48. Skill Decay
High demand jobs (like fighter pilot, emergency medicine, trauma surgery, etc.) require continued exposure to the field of operations for maintenance of top level sharpness. In today’s episode we explore the phenomenon of skill decay and ways to mitigate its effects.
Guest Bio: Joshua Russell, MD is clinician, writer, and educator. Since completing residency training in Emergency Medicine, Dr. Russell has had a varied career including supervising PAs and NPs as a medical director for a regional Urgent Care network, contributing to various Hippo Education podcasts, and serving as the Editor-in-Chief of the Journal of Urgent Care Medicine (JUCM). Most recently, he has completed fellowship training in Hospice and Palliative Medicine at the University of Chicago Medical Center.
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The fact that skill decay sets in rather quickly following an absence from the emergency department [03:50];
When emergency providers return to work after a long vacation, medical leave, or sabbatical, it is the norm to feel rusty and out of practice. It doesn’t matter how many prior years of experience you had; nobody is immune to it.
Managing the complexities of an ED is not like ‘riding a bike’.
How motor skills, like riding a bike, decay much more slowly than cognitive skills [05:20];
Emergency medicine is a cognitively demanding pursuit. Effective clinical practice requires an enormous and varied base of knowledge integrated with a wide array of habits, behaviors, and communication strategies that allow us to evaluate and manage large numbers of patients seemingly simultaneously.
This is the typical scenario: It is 15 minutes into your shift and you have to manage a crashing infant, an impatient lawyer/patient who’s demanding antibiotics for a cough, a weak and dizzy elderly patient who may have a life threat (or nothing at all), and a consultant on the phone who’s refusing to help a patient.
We have to be efficient at problem solving and addressing all of these situations rapidly, while also being able to task switch quickly from one to the next. All the while, we have to make sure that we don’t miss anything dangerous. It’s not easy.
The principles behind skill decay: cognitive load theory and cognitive overload [07:66];
According to cognitive load theory, we have a limited amount of processing bandwidth at any given moment. Our working memory defines the maximum amount of tasks that we can simultaneously process. Most research suggests that only 5-9 tasks can be effectively processed by our working memory at any given time.
Cognitive load theory also suggests that when we exceed our working memory’s capacity, our performance immediately suffers. This is called cognitive overload.
With increasing practice and experience, any given task will take up less of our working memory’s overall capacity. When we are working often, the intellectual processes for a given situation will take up less of our overall cognitive bandwidth than if we are out of practice. Also, we are less likely to become cognitively overloaded.
Strategies for combating skill decay [09:30];
The surefire tactic is to simply work clinically as often as necessary to prevent skill decay. How often this is depends on the individual. Every clinician needs to answer this for themselves.
Given that competence with cognitive tasks reliably will decay within several months, what do you do if you have no choice but to take a prolonged break from work?
How we think is much more important than what we know. Listening to podcasts, reading, and going to conferences will help slow skill decay, but unfortunately the requisite medical knowledge is a relatively small part of the job.
Simulation of tasks can serve as a meaningful way of maintaining skill during a period of non-use. Refresher interventions such as airway courses can be helpful, though clinical emergency medicine is much more complex and unpredictable than any one simulation can recreate.
Proctoring is a reliable way to rebuild the necessary cognitive faculties we need to be an effective emergency physician.
Rob’s approach after a short absence which centered around visualization [12:50];
Step 1 -- Visualize resuscitations in the particular resuscitation bay in which he’ll be working. Work through in his mind complex procedures, such as intubations, chest tubes, and central lines.
Step 2 -- Visualize an actual resuscitation from the point of the patient coming in, to receiving report from the paramedics, to going through the primary/secondary surveys, to managing medications, to working the EMR, and to speaking with consultants.
Step 3 -- Visualize straightforward patients, such as lacerations, fractures, and headaches, and how he’s going to juggle it all.
Shownotes by Melissa Orman, MD
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