By: Gabriele Wulf, Charles Shea & Rebecca Lewthwaite
Motor skills are an essential component of the expertise displayed by, and required of, individuals working in medicine or other health professions. How these skills are taught and practiced has changed considerably over the past few years. For example, with the advancement of technological capabilities, training in surgical skills now makes increasing use of virtual-reality simulation1 and computer-based video instruction.2 Although some studies have found that additional virtual-reality training can facilitate the transfer of skills to the operating room,3 others did not find any beneficial effect of prior virtual-reality training on surgical performance.4 Furthermore, the effectiveness of simulation compared with other methods of medical training has been questioned.5 Some have made suggestions for enhancing the usefulness of simulator training by combining it with instructional techniques that adhere to learning ‘principles’.6 Yet not all such principles have stood the test of time, as we will argue in this review. More recent findings question some of the traditional assumptions regarding learning. Some studies examining factors that have been shown to facilitate learning in the cognitive or motor domain, such as the use of repeated testing7 or summary feedback,2 have already demonstrated their utility for medical training. Other researchers have begun to compare the effectiveness of different practice schedules in the learning of surgical tasks.8
The results of these studies are promising. In this review, we highlight some relatively recent findings (i.e. from the past 10 years or so) that we believe also have potentially important implications for medical education. Specifically, we review studies related to observational learning, learners’ focus of attention, feedback and self-controlled practice. These factors have consistently been shown to affect skill learning. We argue that the effectiveness of certain practice conditions or instructions is, to alarge extent, the result of optimised motivational states of the learner. The role of motivation in learning has, until recently, been largely neglected in the motor learning literature. Consideration of these newer findings in designing procedures for medical training has the potential to enhance performance effectiveness and training efficiency. First, however, we address the distinction between performance and learning, which has important implications for the interpretation of findings and the design of studies.
LEARNING VERSUS PERFORMANCE
Training in the medical field is expensive. Therefore, finding effective and efficient training methods that can result in cost savings is a legitimate and important motive for many researchers. An intuitive approach might be to compare different practice methods in terms of the time needed by participants to reach a predefined level of performance.9,10 Such an approach has significant shortcomings, however. It can only demonstrate how performance is influenced by certain training methods, which may, or may not, have anything to do with how much was learned.
Learning is typically defined as a relatively permanent change in a person’s capability to perform a skill.11 Therefore, researchers use retention or transfer tests (the latter involve a variation of what was practised) that are performed after a certain time interval (i.e. at least 1 day, but sometimes several days or even weeks). The purpose of this interval is to allow any temporary performance-enhancing effects (such as caused by greater guidance) or performance-degrading effects (such as caused by increased fatigue) that certain practice conditions may have created to dissipate, leaving only the relatively permanent, or learning, effects. Another important aspect of retention or transfer tests is that all groups perform under the same conditions (e.g. without feedback or demonstrations).
Only then can the performance of different groups be compared on a level playing field, so that conclusions can be drawn about the effectiveness of different practice methods for learning. In fact, it is not uncommon for practice conditions that facilitate (or prop up) performance during practice to result in less effective learning, and vice versa.11 Thus, one cannot infer that the most rapid change in performance, or achievement of criterion performance – under practice conditions in which feedback, modelling or other interventions are still present – constitutes true learning in the sense of retained or generalisable skill or knowledge. Clearly, as in other areas, the goal of training in the medical field is not to facilitate performance during practice, but to enhance the learning and transferability of clinical skills. In the following sections, we review variables that have been shown to affect learning.