In part one of this series we looked at some of the barriers to learning procedures well in clinical medicine, and what you can do to overcome them.

In this article, I’ll briefly review some of the theories on how we learn. Why?

Because understanding how you learn will help you learn better.

How we learn skills

There are many complicated theories on how we learn motor skills. In general though, learners tend to progress through various stages from novice through to expert. However, while these stages conceptually make sense, they are much more difficult to define.

One model, proposed by Simpson and Harrow (1,2), involves a 5 stage progression. The journey begins with the guided response stage, where a learner is initially introduced to a skill and begins to mimic or reproduce it under direct guidance. As the learner gains some familiarity, they transition to the mechanism stage, marked by a more coordinated performance of the skill, though they may still break it down into steps in their heads.

Over time and with practice, the learner reaches the complex overt response stage, where they can perform the skill fluidly and efficiently without the need to consciously think about each step. As expertise grows further, the adaptation stage emerges, characterised by the learner's ability to modify and adapt the skill in response to unique or challenging situations.

Finally, in the originating stage, the learner achieves mastery, allowing them to create new patterns or methods related to the skill based on their deep understanding and experience.

This progression, from imitation to innovation, encapsulates the evolution of learning a skill and showcases the gradual transformation from a novice to an expert.

In another model by Dreyfus and Dreyfus (3), skill acquisition is characterised by five developmental stages. Starting with the Novice stage, learners begin with no prior experience, relying heavily on explicit rules to perform tasks. As they advance to the Advanced Beginner phase, they start recognising situational elements and move beyond strict rule-following. Progressing to the Competent stage, learners begin to efficiently plan, set goals, and prioritise tasks, developing a sense of responsibility for their actions.

By the time individuals reach the Proficient stage, they have garnered deep domain insights, allowing them to recognize patterns and make decisions based on a comprehensive view of situations. Their actions, though intuitive, may still require conscious thought in challenging scenarios. Ultimately, in the Expert phase, learners achieve a seamless mastery over the skill, predominantly relying on their intuition. Their vast experience allows them to operate fluidly, often transcending established norms, making them true masters of their domain.

How to learn skills in clinical practice

The "Learn, See, Practice, Prove, Do, Maintain" model (4) offers a structured approach to procedural skill acquisition (Kovacs). This model is divided into two distinct phases - the Cognitive Phase and the Psychomotor Phase.

Cognitive Phase

• Learn: At this stage, the focus is on acquiring the requisite cognitive knowledge. This can be achieved through didactic sessions, multimedia-based programs, or assigned readings.

  For example, when learning how to intubate a patient, the initial focus should be on the knowledge required to be able to perform this skill - understanding the anatomy of the airway, the indications and contraindications for intubation, and the general principles of the technique.

• See: Observing the procedure, either in-person or through virtual demonstrations such as video, offers a visual grasp of the skill. Witnessing experts perform can provide insights into nuances that textbooks might miss, and provides a benchmark of the skill you are trying to learn - you now know what you’re aiming to replicate.

Psychomotor Phase

The psychomotor phase represents the process of learning the physical and decision making actions required to perform the skill. During this phase, the learner tries the skill and learns from each attempt, in a cycle described by Adams :

In this cycle, learners perform an action, note the outcome, consider the process and understand the result. This cycle is heavily influenced by feedback, which enhances the learner’s knowledge of the result.

Over time, the source of feedback transitions from external to internal feedback. In the former, the learner has limited understanding of the process, and relies heavily on feedback from external sources such as a supervisor.

As time goes on, the learner develops a much stronger understanding of what they are trying to achieve. This allows the learner to calibrate their own performance, using both internal and external feedback, experimentation, and technique modifications from their own research.

• Practice: Deliberate practice emphasises the role of feedback in skill refinement. The increasing availability of simulation has made this phase significantly easier. Mannequins for example can be used to practice endotracheal tube insertion, focusing on technique under the tutelage of a supervisor.

• Prove: Before transitioning to real-life scenarios, it's important to demonstrate competency. Simulation-based assessments can offer a platform to prove your skills.

• Do: Once competency is proven, perform the procedure on patients under supervision. This phase bridges the gap between simulation and real-world application.

• Maintain: The challenge now is to maintain skills in the face of limited opportunities to practice. Continual rehearsal and staying updated with the latest guidelines ensure the maintenance of procedural skills.

Embracing a structured approach to learning, understanding the underlying theories of skill acquisition, and leveraging feedback can significantly enhance the learning curve for procedural skills. For junior doctors, it's imperative to be proactive, maintain detailed records, and continually seek opportunities to learn and practice. By integrating the "Learn, See, Practice, Prove, Do, Maintain" model into your learning regimen, you set the stage for a safe and proficient clinical practice.

References

1. Simpson E. The Classification of Educational Objectives in the Psychomotor Domain. Washington, DC: Gryphon House; 1972.

2. Harrow A. A Taxonomy of the Psychomotor Domain. New York, NY: David McKay; 1972:14–31.

3. Dreyfus S, Dreyfus H. A Five Stage Model of the Mental Activities Involved
   in Directed Skill Acquisition

4. Sawyer T, White M, Zaveri P et al. Learn, See, Practice, Prove, Do, Maintain : An evidence based pedagogical framework for procedure skill training in medicine. Acad Med. 2015;90:1025–1033.