The ever thought provoking Javier Benitez (@jvrbntz) had this to say recently

Intriguing "Explicit pre-training instruction does not improve implicit perceptual-motor sequence learning" http://t.co/HHPimn0Lcj #MedEd

— Javier Benítez, MD / Pr(Dz | Data) ≠ Pr(Data | Dz) (@jvrbntz) July 6, 2013

The study in question explores relationships between implicit memory [wikipedia saying Implicit memory is a type of memory in which previous experiences aid in the performance of a task without conscious awareness of these previous experiences] and explicit memory [wiki: Explicit memory is the conscious, intentional recollection of previous experiences and information. People use explicit memory throughout the day, such as remembering the time of an appointment or recollecting an event from years ago]. Essentially in the study the participants where asked to perform a task of pressing one of 4 keys in response to different cues falling down a screen. There were two groups all completing a main task but one group given time to memorise the sequence of the falling cues while the other group just had practice time without realising (or more correctly being told) there was a sequence. In this study sequence learning wasn’t improved by  pre-training memorization of the sequence. The authors hypothesised that explicit and implicit memory may be independent of each other.

In response to an initial question Javier clarified by saying in the context of deliberate practice it may well be worth re-practicing rather than re-reading which was summated as:

@jvrbntz okay, learn by reading<learn by doing, but learn by reading then doing (& doing…) = good and resilient?

— Todd Raine (@RaineDoc) July 7, 2013

At this point yours truly, having not really read the initial paper properly, but enough to notice that the task used in the study was similar to sequencing required in a popular game, waded in with:

@RaineDoc @jvrbntz but task was predictable, and previously practiced "guitar hero!' i.e. is it translatable to teaching on airway station?

— Damian Roland (@Damian_Roland) July 7, 2013

Javier pointed out that the tasks needed to be predictable but the overall philosophy was that implicit and explicity are different points of memory.

@Damian_Roland @RaineDoc Deliberate practice needs to be predictable. see chess & music.Their point = implict & explicit r different memory

— Javier Benítez, MD / Pr(Dz | Data) ≠ Pr(Data | Dz) (@jvrbntz) July 7, 2013

Now fully acknowledging I had waded into an area in which I am not familiar (and it’s not great practice to pick up “tweetends” without knowing context!) it still got me thinking about how this piece of research was really applicable to post graduate medical practice, and in particular the busy world of emergency medicine. If we take, for example, putting in a interosseus needle the espouced theory may have some merit. Yes an understanding of the theory is needed but actually it’s not really until you have done it in a real patient (or even a dummy) that you can really understand the practicality of it i.e memorise the sequence all you want but you really need to ‘play’ the game to get the hang of it.

However much of what we practice in emergency medicine at a senior level is a complex array of operations of which are not predictable or follow algorithms. So I responded with

@jvrbntz @RaineDoc Higher level cognition (leading multi-trauma) is by definition unpredictable. ?Memory irrelevant here as not a "skill"

— Damian Roland (@Damian_Roland) July 8, 2013

At that point I confused poor old Javier a bit and this blog serves as a way of clarifying my thought trail (and conveniently may help me frame an argument in one of the chapters of my Phd on junior doctors perceptions of competence and confidence). Does this implicit/explicit memory split really hold for complex tasks? And how would we test if it does. So an open question to the (#FOAMed) world:

It’s 6pm. The Emergency Department is heaving. Red phone goes off. Nine year old, hit by car at 40mph, thrown off bonnet. Initially agitated now quiet, clear open right femur and obvious trauma to chest.

You are team leader: what memory is going to get you through the next 20 minutes….