Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains

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Abstract
The factors that cause large individual differences in professional achievement are only partially understood. Nobody becomes an outstanding professional without experience, but extensive experience does not invariably lead people to become experts. When individuals are first introduced to a professional domain after completing their education, they are often overwhelmed and rely on help from others to accomplish their responsibilities. After months or years of experience, they attain an acceptable level of proficiency and are able to work independently. Although everyone in a given domain tends to improve with experience initially, some develop faster than others and continue to improve during ensuing years. These individuals are eventually recognized as experts and masters. In contrast, most professionals reach a stable, average level of performance within a relatively short time frame and maintain this mediocre status for the rest of their careers. The nature of the individual differences that cause the large variability in attained performance is still debated. The most common explanation is that achievement in a given domain is limited by innate factors that cannot be changed through experience and training; hence, limits of attainable performance are determined by one's basic endowments, such as abilities, mental capacities, and innate talents. Educators with this widely held view of professional development have focused on identifying and selecting students who possess the necessary innate talents that would allow them to reach expert levels with adequate experience. Therefore, the best schools and professional organizations nearly always rely on extensive testing and interviews to find the most talented applicants. This general view also explains age-related declines in professional achievement in terms of the inevitable reductions in general abilities and capacities believed to result from aging. In this article, I propose an alternative framework to account for individual differences in attained professional development, as well as many aspects of age-related decline. This framework is based on the assumption that acquisition of expert performance requires engagement in deliberate practice and that continued deliberate practice is necessary for maintenance of many types of professional performance. In order to contrast this alternative framework with the traditional view, I first describe the account based on innate talent. I then provide a brief review of the evidence on deliberate practice in the acquisition of expert performance in several performance domains, including music, chess, and sports. Finally, I review evidence from the acquisition and maintenance of expert performance in medicine and examine the role of deliberate practice in this domain. The traditional view of skill acquisition is based on the assumption that innate biological capacities limit the level of achievement that a person can attain. Sir Francis Galton is generally recognized for developing the scientific basis for this view in the 19th century. In his pioneering book, Hereditary Genius,1 he presented evidence that height and body size was determined genetically, and most importantly, he argued that similar innate mechanisms must determine mental capacities, stating: Now, if this be the case with stature, then it will be true too as regards every other physical feature—as circumference of head, size of brain, weight of grey matter, number of brain fibres, &c.; and thence, a step on which no physiologist will hesitate, as regards mental capacity [italics added].1, pp. 31–2 At the same time, Galton clearly acknowledged the effects of practice and the need for training to reach high levels of performance in any domain.