Most of us have heard the phrase “practice makes perfect,” probably from a parent, coach, or teacher trying to emphasize the importance of practice in learning a particular skill. But does practice actually lead to improved performance? Not necessarily. Research conducted by psychologist Anders Ericsson, who has devoted his professional career to the study of expertise and expert performance, shows that not all practice makes perfect. He argues that a particular kind of practice—deliberate practice—leads to expertise. In other words, it’s not the duration (i.e., quantity) but the quality of practice that is important.

When most people practice, they focus on things they already know how to do. Conversely, deliberate practice focuses on things that you can’t do well. Ericsson’s research shows that his findings apply to every skill, including memorizing complex lists or playing chess, a musical instrument, or any sport. One of the requirements for deliberate practice is the need to receive immediate feedback against a clear standard. For example, a chess player can practice by comparing his moves with the published play of chess masters. If his move is different, he can find out what the expert saw and what he missed. When we teach our children basic math skills, we provide immediate feedback. Ericsson’s work shows that deliberate practice is often supervised by coaches or teachers. For example, elite athletes and musicians rely on coaches or teachers to tell them how they can improve their technique. As the athlete or musician advances, he must seek out more advanced coaches or teachers to challenge him and drive him to higher levels of performance. Honest feedback can be brutally honest and sometimes painful.

In the United States, we have this belief that high self-esteem leads to high achievement and that failure will traumatize our children and lower their self-esteem. Research shows that the opposite is true—children who understand that failure is necessary for learning actually perform better. For example, in the latest international comparison of math performance, eighth-grade students in the United States dropped in rank to 31st (out of 65 countries) worldwide but ranked first in self-judged mathematical ability. In other words, U.S. students did worse in math than their peers but felt better about themselves and their ability in math. If U.S. students already believe they are good in math, what is their motivation to improve?

Hard work, of course, is important. The student must be willing to spend hundreds and perhaps thousands of hours to improve performance. Ericsson’s research estimates that it requires 10,000 hours, or 10 years (20 hours per week x 500 weeks), of deliberate practice to achieve world-class performance. The proper mindset is also important. Mindset is the view you have of your own intelligence and abilities, and it affects the decisions you make about your learning, such as the effort you put forth, the risks you take, how you deal with failures and criticism, and how much of a challenge you are willing to accept.

Carol Dweck is a psychologist at Stanford who has devoted her career to the study of mindset. Her research shows that people have one of two mindsets: a “fixed mindset” or a “growth mindset.” People with fixed mindsets believe that intelligence is fixed. They believe that you are either naturally smart or talented in a given area or not; there is nothing you can do to improve in that area (“I’m just not good at that”). In fact, people with fixed mindsets believe that students who are smart or talented don’t have to work hard and that the need to work hard is evidence that he or she is not smart or talented. They tend to pursue only activities in which they are certain to excel and avoid experiences in which they may fail. In contrast, people with a growth mindset believe that intelligence grows as you add new knowledge and skills. They value hard work, learning, and challenges and see failure as a necessary step toward success. They see the brain like a muscle that gets stronger and works better the more it is exercised.

A great example of a person with the growth mindset is Warren Buffett, arguably the greatest investor alive today. Every year, thousands of people travel to Omaha to attend the Berkshire Hathaway Annual Shareholders Meeting. Usually held in early May, the meeting this year attracted almost 40,000 shareholders from all over the world. Many people come to see or hear Buffett, but others come to shop for goods or eat foods made by Berkshire Hathaway companies (e.g., Fruit of the Loom underwear, Brooks running shoes, Justin boots, Dairy Queen food, GEICO insurance, See’s Candies, Pampered Chef products). Buffet’s daily schedule contains few meetings—not what you would expect of the CEO of the fifth-largest U.S. company by market capitalization. How, then, does Warren spend his day? He reads. A lot. Warren started reading when he was very young. By age 10, Warren had read every book in the Omaha Public Library with the word “finance” in the title. Warren enjoys meeting with business school students, and he is sometimes asked for his secret to success. Buffett once held up stacks of paper and said he read “500 pages like this every day. That’s how knowledge builds up, like compound interest.” He went on to say that very few people are willing to do that consistently over a long period.

In his book Leading Change, John Kotter shows the power of compounded growth. Suppose you have two twin sisters, Fran and Janice, with the same intelligence, skills, and information at age 30. Fran grows her career-relevant skills and knowledge at a rate of 6%, whereas Janice grows at only 1% per year. The difference after 20 years is huge. If they each start with 100 units of career-related ability at age 30, Janice will have 122 units while Fran will have 321 units when they reach age 50!

What does this have to do with health care and ACCP? The published evidence is incomplete, but a systematic review shows that physician experience is not associated with quality of health care. In fact, about half of the studies reported decreasing performance with increasing years in practice. In an accompanying editorial, the authors discuss the implications of the review. For example, they write that “physicians must know the current evidence-based standards of care” and that “all physicians…must embrace the concepts behind maintenance of (board) certification.” These concepts suggest that high-quality health care performance requires years of deliberate practice with the help of mentors and coaches. Does the current U.S. pharmacy curriculum offer sufficient opportunities for deliberate practice to ensure that new graduates can provide high-quality direct patient care? The draft Accreditation Council for Pharmacy Education (ACPE) 2016 standards require that student pharmacists complete 1740 hours (300 introductory hours plus 1440 advanced hours) of experiential education. The student will spend many of those experiential hours without the close direct observation of a coach or mentor and without a standard of practice, two requirements of deliberate practice. Completion of a residency would more than double the number of hours of deliberate practice in a structured environment under the close supervision of experienced preceptors. That’s why ACCP calls for residency training and board certification as foundational qualifications in its Standards of Practice for Clinical Pharmacists (http://www.accp.com/standards). A clinical pharmacist who completes an accredited residency and is board certified has demonstrated competence consistent with the ACCP standards.

Finally, ACCP is a community of learners who exhibit Dweck’s “growth mindset.” ACCP has the highest percentage of residency-trained and board-certified members among the other pharmacy organizations. Almost two-thirds of members are board certified in a specialty recognized by the Board of Pharmacy Specialties, an impressive figure when you consider that board certification is not usually a condition for employment. ACCP members attend the Annual Meeting and expect to listen to high-level presentations given by experts. Early ACCP Annual Meetings were known for spirited discussions during oral presentations of original research. A criticism of some speakers at ACCP meetings, even when they are presenting cutting-edge data and perspectives, is that the level of their presentation is too low!

Thus, practice is important, if it involves quality practice. For that reason, I encourage you to read carefully the Standards of Practice document, which not only sets forth expectations for the clinical pharmacist’s qualifications, but also the process of care and other professional attributes and responsibilities. Share it with colleagues, students, and trainees. Use it as a metric to assess personal or institutional approaches to practice, education and training, and other professional pursuits. Let’s use the Standards and a “growth mindset” to advance and position clinical pharmacists to help patients “get the medications right.” In this case, practice can make perfect!

References:

• Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005;142:260-73.
• Doyle T, Zakrajsek T. Mindsets toward learning. Tomorrow’s Professor Newsletter. April 17, 2014.
• Dweck C. Mindset: the new psychology of success. New York: Random House, 2007.
• Ericsson KA, Prietula MJ, Cokely ET. The making of an expert. Harvard Business Review. July–August 2007.
• Lipman J. Why tough teachers get good results. Wall Street Journal. September 27, 2013.
• Weinberger SE, Duffy FD, Cassel CK. Practice makes perfect…or does it? Ann Intern Med 2005;142:302-3.