<![CDATA[Rapid Sequence - Blog]]>Sun, 05 Apr 2026 17:24:28 -0700Weebly<![CDATA[Peak - Deliberate Practice]]>Fri, 11 Mar 2022 21:34:01 GMThttp://www.rapidsequence.org.uk/blog/peak-deliberate-practicePicture
Another excellent recent read has been the book ”Peak”, by the late K. Anders Ericsson and Robert Poole. The book is essentially a reader-friendly summary of the work that Ericsson had done throughout his extensive career looking at what makes experts as good as they are. As such, it provides some fascinating insights into many aspects of human learning and development - some of which are quite surprising. It was just by luck that I had also recently read a review on this topic by Duncan Chambliss entitled “The Mundanity of Excellence”. There are some overlapping themes here and both of these pieces are well worth a read. This blog post will primarily focus on the book but I shall draw any parallels where relevant. ​

What's it About?

As already noted, the book is a joint work but focuses primarily on the lengthy career of research that Ericsson had spent looking into the theme of human excellence and it is narrated from his perspective. He brings together the key parts of this research and uses elaborate examples to make the lessons stand out. There is probably one key message that he is trying to convey - the route to excellence is almost entirely through deliberate practice. This is a very empowering and a slightly surprising conclusion when it becomes clear how singularly important this principle is. The myth of talent is effectively dismantled and replaced with the evidence of the profound adaptability of the human mind (and to a slightly lesser degree, body). ​

What are the key points?

Perhaps the most important opening point is to emphasise this concept of human adaptability. This can be clearly seen in the ongoing improvement in human abilities in almost every field of skill. World records are continuing to be broken to such an extent that the world records of just decades ago would barely qualify an athlete for the top flight competitions of today. This is not because we have physically changed or evolved but because our training has improved. Indeed, Ericsson does not see any examples of a field where there is evidence that we have reached the limits of human potential. Such barriers as were erected in the past (he gives the example of the 4-minute mile) look almost comically pessimistic when looked back on now. The reason for this is that we are a species that has incredible adaptability, especially when it comes to our neurology, and this is coupled with an ability to be self directed. This leads to the concept of practice and the transformative power of it.

However, Ericsson is quick to point out that not all practice is the same, a much misunderstood idea. The gold standard is deliberate practice, standing at the opposite end of the spectrum from naive practice, with purposeful practice between them. Naive practice is what a lot of people might confuse for practice; that is, time just spent doing an activity. Examples could be the time we spend driving a car or playing a sport socially. Because we put the time in it feels like we should be getting better, almost by default. Unfortunately, this is not the case. Indeed, there are certain examples of this where skill may actually deteriorate over time as we become lazy or develop bad habits. Instead, practice has to have some additional features to it to allow one to develop steadily over time. Purposeful practice is the next step along this dimension and is typified by some notable characteristics: there is a clearly defined goal in mind, there will be focused adjustments of the skill towards this goal, and there will be feedback about the effectiveness of such adjustments. Also, the difficulty of practice will be in a sweet spot of being beyond the comfort zone of the individual but still achievable. All these features will result in a steady improvement towards the desired goal. However, some domains are also amenable to what Ericsson terms “deliberate practice”- the most effective form of training. This is seen in some of the skills that have been around for a long time with a well established tradition of training, clear objective outcomes, a competitive drive amongst trainees and a cohort of trainers who were/are experts themselves. A good example of this could be ballet, or proficiency at a classical musical instrument. In deliberate practice, a skilled teacher will be able to guide the trainee through their training, in many ways similar to purposeful practice but with the benefit of their own deep rooted expertise of the domain to hone the appropriate exercises and feedback. 

Ericsson describes that the key underpinning reasons for the effectiveness of this training lies within the idea of mental representations. Experts are as good as they are because they have the best mental representations. These are the psychological models for the skill in question, and likely represent numerous models within models. Indeed, our limited working memory means that we can only hold a few models within our mental workspace at any one time. The expert has honed these models over years of practice to make them incredibly efficient as well as powerful. A tennis professional can integrate huge amounts of information about the flight of a ball, the position of himself and the opponent on the court, and the opponents abilities, all within the fraction of a second that the ball is crossing the court. An amateur may have to focus on making contact with the ball, think about his foot positioning and also be thinking about his opponent's court position - an amount of cognitive processing that one can not effectively process actively. Experts, in contrast, have excellent automatic processing of information that they are able to keep under close active review with their free cognitive bandwidth. 

One final crucial insight that Ericsson provides is the dismantling of the myth of talent. Ericsson describes his detailed exploration of this myth over his years of research. This has included a detailed look at the many prodigies that have been lauded through history, from Mozart through to world class athletes. Despite some of their incredible abilities, he still finds the same story behind their success. They have become so good after many years of intense practice within that field, with no examples that he can find of this not being the case. He does concede that there can be a genetic influence in some abilities, and these are the most clear in cases where physical attributes give a definite advantage (it’s hard to be a short basketball star). There may also be certain difficult to assess traits that would make someone more inclined towards effective deliberate practice (for instance, some genetic predisposition towards concentration or the like). However, whatever your starting genes, you cannot become an expert without putting in the hard work of repeated deliberate practice and it seems to be the practice that is the main determinator for the end result. This seems both empowering and a touch daunting. On one hand it hands us all the potential to become incredible at almost anything that we would wish to pursue. On the other hand it reminds us that this is a very challenging path to walk. Indeed, Ericsson deconstructs the notion that you can just put in the 10,000 hours of time that was popularised by Malcolm Gladwell on the topic. Instead this time (plus or minus a few thousand hours, depending on the expertise desired) has to be spent undertaking a high degree of cognitive effort that is usually at least a bit unpleasant to do. There is nothing passive about becoming an expert.

Final Thoughts

To summarise, this book provides an excellent review of the evidence behind becoming an expert. The formula for this is surprisingly straightforward. First, there might be some benefit to having a good genetic starting point but this will mostly not limit your ultimate final potential (with some physical exceptions). Secondly, you move towards your desired goal with a deliberate practice approach. This approach involves the support of an expert teacher who will help you identify key development goals, utilise exercises that will most effectively move towards these goals, and push you just the right distance from your comfort zone, all whilst providing focused feedback. After extensive time with this approach (many hours over many years) you will become an expert. Whilst some of the conclusions that Ericsson comes to are surprising (the myth of talent stands out to me) he argues his case powerfully and he clearly has a wealth of experience in trying to answer this question. Ultimately, I think his message is an empowering one as he reiterates how maleable our neurology is and how much potential control we have over it. You just need to be sure you know what you want to do before you set out to achieve it, as the path is definitely not an easy one. 
Thank you for reading and, as always, I would love to hear your thoughts on the topic.
Tom

Links & References

  1. K. A. Ericsson, R. Poole. Peak. Random House. 2016
  2. Chambliss, D. The Mundanity of Excellence. 1989. https://academics.hamilton.edu/documents/themundanityofexcellence.pdf
]]><![CDATA[Moonwalking With Einstein - The Memory Palace]]>Sun, 20 Feb 2022 20:33:23 GMThttp://www.rapidsequence.org.uk/blog/moonwalking-with-einstein-the-memory-palacePicture
Whilst I have been exploring the different approaches to educational theory there is a book that I have heard mentioned a few times. I think it was probably first highlighted to me in the “Learning how to Learn '' course from Barbara Oakley, and it was one of those that I had put away on my list of books that I would one day get around to (this is a very long and increasing list). Now, finally, we have crossed paths and the lessons from it seem particularly relevant to some of the other areas of learning theory that I have touched upon before. As such, I wanted to put some of my thoughts together and share them here. Let’s begin.

What's it about?

The book starts with the author, a writer called Joshua Foer, who is attending the US Memory Championships in order to write about it. Here he is able to witness the unique subculture of competitors who are able to memorise multiple decks of cards, recall long strings of random numbers and recite reams of poetry from memory. His interest is captured enough by what he sees to dive into the sport himself, perhaps driven by the desire to explore the assertions of many of the people he meets that “anyone can do it”. After a bit of encouragement from one of the competitors that he befriends, who becomes his coach, he begins his training to try and compete in the next US championships as a ‘mental athlete’. The book details his journey and provides a fascinating insight into some of the potential of the human mind. 

A major thread of the book is Foer analysing the role of memory through human history. Much of the techniques he learns and utilises were commonplace in the ancient world, where many of them are described. Indeed, the Rhetorica ad Herennium (https://penelope.uchicago.edu/Thayer/E/Roman/Texts/Rhetorica_ad_Herennium/home.html) is the classic text for mental athletes to start learning about some of these techniques. Some authors of antiquity felt that the techniques were so well known that they have commented in their own writings that they won't even waste paper recounting them. Even in more modern history ‘rote learning’ was a part of standard education that students were expected to undertake (often with unpleasant associations). Foer notes that the externalisation of memory through our technology has meant that this is now much less important. Firstly, writing made conservation of knowledge in a physical form possible, then the printing press made such information much more widely available. Finally, we now have the magic of the internet where there is the entire history of human knowledge just a few keystrokes away. The question therefore becomes, quite rightly, why bother to remember so much? Indeed, rote learning has become a taboo of modern education with the increasing recognition that it is the higher level information processing that is important rather than simple memorization of facts. The skills we now need are more related to the abilities to navigate this world of immeasurable external memory rather than the laborious process of creating precarious internal memories. 

Another part of his analysis was to explore the unusual cases of some people with incredible natural memory, and those with no memory. A famous case from the scientific literature is a journalist known as S who amazed psychologists with his near perfect ability to remember, such as recalling a sequence of numbers that he had been told just the once months previously. Interestingly, S was a synesthete, a condition where there is some degree of overlapping of the senses. As such, to him numbers had additional characteristics like shape and colour, which is probably highly relevant for his abilities (as well shall look at). In contrast, the patient EP had suffered from a case of HSV (herpes simplex virus) encephalitis that had left unusually symmetrical destruction of his medial temporal lobes, including both his hippocampal regions. The result was profound retrograde and anterograde amnesia; an inability to create new memories or recall old ones. Thus, he was stuck in time in a period in his early adulthood (where there was some memory preservation). It was interesting to note that he was still able to create some non-declarative memories (for instance, unconsciously navigate his neighbourhood) but not much more. The interesting point is how Foer highlights the converse interpretations of these conditions. Whilst we may envy the perfect memory of S, he notes how he was in some ways disabled by his condition. His ability to perform higher level processing was handicapped by his literal interpretation of the world. Because of the intense sensory interactions between concepts, abstract ideas were very hard for him to comprehend. Indeed, Foer notices that he was unable to really function as an effective journalist because of this. In contrast, whilst we may feel that EP was terribly unlucky because of his injury (and he certainly is in many ways) Foer also notes how contented he is. He comments that he may have actually achieved the Buddhist goal of being perfectly in the present moment, in his case because he has no other tense within which he can be. Both cases highlight the importance of having an effective memory and some of the ways that it could significantly affect our lives. By this point in the story Foer has been well and truly intrigued by the journey that he has started on and begun to get deeply engaged in developing the skills of professional mnemonists.

The Technique

So what are the techniques that Foer developed? The key part of understanding the techniques at play here are that we are already naturally incredible memorisers. The ‘problem’ is that much of our evolutionary development of this has been towards the visual and the spatial, helping as it did with our hunter-gather past. As such, the abstract world of words, numbers and concepts is pretty new to us. The simple trick that champion memorisers use is to translate the abstract into the visuospatial. Once in this format it is incredible how well it can be retained and recalled. As such, the memory palace is a technique that is frequently utilised. This involves creating a mental image of a real physical space that you know very well. You then place highly memorable images around this physical space, with the image-encoded representations of what you need to remember. And that is it. When you need to recall the information you start to mentally walk around your memory palace and look at all the different images that you stored there. It is incredible to note how much more memorable such visuospatial stuff is than just a simple list of words. This is termed elaborative encoding, translating something that has no great meaning to you into something with extensive connections that will make it much easier for you to retrieve it later. The specific approach using a physical space, as described above, is known as a memory palace, although there are other ways of employing such memory skills. 

There are, unsurprisingly, a number of pearls and pitfalls to this. The most obvious is to use techniques that make the images you choose more memorable. As has been noted for centuries, the more lewd and/or shocking such images are, the better that they stick. They have to be something out of the ordinary to capture your interest. Obviously they also need to be connected to the thing that you are trying to remember, and this is where a good degree of creativity needs to come in. This is harder for more abstract concepts, but can still be done. The most advanced mnemonists have come up with very advanced systems for memorising things such as numbers and cards. The person-action-object (PAO) system is one such technique for long numbers. Every double figure number (00 to 99) is given a very clear mental image of a person doing an action with an object. When it comes to remembering numbers, these can be combined. For instance, with a 6 digit number you take the person of the first two digits, the action of the second and the object of the third. This creates a unique image in your mind which can easily be translated back into a 6 digit number. This allows the ‘mental athletes’ to store huge lengths of numbers in their head, all encoded in such pictures. The obvious challenge is the preparatory effort to learn this new language of images; 99 unique PAO characters is no small undertaking, especially as they need to be known intimately. This is a major barrier to some of the higher level memory abilities, although not necessarily the underlying concept. Indeed, it is the clarity of visualisation that seems relevant and the connection that can be made to the desired learning material is a feature of creativity rather than effort. Admittedly the bespoke language of the mnemonists is a major advantage for their specific categories, but unless you are going to be memorising packs of cards or long random number lists then it probably is not that relevant.

Final Thoughts

Speaking of the relevance of this all, I finally wanted to turn my attention to what actually is the point of all of this messing about with memory palaces and other memorisation techniques? This is a question that Foer asks himself after he has gone on to win the US memory championships. When he reflects upon the benefits of all of his intensive training it looks like a bit of a mixed bag. His cognitive abilities had shown some improvements in some areas when tested in laboratory conditions (something undertaken in parallel to his training by Anders Ericsson) and he has clearly managed some pretty impressive feats of memory to be able to win the memory championships. However, he goes on to recount an anecdote where he had gone out to dinner and completely forgot that he had driven his car there, instead ending up getting the train back. This is a rather humorous thing for the US memory champion to be doing, raising the question about the broader applicability of his training. Indeed, Foer doesn’t seem to think that there are broad magical gains in memory from these skills that he has spent time developing. They are very effective but they are still laborious and it is just far easier to use the technology that we have at hand for externalising our memory. A caveat to this is the central point that memory still seems to play within our greater functionality. Many higher level cognitive skills involve the reappraisal and connection of key bits of information. This is true even of more ‘creative’ feats. As such, if we don’t have the points of reference, the underlying building blocks, then we will not be able to do this. Foer thinks that this is what retained memories are; anchors which we can build other learning upon and use for new creative and higher level thinking. Therefore, it is important that we don’t just try and externalise everything, otherwise we would lose a huge amount of our ability to problem solve and be creative. 

I do buy into this and think that there is some applicability to medicine. Admittedly, I am not sure whether the significant efforts that have been applied to be able to learn a pack of cards or a string of random numbers has any role, but the underlying principles seem relevant. Most of my retention of important facts has been achieved using a spaced repetition approach with only a single trial of a memory palace (the drug causes of anticholinergic syndrome, since you were wondering). My main concern is around the long term use of such techniques for practical use (as opposed to memory competitions). There seem to be a number of mnemonic tips that can be taken from here, the most obvious being to make learning highly visual and memorable, and even to try and add spatial significance if this is at all possible. I still don’t know how I might navigate a memory palace if I did want to store loads of information in this way. How would I know which room to look in for the differential diagnosis of one condition, or where to go to remember the treatment options for something else? As such, I think this is a skill that may remain purely within the realm of professional mental athletes. I will continue to reflect on ways to incorporate effective components into my regular spaced repetition, and will be increasing my home made drawings for new learning. The utilisation of real world information also seems likely to bring the visuo-spatial benefits, such as with real cases or well designed simulation. If new applications come to my attention I will try and flag them here, and please let me know if there are any uses that you think are highly valuable. I would still highly recommend the book as a read for some excellent insights into memory and learning overall, which is primarily what it is about. Foer has highlighted how our memories are actually pretty incredible and how we can probably all utilise them a bit better if we wish to. Perhaps this is the most important lesson we could take from this, especially when we are doubting our ability to remember enough exam material. Ultimately, it is probably a matter of what you want to achieve and how much effort you want to expend. I can’t imagine many of us want to become competitive mnemonists, but there are enough simple techniques to make our everyday functionality that little bit better. 
Thanks for reading.

Links & References

  1. Foer, J. Moonwalking with Einstein. Penguin. 2012. 
  2. Foer, J. Feats of memory anyone can do. TED. 2012. https://www.youtube.com/watch?v=U6PoUg7jXsA
  3. Rhetorica ad Herennium. https://penelope.uchicago.edu/Thayer/E/Roman/Texts/Rhetorica_ad_Herennium/home.html
  4. Farnam Street. Remembering more of everything: the memory palace. https://fs.blog/the-memory-palace/#:~:text=The%20memory%20palace%20technique%20is,your%20memories%20to%20recall%20them
  5. Art of Memory. How to build a memory palace. https://artofmemory.com/wiki/How_to_Build_a_Memory_Palace/
  6.  Oakley, B. Learning how to learn. Coursera. https://www.coursera.org/learn/learning-how-to-learn
]]><![CDATA[Micromastery]]>Thu, 13 May 2021 20:08:12 GMThttp://www.rapidsequence.org.uk/blog/micromasteryPicture
My ongoing interest in learning techniques has led me to the book “Micromastery” by Robert Twigger. This is a fascinating read which promotes a slightly different approach to learning than I have ever previously explored. He describes how the “mastery” of small and well defined skills can actually provide notable educational benefits that go beyond the sum of these component parts. As such, it is really more a book about an approach to life than it is about educational theory, but this definitely adds to the relevance rather than detracts from. Indeed, its pages contained some great ideas that I wanted to share with you here. So let’s dive in.

What is it about?

Twigger opens the book with an observation about a major theme in modern life: professionalism. That is, there has been an inexorable move towards greater complexity in all aspects of our life (in part due to our technological progress) and this has led to the rise of the “professional”. There is a need for a great degree of knowledge and experience is their domain and so the professional spends an increased amount of time acquiring this knowledge and the associated skills. Whilst clearly important, problems can arise from the impact that this has on being able to explore other domains. The associated culture directs people down this single path more and more, with time spent covering ‘unrelated’ topics almost seen as being wasted. If the domain you are working in is increasingly competitive and complex then clearly you need to put more and more of your focus within this area, right? 

No doubt there is some truth in this (you obviously do become a master of a subject through spending intensive time studying it) but there is less thought given to the opportunity costs of this. If you spend all your time doing this, what are you not spending your time doing? Twigger argues that we have evolved to be a “Jack of all trades” and that actually there may be some quite significant costs involved in being so narrow. He notes that there can often be a degree of boredom that sets in with one’s profession where it feels like there is something missing. People can feel incomplete. Whilst there is a clear benefit to becoming a master in a field, it seems a mistake to define yourself solely by this field. As well as seeming unnecessary and costly, Twigger makes some arguments that it may be suboptimal. 

Some examples he gives are around the clear benefits of polymathy - being skilled in multiple different domains. He notes that many of the greatest thinkers (he uses the examples of Leonardo da Vinci and a number of Nobel Prize laureates) had wide ranging interests. These could range from the scientific domains of maths and physics through to the ‘creative’ skills of drawing, playing music, acting and singing. He argues that, rather than being a distracting force, these disparate interests produced a degree of synergy. Skills learned through creative endeavours provided boosts to scientific pursuits and vice versa. In addition there are global benefits to having multiple domains of interest. If you are constantly exploring new areas then you are more likely to maintain your passion for learning in general. If you feel that you are a multifaceted individual then you are less likely to be unbalanced by challenges in your primary area. At least that is the idea.

What is a micromastery?

Twigger advocates the use of micromasteries as an answer to this challenge. A micromastery is a mini skill that has a strong degree of independence. That is, whilst it can often be a part of a large domain or skill set, it also stands just as well on its own. The example that he uses in the book is making an omelette. One might assume that this is a component of the wider domain of cooking but reflection on it shows that something like this requires no additional expertise as a cook. It is simple enough for a complete novice to start on and yet you can quickly develop a honing of the process that produces excellent results. You can fine tune the aspects such as time on the heat, temperature used, seasoning, method of mixing etc. He notes that this can be practised in isolation a number of times to fine tune the process and the result can be a delicious meal. But the understanding of cooking that arises from this single skill is then highly applicable. You can understand how the use of temperature can affect the cooking process, how different seasoning impacts on taste, how you can add novel ingredients to improve your recipe. In short, you have started to learn to cook. 

It can be seen that a micromastery has to have some important features that differentiate it from other things that we might learn. Indeed, to start using micromasteries Twigger describes there as being 6 key components: 
  1. Having an entry trick
  2. Overcoming the “rub-pat” barrier
  3. Optimising background support
  4. The payoff
  5. Repeatability 
  6. Experimental possibility 

The entry trick is something pretty easy that immediately gives you a sense that you can actually achieve this skill, and even do it well. There can be a number of these for the same skill, but they should allow you to go from complete novice to practitioner without excessive time and/or effort. In essence, you should be able to get a foothold on the skill early on to keep your interest and confidence on track.

The “rub-pat barrier” derives its name from how difficult it is to rub your stomach and pat your head at the same time. If you are not prepared for the first challenging barrier in a skill, you can easily become disheartened and give up. The biggest obstacle to learning is giving up because it gets too hard. Hopefully the entry trick will have mobilised the sense of possibility in you, but being mindful of the hurdles is essential. There are a few tips for tackling this challenge. You can try and focus on only one component at a time or build more ‘non-thinking time’ into practice (thereby trying to promote greater subconscious activity). Either way, the point is to remain motivated and confident of success. The focus on optimising background support is a clear extension of this, and is the fairly obvious step of trying to maximise your ability and desire to keep learning (I think there are some excellent tips from James Clear in his Atomic Habits book).

The payoff is another extension of these themes of motivation. The skills should ideally have a nice, obvious payoff from it and their nature should be that they are standalone, thus not needing anything extra to achieve this. The omelette skill above is a great example of this; you get a tasty meal at the end, and maybe even some impressed family and friends. Other good examples he gives include learning a specific magic trick, learning how to sharpen a knife, or developing beautiful handwriting (perhaps easier than it sounds, although I am yet to confirm this). 

Repeatability refers to the timescale of the actual skill. It has to have a level of time investment (and other resources) that allows a high degree of repeatability. This enables the high degree of repetition and practice that is the cornerstone of becoming good at anything. However, if the resource investment is low, this can be achieved on a short timeframe, keeping your interest and giving early results. Making an omelette only requires a few minutes and some simple equipment and ingredients - you can become pretty skilled within a few weeks, depending how frequently you want to eat omelette. If your goal is something larger, breaking it down into smaller components like this can be the starting point to reaching your goal. If you would love to write a bestseller, maybe try writing a few blog posts or short stories first. The repeatability of these will lend themselves better to your skill development and before you know it you will be a full on author.

Finally, there should be scope for experimentation. Boredom with a skill is another reason to give up. Indeed, if there is no scope for variation then it may be difficult to appreciate the components that make the skill. Experimentation allows you to explore the components of a skill with a degree of playfulness that keeps the pleasure in the learning, and thus helps its effectiveness. Cooking would seem to be an excellent example of this, and learning to make a perfect loaf of bread offers a huge scope for experimentation once you have got the initial recipe cracked. Most skills have some scope for experimentation, although you may need to think creatively.

What next?

So that is the summary of a micromastery. Essentially, these are small, focused skills that can be developed in isolation and provide a rewarding output. Their nature (and some hacks that can be applied to approaching them) should mean that they are engaging, suitably challenging and repeatable enough to allow a relatively speedy production of a tangible output. All that seems to remain is to see how we might want to try and utilise this approach to our own learning. 

I’ve had a think about some micromasteries that might work well in the world of anaesthesia and critical care medicine. Indeed, I think this concept has been recognised in some of the items below. See what you think:
  • Become an expert at ultrasound cannulation
  • Learn lung ultrasound (already encompassed by a FUSIC programme)
  • Learn focused echocardiography (again, already encompassed by a FUSIC programme)
  • Learn depth of anaesthesia EEG interpretation
These are just a few skills that might not necessarily be part of a standard training programme (at least early on) and probably include many of the traits that would make something a micromastery. I think most have a decent entry trick, there is a manageable rub-pat barrier, there is a lot of background support available for learning them, the payoff can be pretty good (whipping out the echo probe in a peri arrest patient can be very helpful), they are all pretty repeatable, and you can start to experiment with their application. And there are probably a good number of other examples that you could probably think of in addition. 

Perhaps more importantly though, a major aspect of the micromastery concept is the exploration of completely different domains. Therefore, whilst the concept still seems applicable to medical training, I think my preference for applying it will remain for outside of this. It seems to be perhaps best utilised as more of a complement or alternative to the training as a professional, where the wide ranging skills that you develop can subsequently be employed to see your primary profession from different perspectives. I am not sure what my next micromastery will be, but I am actually quite excited by the prospect. As always, thank you very much for reading and I’d love to hear your ideas on any micromasteries you have in mind or have already tried. 
BW
Tom

Links & References

  1. Twigger, R. Micromastery: learn small, learn fast, and find the hidden path to happiness. 2017. Penguin Life. 
  2. Twigger, R. Why you don’t need 10,000 hours to master a skill. TEDx Talks. Youtube. 2019. https://www.youtube.com/watch?v=zEUIfXbz0PA​
]]><![CDATA[The Milk of Amnesia?]]>Fri, 12 Mar 2021 20:21:39 GMThttp://www.rapidsequence.org.uk/blog/the-milk-of-amnesiaLet’s run a little thought experiment.
Your anaesthetist comes and talks to you before your surgery. Following his thorough yet efficient pre-operative assessment he tells you that it may be possible that his anaesthetic is simply a perfect amnesic agent. You could potentially experience the entire operation in the moment (unable to move or do anything about it) but at the end you would have absolutely no recollection of these events. You would ‘wake up’ from the anaesthetic with a perfect gap in your episodic memory; to all intents and purposes a period of ‘unconsciousness’. No one would know if you experienced anything (particularly you), and it would be exactly as if you hadn’t. But maybe you had.
Would this bother you? And if it did, why?
This question has come to me before when I have been studying the problem of awareness under anaesthesia, but it has recently cropped up again during a tutorial on the philosophical topic of personal identity. When we think about what it means to be the ‘same person’, there are a few surprisingly challenging questions that arise. One line of reasoning (particularly forwarded by Locke) puts a strong emphasis on the continuation of personal identity being dependent on the psychological continuity of the person. Memory is almost certainly the foremost of these psychological factors (although not the only one) which leads us into some of these interesting conundrums. If you have no psychological connection to the person that experienced the event (for example, absolutely no memory of it), did that happen to ‘you’ or not?

Let’s dive into some of the conflicting intuitions that I have on this topic. My first instinct is that of course it matters. As a conscious agent I would be aware of someone sticking a knife into me, manipulating internal parts of my body and then sewing me up, all the while being unable to move. The process of imaging what this would be like is quite unpleasant, and gives me additional empathy towards anyone that has experienced awareness under anaesthesia. It is not something that I would wish on myself or anyone else, and would fill me with a dread of having to have an operation if I knew that this was what happened.

However, I must then ask myself “maybe this has happened to me!?” I have had an operation, for which I had an anaesthetic. I have complete amnesia for the period of my general anaesthetic (and some of the recovery period) and that is all I can actually say about that event. From my perspective now, the contrasting alternative experiences of myself at that time (unconscious versus aware-but-amnesic) are genuinely indistinguishable from each other. If I had had the complete amnesia experience, then I now genuinely don’t care about it. Primarily because, from my current perspective, it didn’t actually happen to me. It seems that in order for it to have happened to me (the current me who is writing this blog post), it does seem to need to be psychologically connected to my current self. I can raise a similar question for when we sleep. I don’t remember my non-REM sleep and yet my brain is very active at this time. Am I ‘conscious’ of any of this neuronal activity and simply amnesic of it, or am I genuinely unconscious throughout (perhaps this example says more about the mysteries of sleep and consciousness than anything else though). Either way, I don’t have any psychological connection to this sleeping version of me and it doesn’t seem to bother me if I happened to routinely spend these hours in torment as my brain reorganises itself and then deletes my memory of the period.

To bring this abstract thought experiment closer to reality, I feel that I have seen cases like this. Some cases of conscious sedation appear to be having consciousness at the time of certain procedures (evidenced by appropriate motor activity) but profess absolutely no recall afterwards. I have even seen an example where they were still awaiting the procedure that had already happened. Admittedly the complete unawareness of the procedure was not part of what was offered from the sedationist here (something that I am very clear about in the consent process for any cases of conscious sedation that I do) but they seem to have still managed to end up with the same final outcome as our general anaesthetic case. I concede that I have not done a detailed follow up to analyse how dense their amnesia truly was, but the point remains. And much more commonly than these cases are when we routinely see the preservation of the nociceptive response to noxious stimuli in patients who are under general anaesthesia. It is only retrospectively that we can truly label these as nociception rather than pain, when we establish that there was no conscious component to it. However, there is clearly a neurologically mediated physiological response going on here which, if we are physicalists about the nature if consciousness, is all that consciousness really is. We are simply much more reassured that consciousness isn't present by the visible correlates of this: the absence of appropriate motor activity, the presence of associated EEG patterns (if monitoring these), and (the topic of this post) the lack of any recall after the event. Indeed, some motor reflexes appear to persist despite 'deep' levels of anaesthesia - something that gave me quite a shock when I first started anaesthesia training. Even now I get a bit of a jump when I see an unexpected spike on my BIS monitor. This leaves the absence of recall of the events as the ‘gold standard’ of our anaesthetic, with a problematic retrospective nature to it.

All of this brings me to a sense that, although we are pretty convinced that people are not conscious, much of this is founded on these visible correlates. The biggest reassurance is the very reliable lack of recall, but this is identical in the 2 alternative situations initially described. This therefore brings me back to the relevance of the second question: "should we care?" When I think about this question I get a very strange sense of time-dependency to it. It is ‘me’ when the event is in the future (I am concerned about what ‘I’ will have to experience), but it is not ‘me’ when the event has passed (I don’t even know that anything happened). My answer is therefore somewhat dependent on when you ask me although I would still tend towards saying that it does matter. Even if the ‘past me’ feels very separate from the ‘current me’, I can still imagine that his experience is an unpleasant one to go through and I have some empathy with this ‘stranger’. This would seem to negate the argument of amnesia, given that someone has had to go through that experience, even if that person doesn't really ‘exist’ any more after the event, as the amnesia kicks in. In my mind it is probably this factor that we need to weigh most strongly when we are answering this second question. Someone is suffering and this seems ethically undesirable. 

So let’s wrap up. I think there are some fascinating questions thrown up by this thought experiment, flagging up some of the real complexities of consciousness, personal identity, memory, and the mysteries of anaesthesia. I am personally quite swayed by the importance of psychological continuity as a core part of our personal identity. This has left me a bit puzzled over the significance of the different cases here. However, it seems clear that the presence of any consciousness during such an unpleasant event as surgery is highly undesirable, regardless of its duration or impermanence. Indeed, this is part of the brilliance of anaesthesia. It is a central part of our role as anaesthetists to be able to bring this true unconsciousness, and it is clear that amnesia is not good enough, no matter how confident we could be with it. It seems a rare scenario where we would be forced into this problem, but should still remain a guiding principle to our clinical approach. 

Links & References

  1. Locke, J. Of identity and diversity, in: An essay concerning human understanding. 1689. Available at: http://www.gutenberg.org/cache/epub/10615/pg10615.html
  2. NAP5: Accidental awareness during general anaesthesia in the UK and Ireland. https://www.nationalauditprojects.org.uk/NAP5home
]]><![CDATA[Medical Education: Spaced Repetition Revisited]]>Fri, 15 Jan 2021 11:49:40 GMThttp://www.rapidsequence.org.uk/blog/medical-education-spaced-repetition-revisitedA couple of years ago I wrote a blog post looking at the technique of spaced repetition. With my (hopefully final) exams now completed I wanted to revisit the topic and add a few additional points that I think complement this approach to learning. These are ideas that I have come across over the intervening years of using spaced repetition, as well as from ongoing study around learning techniques. One of the most useful of these resources has been the free online course “Learning How to Learn” by Dr Barbara Oakley and colleagues on Coursera ( I believe I have read that this is the most popular course on Coursera). This course highlights some of the key evidence-based approaches to effective learning and I would strongly recommend the modest time investment involved in completing it. In addition, although I was still digesting it at the time of writing my initial blog post, I feel I have been able to absorb more of the concepts from the brilliant book ‘Make it Stick’. Although this is a more detailed dive into the evidence, this blog post from Eva Keiffenheim provides an excellent summary of some of the key themes which is well worth a look at. But now I’ll give a quick summary of some of my own learning points. These are all related to the optimal use of my flashcard deck using the Anki app, so some points may be more or less applicable to you depending on your own approach. ​

Note Making

This is a component of learning that I am sure is not new to most of you. However, I feel I have really increased the potency of my learning when combining effective note making with a spaced repetition technique. The educational theory that this is built on is all about constructivism; that is, we construct our knowledge, fitting it in with what we already know, rather than a simple copy and paste onto our harddrive. As such, taking the time to read, digest, then create your own understanding of a topic is a very powerful way for making sure it is retained. This is, therefore, actually quite a laborious process to do effectively, partly because of the time commitment, but also because of the cognitive effort involved in the full reconstruction of a topic in your own words. However, as is repeated through all of the sources, it is this sense of hard work that is part of the reason why it is effective learning. Learning requires the creation and reinforcement of new neurological connections and pathways, and this feels effortful. This does mean that I find that topics take longer for me to cover than previously, but I feel that the benefit is felt many months (maybe even years) later, when I still feel I have a strong grasp of the subject. Once I have put this effort into my notes, I feel I have a clear idea of which are the key nuggets of information that I want to add to my flashcard deck and work to commit to memory. I feel I then know the topic well and have created the global cognitive connections that have allowed me to ‘understand’ a topic. The role of the spaced repetition is then to help me remember the bits that I think will decay. This covers a huge range of things but will be clear to me once I have finished the topic. This process of creating my flashcards at the end of creating my notes also serves as a great revision session in itself, as I look through the topic once again to extract the key points. Indeed, I wonder if approaching a topic with this end in mind also helps me to engage with the source material more effectively, optimising the integration with my current learning because I am actively trying to construct my information. 
Bearing all this in mind, I think I would summarise the key points to think about when making notes as such:
  • Using electronic notes is useful to allow repeated re-editing of your notes as your go (I use Google docs to allow me to edit documents wherever I am).
  • Try and rephrase/reformat the source material as much as possible. I use some general structures for my notes that I fit the source information into e.g. definition, classification.
  • Creating flashcards at the end of the note making process serves as a good revision process in itself, helping with the consolidation.

Flashcard Creation

Now there is a bit more technique in creating the optimal flashcards than I first appreciated. The goal is to create the optimal questions for improving your retention, but also for maintaining your habit (covered more below). Whilst you want there to be some effort in answering the cards, you don’t want to be demotivated because you are continually repeating cards that you get wrong. I have found that the key to this is to focus on making the answer component of the card as concise as possible. The smaller the information package in the answer, the easier it will be to answer in one go, without the problem of only half answering a question (and the subsequent issue of having to repeat it). I have found that this has helped me with answering the questions, improving my retention of the answers and also making it more pleasant to get through cards. This can be a bit of a challenge with some concepts e.g. treatment strategies, but just needs the focus on trying to keep the answer brief. In some cases, there has been a need to essentially turn a big answer into multiple smaller answers, although I think that some of the systematic approaches within medicine helps with this. For instance, instead of listing all the features of a disease, I might list the different systems involved as the answer to one question (respiratory, haematological, etc). I would then create a separate card about the specific systems e.g. list all the respiratory features of this condition. This can be done with examination findings, investigations (e.g. blood findings, ECG changes), and even management (medical options, surgical options). The more practice I have done the better I have got at this, but I can definitely tell that my newer cards are better than my old ones. 

A final, albeit slightly separate, component of creating cards is about using pictures. I have not gone into detailed exploration of the theory beyond this (I am not sure how valid the VARK system is anymore) but I notice that some things are just better visually represented rather than in words. I think I have a preference for diagrams in my own learning, and so making sure that I could use these in this technique was important to me. I know I touched on this in the last article, but adding images to my card deck is very useful for a number of topics. What I have found to be helpful is to be sure that I have the facilities to draw and sketch when I am answering my cards. A piece of paper works well, but I have also downloaded a very basic drawing app on my phone that lets me simply sketch a simple diagram or equation if I need to. This additional engagement of drawing out an answer has helped make some of these topics much more ingrained than they otherwise might have been. Indeed, I find that writing out the written answers in some cases is also really helpful (e.g. lists or categories), but doing it for every question has always seemed a bit too laborious to work for me. 
Key points:
  • Keep the answers short. More questions with shorter/smaller answers seems to work better for retention, as well as motivation for doing the cards.
  • Break down larger answers into multiple small parts where possible
  • Try adding in the facility to draw and sketch diagrams or equations for some topics

Forming the Habit

A key factor in deriving any benefit from this technique is actually answering the cards. I think this is even harder than it sounds and I recall the despair of missing a few days of questions and then finding 100 questions waiting for you when you next open the app. As well as being demoralising, I think this probably impacts on the efficacy of the spacing. The motivation of the exams was some help with this, but I have gone off the belief that willpower alone is an effective strategy here; it just seems too fickle and dependent on everything else that is going on in your life. I reviewed the excellent ‘Atomic Habits’ book here, and it is within these pages that I hope to have found the answers to this. I think turning it into a core habit is the best way to make sure you are getting effective utilisation of the learning. I would recommend that you go and read my post on the topic, or even better read the book, but will just focus on some key tips here. I have already touched on one, which was to make the answering of the questions as easy as possible (whilst still being effective). More cards with shorter answers is what I find suits me best, and creating more cards like this has made answering them less of a chore. There may be some personal preference here, but I would reflect on what you find is making it hard for you to answer your cards and try to combat it. As I note in my habit post, I use a habit tracker app to help me with this. This is simply a tick-box chart that lets you keep track of whether you have done that habit each day. The tick-box nature provides some form of incentive (the enjoyment of ticking things off a list) and identifies when you might be struggling. Again, you may have your own thoughts and preferences on this, but I would strongly encourage you to think about how you can ensure that the answering of all your cards is a daily practice.
  • Create a habit of finishing your cards every day. I use a habit tracker app to help me with this
  • Optimise your card writing to make them easier to do

Final Thoughts

With those three areas covered I think I will wrap things up. I hope these tips are ideas that may help you in your own learning practice and make learning easier, more effective, and hopefully maybe even more enjoyable for you. I will end with a confession: despite having finished all my exams I am still continuing with my flashcard deck! I know this is in the spirit of the lifelong learning that is part of medicine, but it is not something that I was sure I would have the desire or ability to do. A brief reflection on the reason why is that it is both enjoyable and pretty easy. Without adding loads of new cards each day (as during the peak of exam prep) the daily question load is pretty gentle. I find a modest degree of pleasure in a daily quiz on a few medical topics, and (I may be alone in this) find there is a little dopamine hit from getting answers right. Indeed, through my reading I am beginning to believe that there is something innately pleasurable in learning for us humans. It seems to have its own degree of reward, independent of any goal that it is directed to. And that is without even saying that being knowledgeable about things within your specialty is also quite a nice scenario for you to create for yourself. In addition, I feel I have spent too much effort in acquiring all this knowledge in the first place for me to simply let it decay. The cost seems small, and the benefit high, but we will have to see how these balance up in the long run. I hope that this may provide some further inspiration for you, and thank you again for reading.

​BW
Tom
  1. Heaton, T. Medical Education: Spaced Repetition. Rapid Sequence. 2019. http://www.rapidsequence.org.uk/blog/medical-education-spaced-repetition
  2. Oakley, B. et al. Learning how to learn. Coursera. https://www.coursera.org/learn/learning-how-to-learn
  3. Keiffenheim, E. How to remember everything you want from non fiction books. Medium. 2020. https://medium.com/better-humans/how-to-remember-everything-you-want-from-non-fiction-books-df17096d517f
  4. Brown, P. Roediger III, H. McDaniel, M. Make it Stick: The Science of Successful Learning. 2014. The Belknap Press. Cambridge:Massachusetts.
  5. Heaton, T. Atomic Habits. Rapid Sequence. 2020. http://www.rapidsequence.org.uk/blog/atomic-habits
]]><![CDATA[How do we know? 3 - Gettier Cases]]>Mon, 28 Dec 2020 09:25:50 GMThttp://www.rapidsequence.org.uk/blog/how-do-we-know-3-gettier-casesThere is a saying that I like: "even a stopped clock is right twice a day". Now this is usually used as a bit of a mean joke when someone gets something right when you might not expect them to. However, we can use this as an example of a 'Gettier Case' (I think it is probably my favourite one). As I alluded to at the end of the last post, Edmund Gettier was a philosopher who demolished the classical definition of knowledge (Justified true belief) with a concise paper consisting of a few examples where there is a belief that is true and justified but is quite clearly not knowledge. Why is this important? Well his observation, demonstrated through his examples, made it quite clear that we don’t really have a great way of describing why one thing would count as knowledge, and another thing would just count as fluke, or a lucky chain of events. This is an issue that can impact significantly on how confident we can be in some of the things that we ‘know’. Let’s delve a bit deeper. ​

The Problem

Now the publication that started this all off has to have one of the greatest word count to impact ratios of any academic paper. In 1963 Gettier published ‘Is justified true belief knowledge?’, with a concise two and a half pages that quite clearly answered his title question in the negative. He gave two examples that demonstrated the problem with the justified true belief definition, and the epistemology world has been discussing it for the following 50 plus years. Whilst his cases do work, they aren’t my favourite examples. As such, I will use the clock case that I have just hinted at. This has actually been attributed to Bertrand Russell, albeit in a different context, but I think it nicely highlights the problem. 

You have just come downstairs in the morning. You look at the clock and note it is 8.50 (we’ll use the example of it being an analogue clock). This is indeed the time. However, the clock actually stopped working at 8.50pm last night and it just so happens that you are looking at it exactly 12 hours later. So did you know the correct time when you looked at the clock? The instinctive response is that of course you didn’t. You are looking at a broken clock, therefore you didn’t actually know the time, even though by chance it was correct. However, the JTB definition would have said that you did. The time was correct (true), you believe it to be true, and looking at a clock is a very reasonable (justified) way to know what time it is. Therefore, you have a justified true belief. I think from this you can get a good idea of what the Gettier cases show. In essence, they show that, with a bit of luck, you can actually end up with numerous examples of justified true belief, that we intuitively feel are clearly not knowledge. Indeed, there is even a formula that we can create to describe what would constitute a Gettier case:
  1. Take a belief that is justified but would normally be false
  2. Modify the details of the case so that, by luck, it is actually true
In the above example, we would normally look at a broken clock and get the wrong time, thereby clearly not having knowledge. However, with enough luck, this can actually give us the truth, causing the problem with the JTB definition we have outlined.

So What?

The non-epistemologists amongst you may be asking the above question. Fair enough. However, I think there is a very important issue that is highlighted within this. Indeed, it comes back to the very title of this series: how do we know? If we can, through luck, end up with a scenario that ends up looking just the same as knowledge, what actually is knowledge? If having a reasonable justification in your true belief isn’t enough, then what is enough? This creates two big opposing problems in my mind. 

The first is the problem of skepticism. By working through some of the problems that Gettier Cases pose, we may actually end up finding that we don’t know very much at all. One answer to the Gettier problem is to make our true belief infallible. This is also problematic. I am not planning on going deep down the rabbit hole of skepticism in this series, but infallibility is quite a high bar to clear for something as important to our daily lives as knowledge. Indeed, some forms of radical skepticism (Descartes’ thought experiment is what springs to my mind) would suggest that we can ‘know’ almost nothing. The presence of hallucinations and illusions, the fallibility of our senses, and the innate urge to find patterns where they may not exist, mean we may not actually be well connected to the reality that we think we are. The Matrix might actually be true! If this is hard to believe (which I find that it is), what is harder is where you draw the line between what is possible (we may be in the Matrix if we really think it all through), and what is probable and useful. But that means we have to find some nondescript threshold, somewhere away from infallibility, that defines when we truly know something.

The second point, following on from this first conclusion, is that of luck. If luck can play such a role in how things play out, where does this leave our system of knowledge. Isn’t this just an excellent breeding ground for the retrospective attribution of justification that we see in the different pseudosciences? If my horoscope uses broad enough language, it can be true enough times to make me stop and think. And if justification doesn’t actually help us separate what we know, then the pseudoscientific stories that get retrofitted are as useful to defining knowledge as any others (I am almost certainly overstating the point here though). So to summarise, it is actually a bit of an issue when we want to start to look at the different methods of getting to the truth as there almost seems to be some need to set a threshold for the concept of knowledge to make sense. ​

Attempted Solutions

As you may be able to tell, these issues have made epistemologists uneasy. It feels like there should be an answer to this problem, given that we seem to be able to know what we mean when we say know. This has led to a number of efforts to both repair the JTB definition, often by adding some extra component, and efforts to create an entirely new definition. Whilst I won’t go through many of these, there are a number of themes that have been put forward.

A couple of examples include the no-false lemmas and no-defeaters arguments. These appear to be centred around the confidence of the justification process. A lemma is a term for a false assumption, and a defeater is a piece of information that exists (although not known to the believer) that would ‘defeat’ their justification. The proponents of these responses have suggested mitigating against these factors by adding them as a fourth component of JTB, thereby patching it. These seem to perform fairly well in some of the Gettier cases that have been described. However, greater exploration can lead us back to the spiral of problems that we see in skepticism when we have to decide where we want to set our thresholds. What counts as a false assumption? How wide do we have to cast our net to make sure that there are no defeaters? If we think about this broad enough we end up back with the problem that we may not actually know anything with adequate confidence.

The reliabilist theory comes up against similar problems. This theory replaces the concept of justification with the component that the true belief must be formed from a reliable process. This seems like another reasonable definition, but comes apart again with some simple examples-the lottery example probably being the best. Using a reliabilist approach, we would be able to say that we know that we haven’t won the lottery every time that we buy a ticket, because the odds would say that this is a reliable route to a belief (>99.999%). However, it runs against our intuitions so say that we know this even before the numbers have been drawn. This leads us to think that there is something different from pure probability that goes into determining whether we know something.

Summary

To summarise, I think the Gettier problem brings into focus the problem of balancing skepticism against luck. If we are too strict on our requirements for certainty then I think Descartes may have been correct when analysing that we would appear to know almost nothing. However, if we are not stringent enough, it appears that luck can begin to play a much more prominent role and hence the existence of Gettier cases (as well as cases of mistaken belief). My intuition from all of this is that, like quite a few other things, knowledge is a spectrum rather than categorical. You can know something to a greater or lesser degree, and indeed this may be reflected in some of the other words that we supplement the verb ‘to know’ with: certain, probable, possible, etc. As I imagine we will explore as we delve into the philosophy of science, much of our scientific method recognises this. We use an iterative and probabilistic approach to much of our knowledge (I am particularly thinking of the famous p value here) that increments in its confidence over time. As such, I think the vagueness of the definitions that we noted above are actually appropriate. We know something if we have a justified true belief with a strong degree of confidence against luck. And this is why I think the scientific method and mindset is so important; we must go looking for this luck to avoid being deceived. Indeed, I am beginning to believe that many of the answers to our epistemological challenges may be found in these anti-deception strategies.  However, I guess I can’t yet say that I know this...

Links & References

  1. Lacewing, M. Philosophy for AS and A level: Epistemology and Moral Philosophy. Routledge. 2017. 
  2. Epistemology. The Basics of Philosophy. https://www.philosophybasics.com/branch_epistemology.html
  3. Stanford Encyclopedia of Philosophy. Epistemology. 2020. https://plato.stanford.edu/entries/epistemology/
  4. Wireless Philosophy. Philosophy - Epistemology. Youtube. 2016. https://www.youtube.com/watch?v=r_Y3utIeTPg&list=PLtKNX4SfKpzUxuye9OdaRfL5fbpGa3bH5&index=1
  5. University of Edinburgh. Introduction to Philosophy. Coursera. 
  6. Hetherington, S. Gettier problems. Internet Encyclopaedia of Philosophy. https://iep.utm.edu/gettier/​
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