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How do you get to Carnegie Hall?

September 26, 2014

In case you have forgotten, dear reader, I used to be a violinist.  My oldest daughter has recently started piano lessons, and this has made me think back to my own musical training as I attempt to create in her the same love of music that I have.  In the course of my reading about learning and musical education I came across Daniel Coyle’s book The Talent Code.  In it he describes how accomplished, high performing people get the way they are.  He suggests that the key variable is what he calls “Deep Practice”.  This involves long hours of repeatedly coming up against technical difficulties, recognizing them, and learning how to deal with them.  It occurs to me that this idea is a useful framework for making training decisions that will result in happy nurse practitioners and doctors.

Medical students, at the end of training, are not really equipped to take care of people.  They have knowledge but not the practical application of that knowledge.  They must do the clinical training first, in a residency program.  This clinical training is intense and long.  It is designed to expose the young doctor to as many disease processes as possible, as repetitively as possible, so that the work of formulating a differential diagnosis becomes second nature and diagnostic and treatment decisions can be made with confidence when it is most important.  This requires thousands of hours.

Here is the parallel musical example.  When a violinist practices (clinical training) over time she is exposed to every technical difficulty (disease) she could possibly encounter, repeatedly, in multiple settings.  The goal of practice is to recognize the difficulty (diagnosis) and figure out ways to overcome it (treatment), so that she can perform with confidence when it is most important.  There is no way around this process, even if you are Itzhak Perlman.  It requires thousands of hours of deep practice.  This is also true of medicine.  There is no way around the time and training required to become a doctor.

A violinist who has been doing deep practice for three or four years has a solid training in the basics.  The violinist is qualified to play confidently pieces of music within her experience base.  She is not going to go play the Tchaikovsky concerto or audition for the New York Philharmonic.  She is not qualified to do so, nor would she want to. This does not make her less intelligent or less gifted than a more advanced player.  Knowing the basics is a great foundation upon which to build a lifelong love of music.  If she did want to play for the New York Philharmonic she would have to devote more years and specialized training at the conservatory level to become adequately qualified.

The nurse practitioner, at the end of her training, has 500-600 hours of clinical experience specific to the role of the NP.  She is qualified to confidently diagnose and treat basic problems.  This does not make her less intelligent or less able than a doctor.  She is not qualified to diagnose and treat complex medical issues, nor does she want to.  She has a great foundation upon which to build relationships with patients and with medicine for lifelong professional satisfaction.  If she wants to diagnose and treat complex problems, she has to go to medical school.

Happy nurse practitioners are happy because they have solid training in the basics and like to work at that level.  Unhappy nurse practitioners wish they were playing for the New York Philharmonic.

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