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Stressing Your Students is Ok! The application of the challenge point framework in medical education Guadagnoli M et al. Medical Education 2012; 46:447-453

Reviwed by Lavjay Butani

What is the focus of this paper?
This paper reviews the challenge point framework (CPF) model of learning (described by Guadagnoli and Lee in 2004). The examples focus on the learning of technical skills.

What is the Challenge Point Framework?
A paradoxical relationship sometimes exists between practice performance and real-life performance. For instance, sometimes there is a direct relationship between practice performance and real-life - or retention - performance. Sometimes, though, there is an inverse relationship between these two and poor performance during practice may actually translate into fine performance later on. The CPF model aims to explain and reconcile this paradox.

The more a learner is challenged during the learning phase, the lower his or her performance will be during the learning phase but the greater his or her performance will be during the retention phase - up to a point (the challenge point!). Further challenge will result in fine performance neither during the learning phase nor during the retention phase.

How can we structure practice to enhance learning?

  1. Provide frequent feedback for novices or for trainees learning a complex skill - but provide less frequent feedback for more experienced trainees so that they learn to rely upon themselves for feedback.
  2. Provide "blocked" practice for novices (repeating the same skill over and over) but "random" practice for more experienced trainees (practicing, say, three different skills in random order).
  3. Adjust task complexity based on learner competence - break complex tasks into simple steps for novice learners but add contextual interference (e.g. time constraints) for advanced learners.
  4. Modify the consequence of the task. Practice in a simulation lab for novices, but watch more experienced trainees deal with real patients.

What are the implications of this learning theory?
This paper calls us to get to 'know thy learner,' since the optimal level of 'challenge' is not a fixed entity based solely on the task; rather, it is determined by a complex interaction between the task and the learner. This article also reminds us that we need to be wary of gauging 'competence' in learners based on practice performance without assessing habitual 'real-life' performance in a deliberate manner.

Editor's note: The authors urge us to accept that "an appropriate degree of challenge will create some degree of failure. This appropriate failure during practice will yield success when it really counts during times of stress." They challenge us to create learning environments that are stressful enough - but not too much! - to optimize not practice success, but, instead, learning. Their examples relate to the learning of technical skills and some of this is more difficult to apply to the learning of histories, physical exams, communication skills, and diagnostic reasoning. But when I start two weeks of service as a hospital pediatrician tomorrow, I will nevertheless be thinking about creating learning environments that stress and challenge my trainees just enough! (SLB)

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