During my career, I have heard persistent arguments regarding the aspects of training and education that differentiate various professionals within the health sciences. The most common differences cited are between physicians and nurse practitioners and physician assistants; however, vast differences exist among the entry-level training programs of many health-care professionals.
As a university professor, my research efforts have involved differentiating the aspects of professional development that result in the expert practitioner. This type of research calls upon a variety of modalities, including clinical simulation, to assess levels of actual performance in well-controlled environments.
Let me put something to rest: No studies, including my own, have demonstrated superior clinical performance of any one type of primary-care provider over another based upon a particular course of educational preparation.
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Traditional views of expertise tend to focus on the term of a person’s experience as a key factor to the development of clinical skill, as described by Patricia Benner, RN, PhD, in her 1984 book, From Novice to Expert: Excellence and Power in Clinical Nursing Practice (Prentice Hall). Yet surprisingly, some studies have shown a negative relationship between experience and clinical outcomes. For example, Choudhry and colleagues found that physicians who have been in practice longer may be at risk for providing lower-quality care (Ann Intern Med. 2005;142:260-273). This is the consequence of our overly quantitative view of experience; many health-care professionals fail to focus on its qualitative nature. Consider the case of health professionals who graduate, achieve licensure, and enter practice without continuing to enhance their knowledge and skills. They will find themselves lagging behind the current evidence base and will inevitably find their patients’ outcomes to be poorer than those of their more studious colleagues.
I have had the pleasure of working for the past five years with K. Anders Ericsson, PhD, a cognitive neuroscientist who has dedicated his life to establishing the factors associated with the development of expertise in multiple domains (www.psy.fsu.edu/faculty/ericsson.dp.html). His research has centered on a concept referred to as “deliberate practice”—deliberate, solitary, and sustained practice focused on improving one’s performance (Acad Med. 2004;79[10 Suppl]: S70-S81). In the context of clinical practice, this might involve such activities as maintaining a log of patient visits, seeking information regarding patient conditions and associated treatments, and then following up with patients in order to establish actual outcomes. The level of reflection associated with this form of practice is far greater than that required for practice that is based simply on protocol and on “getting the job done.”
We must all strive to engage in deliberate practice in order to refine our clinical skills. These efforts should span our entire careers rather than just the course of our entry-level professional education. NPs and PAs in particular must always hold themselves to the highest of standards in response to some who question our expertise. Does the fact that we are not physicians limit our learning and job performance over a career? Can we not continually advance our skill to levels that rival those of physicians as well as other providers? The evidence base says, resoundingly, that we can. We must simply decide, collectively and individually, to aspire to the highest standards and go the extra mile to engage in deliberate practice over the term of our careers.
