The greats weren't great cos at birth they could paint. The greats were great cos they painted a lot

I was first introduced to this video by our medical director and anaesthetist Matt Matton-Howarth during the airway session in one of our PHTLS courses. I have watched it several times since because although it is a brilliant lecture on the psychology of airway management its true value (I believe) lies in a far greater context, namely how do we achieve competence?

Competence requires deliberate practice within an appropriate educational framework. The key is not only that the learner have the opportunity to practice but also receive timely feedback as an essential component of the exercise. This practice should be "effortful" meaning that the student practices under increasingly stressful and challenging situations that mirror reality. This is where simulation training becomes essential. Skills need to be forged in challenging and difficult scenarios under simulated conditions.

Malcolm Gladwell in his book "Outliers" infers that it takes about 10,000 hours or roughly 10 years to become achieve expertise in a skill. Once deliberately attained the skill level needs to be maintained through "effortful" practise over time or it will degrade. If we look at other professional groups such as musicians, professional athletes and fighter pilots they spend upwards of 90% of their time practising and less than 10% of their time performing. Interestingly in medicine we do completely the opposite.

In order for practise to be meaningful it must be deliberate. The sensory information the learner experiences including smells, temperature and sounds in the room, the auditory alerts of the equipment all need to be present for the practise to have value in maintaining the skill. Feedback should be frank and honest. Being unsuccessful in practising a skill should be explored and the reasons for failure sought and corrected. To be unsuccessful is one thing. To be unsuccessful without knowing why is not only wasted time but can be detrimental to the learner. We need knowledge of results in order to grow.

All of this "effortful practise" needs to be set in an appropriate context. That is the external environment. We at EMTG have the tools including 2 simulation suites where we can manipulate the ambient noise, temperature, smell and location to suite the learner's needs (please take a look at our gallery) as well as utilising the life-like manikins and ALSi monitoring devices. By repeatedly placing the learner into these simulated environments they can learn to handle their own internal environments and perform better under stressful yet challenging conditions while remaining completely safe themselves.

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