-assisted surgery continues to expand at a time when trainers and proctors have travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic.

Objective

To provide guidance on setting up and running an optimised telementoring service that can be integrated into current validated curricula. We define a standardised approach to training candidates in skill acquisition via telepresence technologies. We aim to describe an approach based on the current evidence and available technologies, and define the key elements within optimised telepresence services, by seeking consensus from an expert committee comprising key opinion leaders in training.

Evidence acquisition

This project was carried out in phases: a systematic review of the current literature, a teleconference meeting, and then an initial survey were conducted based on the current evidence and expert opinion, and sent to the committee. Twenty-four experts in training, including clinicians, academics, and industry, contributed to the Delphi process. An accelerated Delphi process underwent three rounds and was completed within 72 h. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement.

Evidence synthesis

There was 100% consensus regarding an urgent need for international agreement on guidance for optimised telepresence. Consensus was reached in multiple areas, including (1) infrastructure and functionality; (2) definitions and terminology; (3) protocols for training, communication, and safety issues; and (4) accountability including ethical and legal issues. The resulting formulated guidance showed good internal consistency among experts, with a Cronbach alpha of 0.90.

Conclusions

Using the Delphi methodology, we achieved international consensus among experts for development and content validation of optimised telepresence services for robotic surgery training. This guidance lays the foundation for launching telepresence services in robotic surgery. This guidance will require further validation.

Patient summary

Owing to travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic, development of remote training and support via telemedicine is becoming increasingly important. We report a key opinion leader consensus view on a standardised approach to telepresence.

Domain-Specificity of Educational and Learning Capital: A Study With Musical Talents

The Education and Learning Capital Approach (ELCA) has been widely used to investigate talent development. A research gap is the implicit consideration of the domain specificity of educational and learning capital. In an empirical study with 365 school students we investigated the domain specificity of the approach for the domains of school learning and learning to play a musical instrument. At the beginning of the school year, students filled out a version of the Questionnaire for Educational and Learning Capital (QELC) for both domains and also responded to other domain-related measures (self-efficacy, grades). Six weeks later, students filled out a learning diary for 1 week in which they reported their activities on an hourly basis and responded to questions concerning these activities. Based on the Sociotope Approach this procedure helped to identify times in which students actually practiced their musical instrument, times that students could potentially practice their musical instrument (objective action space), and times that students would be expected to practice their musical instrument (normative action space). Three hypotheses were tested and could be supported. First, the availability of educational and learning capital for school learning and learning an instrument differed. Second, a confirmatory factor analysis supported the factorial validity of the domain-specific capital measurements. Third, domain-congruent correlations were mostly higher than domain-incongruent correlations, i.e., the availability of educational and learning capital for school learning correlated more closely with variables related to school learning than with variables related to learning a musical instrument. Similarly, the availability of the capitals for learning a musical instrument correlated more closely with variables related to learning a musical instrument.

Limits of Neural Computation in Humans and Machines

Aicardi et al. (Ethical and social aspects of neurorobotics, Science and Engineering Ethics, 2020) look to neuroscience to mitigate the limitations of current robotics technology. They propose that robotics technology guided by neuroscience has the capacity to create intelligent robots that function with awareness and capacity for abstraction and reasoning. As neurorobotics extends the capability of robotics technology, it introduces new social and ethical concerns, in particular co-opting civilian applications for military use (dual-use), conflicts between industry and the academy (industry-academy partnerships), and data security (data governance). However, here we argue that empirical evidence has shown that human cognition is faulty; therefore there is not a clear motivation to build intelligent robots on a human model; representation of meaning in the brain is not well-understood; therefore neuro-robotics is limited; and to the extent that intelligent robots become a reality, the ethics of robot rights will be of central concern.

Fundamentals of Anorectal Technical Skills: A Concise Surgical Skills Course

INTRODUCTION

Anorectal diseases, among the most common surgical conditions, are underrepresented in medical training. The Fundamentals of Anorectal Technical Skills course was developed to provide cost-effective formal training in diagnosis of common anorectal conditions and in commonly performed anorectal procedures using the theories of deliberative practice and perceptual and adaptive learning.

MATERIALS AND METHODS

First- through third-year general surgery and internal medicine residents and third- and fourth-year medical students participated in a course consisting of didactic instruction and hands on skills stations. The course covered common anorectal conditions, including internal and external hemorrhoids, fissures, condylomata, abscesses, fistula-in-ano, rectal prolapse, pilonidal disease, pruritis ani, and anal and rectal cancer, as well as common procedures such as anoscopy, excision of thrombosed external hemorrhoids, banding of internal hemorrhoids, rigid proctoscopy, incision and drainage of an abscess, administration of local anesthesia, and reduction of rectal prolapse. Before the course, participants completed a questionnaire consisting of demographics; previous anorectal experience, as measured by procedural case volume; confidence diagnosing and treating anorectal conditions; and a clinical knowledge multiple-choice quiz. Immediately following the course, participants took an additional survey reassessing their confidence and testing their clinical knowledge. This study was granted an educational exception by the Institutional Review Board at Walter Reed National Military Medical Center.

RESULTS

Forty-three learners participated in this course. Forty-six percent of participants had not participated in any anorectal cases, 26% had participated in 1 to 5 cases, 17% had participated in 6 to 10 cases, 6% had been involved with 11 to15 cases, and 6% had been involved with more than 15 cases. For learners who had no prior experience, 1 to 5 prior cases, or 6 to 10 cases, there were statistically and educationally significant increases in confidence for all diagnoses and procedures. Additionally, there were statistically and educationally significant increases between pre-course and post-course quiz scores for learners who had no prior experience (7.8 ± 2.0 vs. 11.8 ± 2.5, P < 0.01, Cohen's d = 1.8) and for those who had only participated in 1 to 5 cases (11.0 ± 3.7 vs. 14.2 ± 2.0, P = 0.04, Cohen's d = 1.1). The changes in quiz scores for learners who previously had been involved with six or more cases were not statistically significant.

CONCLUSION

This course provides a cost-effective training that significantly boosts learners' confidence in diagnosis of common anorectal procedures and confidence in performance of common anorectal procedures, in addition to improving objectively measured anorectal clinical knowledge.

Transitions in the Careers of Competitive Swimmers: To Continue or Finish with Elite Sport?

An athletic career is a succession of stages and transitions (normative and non-normative), which may have decisive effects on either maintaining a satisfactory and/or successful course or deciding about premature career termination. The main purpose of this study was to identify differences between swimmers (M_age = 21.32, SD = 2.62) who after undergoing the transition from junior to senior level either: (a) continued their career hoping to improve their performance regardless of low success at the elite level—Group I; or (b) decided on premature athletic career termination—Group II. The criteria for inclusion included having undergone the transition from junior to senior level and having competed at elite level for at least a year (M = 4.14 years, SD = 1.74). The participants were administered a demographic survey and a structured interview. The results revealed differences in developmental stages. The exploration phase was longer (M_{Group I} = 5.8 yrs, SD = 2.04, M_{Group II} = 4.6 yrs, SD = 2.4; Z = −1.902, p = 0.057); the commitment phase was shorter (M_{Group I} = 3.6 yrs, SD = 1.3; M_{Group II} = 4.6 yrs, SD = 1.7; Z = −1.735, p = 0.083); the number of hours of structured practice were (M_{Group I} = 5975, SD = 2474; M_{Group II} = 7623, SD = 2660, Z = −1.928, p = 0.054); the number of perceived costs were (Group I = 22, Group II = 34; Z = −2.209, p = 0.0027); and the most often pointed benefits of a sporting career were (Group I—94% health & physical fitness; Group II—88% personal growth & life skills). Furthermore, essential inhibitors and facilitators of athletes’ development were identified. The findings of the study have practical applications for athletes, coaches, parents and sport psychology professionals. For instance, appropriate social support can help to prevent elite athletes’ premature career termination from professional sport during and after their normative transition from junior to senior level.

Is the Deliberate Practice View Defensible? A Review of Evidence and Discussion of Issues

The question of what explains individual differences in expertise within complex domains such as music, games, sports, science, and medicine is currently a major topic of interest in a diverse range of fields, including psychology, education, and sports science, to name just a few. Ericsson and colleagues' deliberate practice view is a highly influential perspective in the literature on expertise and expert performance-but is it viable as a testable scientific theory? Here, reviewing more than 25 years of Ericsson and colleagues' writings, we document critical inconsistencies in the definition of deliberate practice, along with apparent shifts in the standard for evidence concerning deliberate practice. We also consider the impact of these issues on progress in the field of expertise, focusing on the empirical testability and falsifiability of the deliberate practice view. We then discuss a multifactorial perspective on expertise, and how open science practices can accelerate progress in research guided by this perspective.

A Process Evaluation of a Performance Psychology Intervention for Transitioning Elite and Elite Musicians

The present study presents a process evaluation of a performance psychology intervention for transitioning elite and elite musicians. The goal of the intervention was to provide participants with an amalgamation of evidence-informed principles, aimed to improve their quality of practice and performance preparation. The intervention consisted of an educational session followed by four workshops. In total, eight transitioning elite and seven elite musicians participated. Process measures included quantitative and qualitative workshop evaluations, monitoring logs, and semi-structured interviews. Overall, the intervention was evaluated positively by the participants. However, differences were present between the groups, with the elite musicians typically evaluating the intervention more favorably compared to the transitioning elites. Specific positive outcomes included an increased awareness and re-examining of current practice strategies, more structured and goal-directed practice, increased practice efficiency and focus, a more proactive approach to performances, and increased attention for the physical aspects of playing. Moreover, a number of contextual considerations and implementation challenges became evident. Important implications for performance psychology interventions and practitioners in music are discussed.

Given that the detailed original criteria for deliberate practice have not changed, could the understanding of this complex concept have improved over time? A response to Macnamara and Hambrick (2020)

In their commentary, Macnamara and Hambrick (Psychol Res, 2017) accused my colleagues and me of systematically changing the definition of the concept of deliberate practice. Deliberate practice was the result of a search for characteristics of effective practice in the laboratory that was shown to improve expert professional performance in domains, such as music. In this reply, I will first describe five different criteria that defined the original concept of deliberate practice and each of them is presented with directly supporting quotes from Ericsson, Krampe, and Tesch-Römer (Psychol Rev 100:396–406, 10.1037/0033-295X.87.3.215, 1993) paper. Unfortunately, Macnamara, Hambrick, and Oswald (Psychol Sci 25:1608–1618, 10.1177/0956797614535810, 2014) misinterpreted our concept of deliberate practice, and defined it much more broadly: “as engagement in structured activities created specifically to improve performance in a domain” (p. 914). This definition led them to include activities, such as attending lectures, studying alone by students, and group activities led by a coach, where each activity does not meet one or more of our criteria for deliberate practice. In this commentary, I will argue that Macnamara and Hambrick (2020) became aware of some of the original criteria for deliberate practice, such as the role of individualized training by a teacher, and these discoveries misled them to assume that we had changed our definition. The intended meaning of sentences that Macnamara and Hambrick (2020) had carefully selected is shown to have an appropriate interpretation in Standard English that is consistent with our original definition of deliberate practice. In conclusion, I will give a proposal for how the different perspectives can be reconciled.

Standardizing education in interventional pulmonology in the midst of technological change

Interventional pulmonology (IP) is a maturing subspecialty of pulmonary medicine. The robust innovation in technology demands standardization in IP training with both disease and technology driven training. Simulation based training should be considered a part of IP training as seen in other procedural and surgical subspecialties. Procedure volume is a component of training; however, this does not guarantee or translate into competency for learners. Basic competency skills can be assessed using standardized well validated assessment tools designed for various IP procedures including flexible bronchoscopy, endobronchial ultrasound guided transbronchial needle aspiration (EBUS TBNA), rigid bronchoscopy and chest tube placement; however, further work is needed to validate tools in all procedures as new technologies are introduced beyond fellowship training. Currently there are at least 39 IP fellowship programs in the United States (US) and Canada which has led to improved training by accreditation of programs who meet rigorous requirements of standardized curriculum and procedural volume. The challenge is to be innovative in how we teach globally with intention and how to best integrate new evolving technology training for those not only during fellowship training but also beyond fellowship training.

Towards a science of the acquisition of expert performance in sports: Clarifying the differences between deliberate practice and other types of practice

Ericsson, Krampe, and Tesch- Römer published their research on "The role of deliberate practice in the acquisition of expert performance" over 25 years ago. Since then, hundreds of new articles have been published with findings regarding the effects of practice on performance in sports. The original paper searched for conditions underpinning optimal acquisition of reproducibly superior (expert) performance in domains, where methods for producing such performance had been refined over centuries. At an elite music academy, superior music students were found to have engaged for longer periods in solitary practice guided by their music teachers - an explication of the conditions of this type of practice led to a definition of deliberate practice. When other researchers in sports started searching for optimal practice, they could not find any practice activities meeting all the criteria for "deliberate practice", yet referred to somewhat similar activities using that same term. This paper shows that the effects of these different types of practice activities on attained performance differ from those of deliberate practice and should be given different distinct names. The paper concludes with recommendations for how future research on purposeful and deliberate practice can inform, not just athletes and their coaches, but all adults about how their achievements can be improved with individualized forms of effective practice.