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Deliberate Practice in Medical Simulation

Editor: Tanna J. Boyer Updated: 5/1/2023 6:56:02 PM


You have likely heard the phrase practice makes perfect. Iterative phrases, such as practice makes permanent, and perfect practice makes perfect, may also be familiar. The nature versus nurture debate is also germane to this discussion relative to natural talent/ability versus what can be learned/acquired. In medical education, traditional methods of heavy didactics followed by short clerkships and electives emphasize knowledge acquisition over skills, as evidenced by the adage see one, do one, teach one. This approach implies virtually instantaneous mastery of new procedures and clinical skills with minimal if any, practice or instruction.

Methods of skill acquisition, professional development, and expert performance have long been studied and debated. K. Anders Ericcson introduced a descriptor for his perspective of how expertise, expert performance, and experts develop: deliberate practice (DP) is “when individuals engage in practice activities (which are, at least initially, designed by teachers and coaches) with full concentration on improving some specific aspect of performance.”[1] In addition to observable behaviors and technical skills, expert performers can verbalize their cognitive processes and mental imagery of the events.[2]

Ericcson and Smith empirically studied reproducible superior performance to investigate the underlying methods and mechanisms.[2] Ericsson and colleagues described five foundational elements necessary for instructors and learners to accomplish deliberate practice: (1) motivate the learners; (2) provide clearly defined learning objectives for specific tasks; (3) define precise, measurable metrics of performance; (4) engage in focused, repetitive practice of skills; and (5) deliver real-time, constructive, actionable feedback.[2][3] 

This method, employed in an iterative, active cycle to provide ample opportunities for gradual refinements of learner performance, has been shown to yield significant improvements in performance.[2][3] Deliberate practice has been studied in typists, professional violinists, master chess players, and various athletic sports, including baseball, darts, tennis, and gymnastics.[2] Ericsson et al. studied the deliberate practice in expert musicians, which led to the theory that 10,000 hours of practice are needed to achieve expert performance.[3] In recent years, deliberate practice has been applied to the practice of medicine and medical education, fields of nursing, and many allied health professions from pre-clinical studies through post-graduate training and even into continuing education for practitioners.


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In clinical training/practice, it is rare that opportunities for repetitive clinician-patient skills present in situ. Thus, simulation is an excellent method and learning environment to practice skills in repetition, then escalating difficulty, with an instructor/coach providing feedback, including time for reflections, and having low-stakes concerning medical errors and patient harm.[4] The technical and cognitive skills that are the learning objectives and assigned tasks are often not part of normal clinical practice but are fundamental micro-skills that improve some particular aspects of performance by modifying the control of behavior and thoughts relevant to situational factors and the environment.[5][4] Through empirical research, simulation-based medical education (SBEM) has demonstrated to (a) increase knowledge, (b) provide opportunities for practice, and (c) allow for formative and summative assessment.[3][5][4][6]

Curriculum Development

One useful framework is the SMART goals to create specific, measurable, achievable, realistic, and timely learning objectives. Development of assessments, learning activities, performance metrics, and learning outcomes may be guided by modification of SMART goals as the model does not fully apply to these elements. Setting learner expectations is key for both behavioral and cognitive outcomes. Alignment of assessments, which are ideally developed after learning objectives and before learning activities, supports congruency among these three instructional design elements. Formative assessment is embedded in the repeated practice with coaching/instruction and immediate feedback to the learner, preferably verbal in real-time.[7] Summative assessments should be developed to include behaviors/skills and knowledge, whether by written, computer-based testing, verbal, or direct and indirect observational methods.[8]

Learner motivation is an essential requirement for a well-designed, effective DP. Self-efficacy models list internal and external drivers, but of course, teachers can most readily affect learner motivation via external means. Summative assessments are rated highest, with explicitly established relevance as second (i.e., future summative assessment, required professional activity/skill, a prerequisite to other required skills). Applied skills, that is, skills which the learners anticipate to be valuable or necessary for clinical performance and patient care, rank higher than prerequisite skills. Level of importance may be influenced by teacher/coach selection with respect to their area of expertise (medical specialty/discipline), degree of expertise (years in practice), and near-peer level relationships as having a greater influence on learners than distant, often senior-level faculty. Also, some attention is necessary to delineate the skill hierarchy or degree of relevance; engaging learners in a discussion of their perception may inform the teacher as to the individual student zone of proximal development.[9]

Procedural Skills Assessment

Embedded within the premise of Ericsson's model of procedural skill acquisition is skill assessment. The model requires a coach to observe the practitioner's performance and provide immediate, actional, feedback to incorporate the feedback into the subsequent performance event. Thus, assessment during DP is formative as the goal is to improve performance. When performing a skill for a summative assessment with the intent to pass judgment on practitioner competency, unsatisfactory performance may prompt a course of remediation to include DP as a means by which the practitioner may practice the skill and improve until achieving competency. Documentation of performance is common via a checklist or rubric.

Continuing Education

Once a professional achieves an acceptable skill level, more experience does not, by itself, lead to improvements. “Deliberate efforts to improve one’s performance beyond its current level demands full concentration and often requires problem-solving and better methods of performing the tasks.”[2] This has lead to increased use of specialty-specific interventions, such as surgical skills coaching and hands-on training sessions for airway management and point of care ultrasound.[10][11][12]

Clinical Significance

The end goal of SBEM deliberate practice of technical and cognitive skills is for the transfer of those skills from simulation-based practice to clinical practice situations. Studies have shown deliberate practice to be effective in the performance of many clinical skills in the technical/procedural category: central venous catheter placement;[13][14][15] lumbar puncture;[16] spinal anesthesia;[17] tissue-based coronary surgery;[18] hemodialysis catheter insertion by nephrology fellows;[19] thoracentesis by internal medicine residents;[20] operative performance by surgical residents in obstetrics and gynecology,[21] otolaryngology,[22] and surgery[23][24][25][26][27]; anesthesiology training;[28][29] cricothyrotomy.[30]

Additional studies have supported DP use for teaching and learning skills which require a higher cognitive load (i.e., less likely to be automated as rote muscle memory) and some aspect of hands-on, such as point of care ultrasound (POCUS);[12][31] ultrasound guided regional anesthesia;[32] and team function dynamics during simulated pediatric resuscitation.[33]

Thus, SBEM deliberate practice can be used to acquire new skills, refresh on previously learned but seldom used skills, and continually improve via self-reflection and peer feedback.[34] The range of subject matter and audiences are vast and range from highly technical skills, such as neurosurgery, to soft skills in communication and self-assessment. Limits to utilizing simulation and deliberate practice in medical education are seemingly only within the mind of the course developer. 

Enhancing Healthcare Team Outcomes

So-called soft skills, including leadership, communication, and interpersonal skills, have been taught and learned via DP: standardized handoff communication for first-year residents;[35][36] cardiology course for internal medicine residents;[37] oral case presentation skills for medical students;[38] radiograph interpretation of pediatric residents;[39] debriefing with good judgment;[40][41] code team leadership skills for senior residents;[42] patient assessments by medical students;[43] and interns ordering blood products.[44]

By extrapolating the target audience from primary medical learners, several studies have included secondary audiences vital to medical education. For instance, a few studies utilized simulation and DP for training standardized patients and instructional facilitators.[45]



Ericsson KA, Nandagopal K, Roring RW. Toward a science of exceptional achievement: attaining superior performance through deliberate practice. Annals of the New York Academy of Sciences. 2009 Aug:1172():199-217. doi: 10.1196/annals.1393.001. Epub     [PubMed PMID: 19743555]


Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2008 Nov:15(11):988-94. doi: 10.1111/j.1553-2712.2008.00227.x. Epub 2008 Sep 5     [PubMed PMID: 18778378]

Level 3 (low-level) evidence


Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine : journal of the Association of American Medical Colleges. 2004 Oct:79(10 Suppl):S70-81     [PubMed PMID: 15383395]


Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical teacher. 2005 Jan:27(1):10-28     [PubMed PMID: 16147767]

Level 1 (high-level) evidence


Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Academic medicine : journal of the Association of American Medical Colleges. 2015 Nov:90(11):1471-86. doi: 10.1097/ACM.0000000000000939. Epub     [PubMed PMID: 26375267]

Level 3 (low-level) evidence


McGaghie WC. Research opportunities in simulation-based medical education using deliberate practice. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2008 Nov:15(11):995-1001. doi: 10.1111/j.1553-2712.2008.00246.x. Epub 2008 Sep 22     [PubMed PMID: 18811635]


Watling CJ, Ginsburg S. Assessment, feedback and the alchemy of learning. Medical education. 2019 Jan:53(1):76-85. doi: 10.1111/medu.13645. Epub 2018 Aug 2     [PubMed PMID: 30073692]


Prediger S, Schick K, Fincke F, Fürstenberg S, Oubaid V, Kadmon M, Berberat PO, Harendza S. Validation of a competence-based assessment of medical students' performance in the physician's role. BMC medical education. 2020 Jan 7:20(1):6. doi: 10.1186/s12909-019-1919-x. Epub 2020 Jan 7     [PubMed PMID: 31910843]

Level 1 (high-level) evidence


Sadideen H, Plonczak A, Saadeddin M, Kneebone R. How Educational Theory Can Inform the Training and Practice of Plastic Surgeons. Plastic and reconstructive surgery. Global open. 2018 Dec:6(12):e2042. doi: 10.1097/GOX.0000000000002042. Epub 2018 Dec 12     [PubMed PMID: 30656119]


Min H, Morales DR, Orgill D, Smink DS, Yule S. Systematic review of coaching to enhance surgeons' operative performance. Surgery. 2015 Nov:158(5):1168-91. doi: 10.1016/j.surg.2015.03.007. Epub 2015 May 5     [PubMed PMID: 25956742]

Level 1 (high-level) evidence


Baker PA, Weller JM, Greenland KB, Riley RH, Merry AF. Education in airway management. Anaesthesia. 2011 Dec:66 Suppl 2():101-11. doi: 10.1111/j.1365-2044.2011.06939.x. Epub     [PubMed PMID: 22074084]


Hayward M, Chan T, Healey A. Dedicated time for deliberate practice: one emergency medicine program's approach to point-of-care ultrasound (PoCUS) training. CJEM. 2015 Sep:17(5):558-61. doi: 10.1017/cem.2015.24. Epub 2015 Jun 1     [PubMed PMID: 26030268]


Aggarwal R, Darzi A. Technical-skills training in the 21st century. The New England journal of medicine. 2006 Dec 21:355(25):2695-6     [PubMed PMID: 17182997]


Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. Journal of hospital medicine. 2009 Sep:4(7):397-403. doi: 10.1002/jhm.468. Epub     [PubMed PMID: 19753568]

Level 2 (mid-level) evidence


Corvetto MA, Pedemonte JC, Varas D, Fuentes C, Altermatt FR. Simulation-based training program with deliberate practice for ultrasound-guided jugular central venous catheter placement. Acta anaesthesiologica Scandinavica. 2017 Oct:61(9):1184-1191. doi: 10.1111/aas.12937. Epub 2017 Jul 6     [PubMed PMID: 28685812]


Kessler DO, Auerbach M, Pusic M, Tunik MG, Foltin JC. A randomized trial of simulation-based deliberate practice for infant lumbar puncture skills. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2011 Aug:6(4):197-203. doi: 10.1097/SIH.0b013e318216bfc1. Epub     [PubMed PMID: 21527870]

Level 1 (high-level) evidence


Udani AD, Macario A, Nandagopal K, Tanaka MA, Tanaka PP. Simulation-based mastery learning with deliberate practice improves clinical performance in spinal anesthesia. Anesthesiology research and practice. 2014:2014():659160. doi: 10.1155/2014/659160. Epub 2014 Jul 16     [PubMed PMID: 25157263]


Nesbitt JC, St Julien J, Absi TS, Ahmad RM, Grogan EL, Balaguer JM, Lambright ES, Deppen SA, Wu H, Putnam JB. Tissue-based coronary surgery simulation: medical student deliberate practice can achieve equivalency to senior surgery residents. The Journal of thoracic and cardiovascular surgery. 2013 Jun:145(6):1453-8; discussion 1458-9. doi: 10.1016/j.jtcvs.2013.02.048. Epub 2013 Mar 15     [PubMed PMID: 23499474]

Level 3 (low-level) evidence


Barsuk JH, Ahya SN, Cohen ER, McGaghie WC, Wayne DB. Mastery learning of temporary hemodialysis catheter insertion by nephrology fellows using simulation technology and deliberate practice. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2009 Jul:54(1):70-6. doi: 10.1053/j.ajkd.2008.12.041. Epub 2009 Apr 19     [PubMed PMID: 19376620]


Wayne DB, Barsuk JH, O'Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. Journal of hospital medicine. 2008 Jan:3(1):48-54. doi: 10.1002/jhm.268. Epub     [PubMed PMID: 18257046]


Rackow BW, Solnik MJ, Tu FF, Senapati S, Pozolo KE, Du H. Deliberate practice improves obstetrics and gynecology residents' hysteroscopy skills. Journal of graduate medical education. 2012 Sep:4(3):329-34. doi: 10.4300/JGME-D-11-00077.1. Epub     [PubMed PMID: 23997877]


Ahmed A, Ahmad M, Stewart CM, Francis HW, Bhatti NI. Effect of distractions on operative performance and ability to multitask--a case for deliberate practice. The Laryngoscope. 2015 Apr:125(4):837-41. doi: 10.1002/lary.24856. Epub 2014 Jul 30     [PubMed PMID: 25073874]

Level 2 (mid-level) evidence


Palter VN, Grantcharov TP. Individualized deliberate practice on a virtual reality simulator improves technical performance of surgical novices in the operating room: a randomized controlled trial. Annals of surgery. 2014 Mar:259(3):443-8. doi: 10.1097/SLA.0000000000000254. Epub     [PubMed PMID: 24503910]

Level 1 (high-level) evidence


Marcus H, Vakharia V, Kirkman MA, Murphy M, Nandi D. Practice makes perfect? The role of simulation-based deliberate practice and script-based mental rehearsal in the acquisition and maintenance of operative neurosurgical skills. Neurosurgery. 2013 Jan:72 Suppl 1():124-30. doi: 10.1227/NEU.0b013e318270d010. Epub     [PubMed PMID: 23254801]


Hashimoto DA, Sirimanna P, Gomez ED, Beyer-Berjot L, Ericsson KA, Williams NN, Darzi A, Aggarwal R. Deliberate practice enhances quality of laparoscopic surgical performance in a randomized controlled trial: from arrested development to expert performance. Surgical endoscopy. 2015 Nov:29(11):3154-62. doi: 10.1007/s00464-014-4042-4. Epub 2014 Dec 25     [PubMed PMID: 25539697]

Level 3 (low-level) evidence


Dearani JA, Gold M, Leibovich BC, Ericsson KA, Khabbaz KR, Foley TA, Julsrud PR, Matsumoto JM, Daly RC. The role of imaging, deliberate practice, structure, and improvisation in approaching surgical perfection. The Journal of thoracic and cardiovascular surgery. 2017 Oct:154(4):1329-1336. doi: 10.1016/j.jtcvs.2017.04.045. Epub 2017 Apr 27     [PubMed PMID: 28554678]


McKendy KM, Watanabe Y, Bilgic E, Enani G, Munshi A, Lee L, Feldman LS, Fried GM, Vassiliou MC. Establishing meaningful benchmarks: the development of a formative feedback tool for advanced laparoscopic suturing. Surgical endoscopy. 2017 Dec:31(12):5057-5065. doi: 10.1007/s00464-017-5569-y. Epub 2017 Apr 25     [PubMed PMID: 28444495]


Hastings RH, Rickard TC. Deliberate practice for achieving and maintaining expertise in anesthesiology. Anesthesia and analgesia. 2015 Feb:120(2):449-59. doi: 10.1213/ANE.0000000000000526. Epub     [PubMed PMID: 25602455]


Bhatti NI, Ahmed A. Improving skills development in residency using a deliberate-practice and learner-centered model. The Laryngoscope. 2015 Oct:125 Suppl 8():S1-14. doi: 10.1002/lary.25434. Epub 2015 Jul 7     [PubMed PMID: 26154861]


Petrosoniak A, Ryzynski A, Lebovic G, Woolfrey K. Cricothyroidotomy In Situ Simulation Curriculum (CRIC Study): Training Residents for Rare Procedures. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2017 Apr:12(2):76-82. doi: 10.1097/SIH.0000000000000206. Epub     [PubMed PMID: 28704285]


McConnaughey S, Freeman R, Kim S, Sheehan F. Integrating Scaffolding and Deliberate Practice Into Focused Cardiac Ultrasound Training: A Simulator Curriculum. MedEdPORTAL : the journal of teaching and learning resources. 2018 Jan 19:14():10671. doi: 10.15766/mep_2374-8265.10671. Epub 2018 Jan 19     [PubMed PMID: 30800871]


Ahmed OMA, Azher I, Gallagher AG, Breslin DS, O'Donnell BD, Shorten GD. Deliberate practice using validated metrics improves skill acquisition in performance of ultrasound-guided peripheral nerve block in a simulated setting. Journal of clinical anesthesia. 2018 Aug:48():22-27. doi: 10.1016/j.jclinane.2018.04.015. Epub 2018 May 1     [PubMed PMID: 29727758]


Lemke DS, Fielder EK, Hsu DC, Doughty CB. Improved Team Performance During Pediatric Resuscitations After Rapid Cycle Deliberate Practice Compared With Traditional Debriefing: A Pilot Study. Pediatric emergency care. 2019 Jul:35(7):480-486. doi: 10.1097/PEC.0000000000000940. Epub     [PubMed PMID: 27741071]

Level 3 (low-level) evidence


Duvivier RJ, van Dalen J, Muijtjens AM, Moulaert VR, van der Vleuten CP, Scherpbier AJ. The role of deliberate practice in the acquisition of clinical skills. BMC medical education. 2011 Dec 6:11():101. doi: 10.1186/1472-6920-11-101. Epub 2011 Dec 6     [PubMed PMID: 22141427]

Level 2 (mid-level) evidence


Pukenas EW, Dodson G, Deal ER, Gratz I, Allen E, Burden AR. Simulation-based education with deliberate practice may improve intraoperative handoff skills: a pilot study. Journal of clinical anesthesia. 2014 Nov:26(7):530-8. doi: 10.1016/j.jclinane.2014.03.015. Epub 2014 Oct 27     [PubMed PMID: 25439416]

Level 3 (low-level) evidence


Sawatsky AP, Mikhael JR, Punatar AD, Nassar AA, Agrwal N. The effects of deliberate practice and feedback to teach standardized handoff communication on the knowledge, attitudes, and practices of first-year residents. Teaching and learning in medicine. 2013:25(4):279-84. doi: 10.1080/10401334.2013.827970. Epub     [PubMed PMID: 24112195]


Issenberg SB, McGaghie WC, Gordon DL, Symes S, Petrusa ER, Hart IR, Harden RM. Effectiveness of a cardiology review course for internal medicine residents using simulation technology and deliberate practice. Teaching and learning in medicine. 2002 Fall:14(4):223-8     [PubMed PMID: 12395483]


Heiman HL, Uchida T, Adams C, Butter J, Cohen E, Persell SD, Pribaz P, McGaghie WC, Martin GJ. E-learning and deliberate practice for oral case presentation skills: a randomized trial. Medical teacher. 2012:34(12):e820-6. doi: 10.3109/0142159X.2012.714879. Epub 2012 Aug 30     [PubMed PMID: 22934592]

Level 1 (high-level) evidence


Pusic M, Pecaric M, Boutis K. How much practice is enough? Using learning curves to assess the deliberate practice of radiograph interpretation. Academic medicine : journal of the Association of American Medical Colleges. 2011 Jun:86(6):731-6. doi: 10.1097/ACM.0b013e3182178c3c. Epub     [PubMed PMID: 21512374]

Level 2 (mid-level) evidence


Jeffers JM, Poling S. The development and implementation of a 12-month simulation-based learning curriculum for pediatric emergency medicine fellows utilizing debriefing with good judgment and rapid cycle deliberate practice. BMC medical education. 2019 Jan 15:19(1):22. doi: 10.1186/s12909-018-1417-6. Epub 2019 Jan 15     [PubMed PMID: 30646903]


Griswold S, Ponnuru S, Nishisaki A, Szyld D, Davenport M, Deutsch ES, Nadkarni V. The emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives. Pediatric clinics of North America. 2012 Dec:59(6):1329-40. doi: 10.1016/j.pcl.2012.09.004. Epub     [PubMed PMID: 23116529]


Burden AR, Pukenas EW, Deal ER, Coursin DB, Dodson GM, Staman GW, Gratz I, Torjman MC. Using Simulation Education With Deliberate Practice to Teach Leadership and Resource Management Skills to Senior Resident Code Leaders. Journal of graduate medical education. 2014 Sep:6(3):463-9. doi: 10.4300/JGME-D-13-00271.1. Epub     [PubMed PMID: 26279770]


Reid KJ, Dodds AE, McColl GJ. Medical students' deliberate practice of patient assessments. Medical teacher. 2013 Dec:35(12):1055-6. doi: 10.3109/0142159X.2013.805879. Epub 2013 Jun 28     [PubMed PMID: 23808761]

Level 3 (low-level) evidence


Joyce KM, Byrne D, O'Connor P, Lydon SM, Kerin MJ. An evaluation of the use of deliberate practice and simulation to train interns in requesting blood products. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2015 Apr:10(2):92-7. doi: 10.1097/SIH.0000000000000070. Epub     [PubMed PMID: 25710316]


Bond WF, Gonzalez HC, Funk AM, Fehr LS, McGarvey JS, Svendsen JD, Sawicki R. Deliberate Practice with Standardized Patient Actors and the Development of Formative Feedback for Advance Care Planning Facilitators. Journal of palliative medicine. 2017 Jun:20(6):631-637. doi: 10.1089/jpm.2016.0431. Epub 2017 Jan 13     [PubMed PMID: 28085541]