May 3, 2021
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.
This episode is in support of World Bicycle Relief -- delivering specially designed, locally
assembled, rugged bicycles for people in need. They’ve developed an
efficient, innovative, and scalable model to empower students,
health workers, and entrepreneurs in rural developing regions with
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The fact that skill decay sets
in rather quickly following an absence from the emergency
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
How motor skills, like riding a
bike, decay much more slowly than cognitive skills
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.
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.
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
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
Cognitive load theory also suggests that when we exceed
our working memory’s capacity, our performance immediately suffers.
This is called cognitive overload.
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
Strategies for combating skill
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
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?
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
Rob’s approach after a short
absence which centered around visualization [12:50];
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
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
-- Visualize straightforward patients, such as lacerations,
fractures, and headaches, and how he’s going to juggle it
Shownotes by Melissa Orman, MD