Introduction

Good professional conduct in medicine, as reflected in the requirements of good medical practice (General Medical Council 2009), the principles of medical ethics (American Medical Association 2009), and the oath taken by medical graduates (e.g., Royal Dutch Medical Association (KNMG) 2003), includes the responsibility of physicians to continue learning and keep their knowledge and skills up to date in order to provide competent patient care. To maintain professional expertise, physicians need to incorporate new developments in their field as regards the diagnosis and treatment of patients and learn from their experiences in clinical practice. It has been argued that this requires deliberate practice, i.e., a focused effort to develop performance aspects that need improvement (Ericsson 2004). However, it is not obvious whether physicians invest time in deliberate practice when patient care demands their full attention. The present study explored how physicians learn in, from and for their daily work and how deliberate this learning process is.

Deliberate practice and workplace learning

Deliberate practice has mostly been studied in the domains of music, sports and chess (Ericsson 2006). Based on specific goals to improve performance, experts repetitively practise tasks that allow them to refine their knowledge and skills. They are usually supported by trainers and coaches who design structured practice activities aimed at performance improvement and provide informative feedback, and gradually learn to monitor, control and evaluate their performance, enabling high-quality independent practice. In introducing deliberate practice, Ericsson et al. (1993) argued that deliberate practice might be hard to realise in work settings. At work, people have to give their best performance in job-related tasks in a limited time-frame and usually cannot give much attention to finding and trying out new methods and procedures to accomplish these tasks. Although people might learn from the results they obtain and from feedback, the conditions for learning at work are regarded as far from optimal. Conscious efforts to counteract automaticity and to gain high-level control of performance are deemed necessary to go beyond routine behaviour and achieve real expertise (Ericsson 2004, 2006).

A review of the acquisition and maintenance of expert performance in medicine (Ericsson 2004) has shown that specialised training and immediate informative feedback provide the best conditions for performance improvement. Repetitive practice with representative tasks was found to be realised more often in perceptual diagnosis of abnormality (e.g., library of X-rays) and surgery (e.g., simulators) than in the diagnosis of patients. The lack of clear performance standards was identified as a major problem for building professional expertise in medicine. Work experiences that are thought to contribute to diagnostic reasoning include specialisation by seeing more patients with similar diseases, accurate feedback by using sophisticated diagnostic equipment, interaction with knowledgeable colleagues, involvement in teaching and supervision, and contribution to active research programmes. However, these assumptions have not been tested yet.

Only a few studies have examined deliberate practice in the workplace (Dunn and Shriner 1999; Sonnentag and Kleine 2000; Van de Wiel et al. 2004), relating to the fields of education, insurance and organisational consultancy. These studies looked for activities that are performed with the aim of learning or improving professional competence. The work-related activities identified as deliberate practice in these work settings included preparation, mental simulation, asking for feedback or advice, evaluation, reflection and updating activities. These activities are similar to key elements of self-regulated learning (Van de Wiel et al. 2004; Zimmerman 2006).

Self-regulation refers to self-generated thoughts, feelings and actions that are strategically planned and adapted to the attainment of personal goals (Zimmerman 2000, 2006). The process entails three interrelated phases, viz. before, during and after task performance, and relates to domain and personal knowledge. In the forethought phase, goals are set and strategies are planned. These may be adjusted in the performance phase, based on careful monitoring of task progress, the self and the context. For example, one could seek help when this is necessary to accomplish a task. In the reflection phase, the outcomes are evaluated and reflected upon to generate useful information for subsequent performance. When the explicit goal is to learn from task performance, learning is proactively planned and not merely reactively generated (Pintrich 2000). This focus on competence improvement is known as a mastery goal orientation (Pintrich 2000). In line with deliberate practice theory, a supportive environment, in which (regulatory) skills are taught, modelled, practised and evaluated, is regarded as crucial to achieve high-level performance (Ericsson 2006; Van de Wiel et al. 2004; Zimmerman 2000).

It can be concluded that from the perspective of deliberate practice and self-regulated learning, the processes of reflecting on work experiences and deliberately looking for situations and tasks that may contribute to professional development can be identified as key principles for workplace learning (Van de Wiel et al. 2004). According to the typology of non-formal learning proposed by Eraut (2000), these activities obviously go beyond the unintentional and unconscious implicit learning from experience, but may encompass the reactive learning that is triggered by specific events, and definitely coincides with the highest intentional level of deliberative learning in which learning is planned.

Learning in medical practice

The reflective and self-directed nature of learning in practice is also widely recognised in the context of medical education as an important aspect of the professional development of students, residents and practitioners (Duffy 2008; Epstein et al. 2008; Holmboe et al. 2005; Mann et al. 2009; Wyatt and Sullivan 2005). As life-long learners, physicians need these skills to solve problems they encounter when diagnosing and treating patients and to remedy weaknesses in their knowledge and skills as part of continuing medical education (Duffy 2008; Slotnick 1996). This allows them to expand their expertise deliberately, and go beyond the mere accumulation of experiences (Guest et al. 2001; Mylopoulos and Regehr 2007). This is stressed by deliberate practice theory as applied to medicine (Ericsson 2004), and has been addressed as such by several authors (Guest et al. 2001; Mamede and Schmidt 2004; Norman et al. 2006). Self-assessment of performance and learning needs is argued to play a critical role in advancing knowledge-based reasoning in clinical practice (Epstein et al. 2008; Eva and Regehr 2005, 2008).

The literature on physicians’ learning in clinical practice is dominated by theoretical work, analysing and prescribing what physicians should do, rather than describing what they actually do. Only a few empirical studies have focused on the way experienced physicians learn in practice (Mamede and Schmidt 2004; Sargeant et al. 2006; Slotnick 1999). Some more research is available on learning by residents (Hoffman and Donaldson 2004; Stok-Koch et al. 2007; Teunissen et al. 2007), who are trained while doing their job, and medical students who participate as clerks in clinical work (Deketelaere et al.2006; Dornan et al. 2007; Sheehan et al. 2005). These studies showed that learning in medical practice is very much embedded in work activities. Residents and physicians indicated that they learned from the patient cases they encountered and their cooperation with colleagues and other specialists in daily work routines (Hoffman and Donaldson 2004; Sargeant et al. 2006; Slotnick 1999; Stok-Koch et al. 2007; Teunissen et al. 2007). Slotnick (1999) found that learning was triggered by specific problems in patient care that needed immediate action and by general problems relating to gaps in knowledge and skills. The specific problems were solved by consulting directly available sources, such as colleagues and the literature, whereas the general problems were dealt with more deliberately by planning courses and independent study. This difference between on-the-spot learning and planned learning by goal-setting over time was also found by Sargeant et al. (2006) in a sample of highly competent family physicians. Issues that were found to influence learning were the type of patient cases dealt with, the tension between work load and the time available for teaching and learning, and the learning climate (Hoffman and Donaldson 2004; Stok-Koch et al. 2007).

The present study builds on these findings by questioning if and how physicians exploit learning opportunities in their daily work. In contrast to the previous studies, we reversed the starting point of examination by focusing on relevant work-related activities instead of directly asking for learning experiences and the factors that influence them. This method is based on deliberate practice research (Ericsson 2004, 2006), which investigates the involvement in relevant practice activities, including the underlying goals of this behaviour (Sonnentag and Kleine 2000; Van de Wiel et al. 2004). It has also been advocated for research into workplace learning, as it focuses on normal work situations and allows information on implicit learning to be collected (Eraut 2004). The present study therefore examined the activities physicians engage in during their work that might contribute to professional development, and the extent to which a deliberate effort for learning was made. We focused on the core competence of diagnosing and treating patients (Frank 2005) as the representative task. Because we wanted to study individual practices in detail, we used the method of semi-structured interviews. We interviewed both residents and experienced physicians in internal medicine to be able to identify differences in practice patterns and underlying goals.

The activities we looked at to determine whether respondents deliberately engaged in learning were derived from the theories of deliberate practice and self-regulated learning, and informed by research on workplace learning in medicine. Potential learning opportunities in practice arise when problems are experienced in diagnosing and treating patients. This may induce reflection and problem solving (Ericsson 2004; Slotnick 1999). Consultation with knowledgeable colleagues is a powerful strategy to solve these problems (Eraut 2007; Ericsson 2004; Van de Wiel et al. 2004). In these consultations,differences of opinion concerning patient care may also trigger further thinking and lead to substantiated changes in approach (Van den Bossche et al. 2006). Explaining things to others, as is done in teaching and supervision, also contributes to learning as it requires expressing knowledge and argumentation, and thus elaboration (Eraut 2007; Ericsson 2004; Van de Wiel et al. 2004). The role of feedback in learning is crucial to deliberate practice, as are the criteria set for performance (Ericsson 2004; Zimmerman 2006). Residents get feedback during supervision, but do physicians recognise and seek feedback in other ways, and what criteria do they use to evaluate their performance? Finally, we investigated involvement in specific updating activities, including compulsory continuing medical education and participation in research (Ericsson 2004; Van de Wiel et al. 2004).

Methods