Good: Better: Best: How do we climb the ladder.
I have spent the past week thinking about and engaging in post graduate education which is something, contrary to the appearance of most of my cases, that I do quite a bit. I have also been reading about how I can go about improving my skill set.
Normally in my house self-help books get demoted to the downstairs toilet and are read one poo at a time (too much information?) but occasionally you find a gem of book that is devoured in one sitting (not on the toilet obviously) and then earns a re-read with lots of scribbled notes. “Peak; how all of us can achieve extraordinary things” by Anders Ericsson is just such a book and it has made me re-evaluate my approach to learning and how it is going to develop over what remains of my career.
Peak makes it clear that the short and unavoidable truth about improving our skills is that there is only one way to predictably do it: deliberate practice. Ericsson has spent the past 30 years researching this topic and he is quite clear on this point; if we want to get better “ the right sort of practice carried out over a sufficient period of time leads to improvement. Nothing else” He is equally clear in his statement that “nobody develops extraordinary abilities without putting in tremendous amounts of practice”
If we want to improve any particular skill that you care to think of then we need to get outside our comfort zone in a focused way, with clears goals, a plan for reaching those goals and a way to monitor our progress. Oh and figure out a way to maintain our motivation. (interestingly Ericsson notes that he has found it “surprisingly rare to get clear evidence in any field that a person has reached some immutable limit on performance. Instead, I’ve found that people more often just give up and stop trying to improve”).
The sort of practice that Ericsson is talking about is highly focused and needs constant feedback. It is about putting a series of baby steps together to reach a longer-term goal. It requires teachers who understand what must go into successful training regimes and must be able to modify these to suit students of differing experience and training.
Deliberate practice like that described in this book involves well-defined, specific goals aimed at improving certain aspect of the target performance; it is not aimed at some vague overall improvement.
Now when we read the description of this type of skill development does dental postgraduate education immediately spring to mind as a glowing example of it? No, I rather think it does not, well not in the UK at least.
And this is not too surprising. Research into medical training shows that we have a huge bias to building “knowledge” rather than building “skills”. This again is not too surprising; it is vastly cheaper to “train” doctors and dentists by sitting them 100 at a time in a lecture hall than it is to sit them in small groups with highly skilled operators and educators who can monitor individuals as they repeatedly perform multiple steps along a pathway to developing a particular skill.
Of course, knowledge is needed, within reason, but when we make the mistake of valuing knowledge over skills or assume that if we gain enough knowledge the skills will magically evolve, spontaneously, from this fog of partially hidden ignorance then we are putting our patients at risk and doing them a great disservice.
When Nassim Nicholas Taleb talks about “empirical arrogance” in his excellent book “Black Swan” he is referring to the blind spot that our faith in knowledge will leave us with: it will hide from us the vast ocean of “un-knowledge” that we are totally unaware of and, worse, do not realise we are cast adrift in.
A post graduate industry that provides us an unending banquet of lectures and conferences with the occasional crumb of a hands on course is actually de-skilling us and making us perform worse not better. Ericsson reports that out of 62 studies looking at how doctors improve with experience only 2 showed that they actually do; the rest showed that they stayed the same or got worse.
Again, this is no surprise – if we spend 25 years on auto-pilot mindlessly repeating the same tasks we will get worse at them not better. If mindless repetition of a task improved our skills then our patients, who practice toothbrushing 2 minutes twice a day for decades would be world class at it; which from my observations at least, is not usually the case.
So, if lectures are not going to develop our skills what is? How can I become a more technically skilled dentist and how can I improve my patient outcome? (Assuming I am working on skills that actually do this)
Well the first thing I must do is identify the skills that I am looking to improve (for this I need to know what it is that I don’t know- a skill in itself).
Next, I need to identify those individuals who are performing this skill at a level that I wish to attain and then see if they have well-structured program that will help me learn from them; going to watch them lecture will not be enough and may actually make me worse.
Remember: a one or two-day hands on course will not significantly improve my skills or patient outcomes; at best it will identify my deficiencies and show me where the start of my journey is. Without a structured program of deliberate practice which focuses on particular aspects of these skills and works to improve them specifically, over time with a step-by -step feedback drive approach then I will not get better; I will simply deskill back to where I was the moment my auto-pilot kicks back in on Monday morning.
It is also worth remembering that when we watch the lecturer cut a wonderful crown prep or carve out a perfect composite filling on those models this is not the first or second time they have done this, it is the 1000th time they have. Buying the composite being used on the course will NOT make my work look like theirs but focused, repeated practice will.
The next aspect to gaining a new skill involves ditching three very well-worn myths about learning and ability. Ericsson lists these as
• The belief that my abilities are limited by some genetic prescribed characteristic or that other’s are a sign of pure natural ability.
• The belief that if I do something often enough I will get better at it. This doesn’t work for patient’s toothbrushing and it doesn’t work with our crown preparations-we just get quicker and more adept at cutting corners.
• The belief that if I just try hard enough I will get better; I won’t. If I am not getting better, it is because I am not practicing the right way.
Finally, I need to practice, practice, practice. I can do this on extracted teeth, plastic models, pigs jaws, whatever works but the key to this practice is that I focus on my task, push myself out of my comfort zone and receive meaningful constructive feedback from individuals I have recognized as being highly skilled at these tasks.
Sites like RIPE offer a great opportunity for this sort of feedback but the best of all is personalised mentorship which is probably the gold standard when learning a new skill.
Aristotle said it first when he said “we are what we repeatedly do; excellence therefor is a habit not an act”. My uncharacteristically succinct version of this is “we are the product of our practice”.
This post is dedicated to Dhru Shah who is doing more to improve dental education in the UK than any other single individual and who inspires me every time that I meet with him.