Skills fade is a reality for all medical professionals. Emergency medicine requires constant practice, yet many clinicians find themselves in situations where their skills decline due to lack of exposure. At Tactical Trauma 24, Nathalie Pattyn shared insights into why this happens, how we should address it, and why it’s a systemic issue rather than an individual failure.
Listening time: 16.21
Understanding Skills Fade
Skills fade refers to the decline in clinical and procedural abilities due to lack of practice. It’s often mistaken for imposter syndrome, particularly among young emergency physicians, but it affects clinicians of all experience levels. Rare procedures, such as pediatric resuscitation, are especially vulnerable to skills degradation.
Medicine operates under different expectations compared to other high-stakes fields like aviation. Pilots must retrain after just three months of inactivity, while medical certifications often last for years. This unrealistic expectation leads to gaps in competency and confidence, leaving practitioners feeling unprepared when they return to active practice.
Personal Experience and Systemic Issues
Nathalie’s 15-month deployment to Antarctica highlighted the issue firsthand. She underwent extensive cross-specialty training before departure, yet after her return, she felt out of practice and vulnerable. With no formal re-entry process, she had to arrange supervised practice on her own. While some countries, such as the UK, provide guidelines for clinicians returning to work, many healthcare systems lack structured pathways. This leaves individuals struggling to assess and rebuild their competency alone.
Research shows that skills fade occurs within months, not years. The COVID-19 pandemic underscored this issue, with senior consultants losing their performance edge due to decreased case volume. Despite this, medicine continues to operate under outdated assumptions about how long clinicians can go without performing critical procedures before their proficiency suffers.
Distinguishing Between Skills Fade and Imposter Syndrome
Many clinicians fear they are losing their abilities, but how can they differentiate between real skills fade and mere loss of confidence? This is where structured assessments and retraining become crucial. Without clear guidelines, clinicians may either underestimate or overestimate their deficits, leading to patient safety risks or unnecessary anxiety. Addressing this on a systemic level could help remove the stigma and provide clear pathways for skill recovery.
Gender and personality may also influence self-awareness of skills fade. Some clinicians recognize their decline and seek retraining, while others may overestimate their abilities after a break. Without standardized processes, skill degradation remains a hidden risk.
The Difference Between Teaching and Training
Teaching and training are not the same. Teaching introduces concepts, while training reinforces them through repetition until they become second nature. Many experienced clinicians struggle to articulate procedural steps because they operate on an automatic level, making them less effective at training beginners. Medicine needs to integrate cognitive science principles to ensure clinicians not only learn but retain skills under pressure.
Ageing and Skill Retention
Aging affects psychomotor skills, reaction times, and visual perception. In surgical settings, data suggests that experienced consultants maintain an edge over trainees for a period, but beyond a certain point, age-related decline becomes a factor. The exact point at which this occurs varies by individual, making it difficult to create universal guidelines.
What Needs to Change?
A structured return-to-practice program should be implemented to support clinicians after extended absences. Recertification requirements should be shortened to ensure competency remains high. Medicine must shift from viewing skills fade as a personal issue to addressing it as a systemic responsibility. Implementing evidence-based training methods would reinforce long-term skill retention and ensure patient safety.
Final Thoughts
Skills fade is inevitable but manageable. Instead of placing the burden on individuals, healthcare systems must adopt structured solutions. High-risk fields like aviation prioritize continuous retraining—why doesn’t medicine? Addressing this issue could improve patient outcomes, boost clinician confidence, and create a safer, more competent workforce.
Key Learning Points
Understanding Skills Fade
- Skills fade refers to the decline in clinical and procedural abilities due to lack of practice.
- It’s often mistaken for imposter syndrome, particularly among young emergency physicians, but it affects clinicians of all experience levels.
- Rare procedures, such as pediatric resuscitation, are especially vulnerable to skills degradation.
- Medicine operates under different expectations compared to other high-stakes fields like aviation.
- Pilots must retrain after just three months of inactivity, while medical certifications often last for years.
- This unrealistic expectation leads to gaps in competency and confidence, leaving practitioners feeling unprepared when they return to active practice.
Personal Experience and Systemic Issues
- While some countries, such as the UK, provide guidelines for clinicians returning to work, many healthcare systems lack structured pathways.
- This leaves individuals struggling to assess and rebuild their competency alone.
- Research shows that skills fade occurs within months, not years.
- The COVID-19 pandemic underscored this issue, with senior consultants losing their performance edge due to decreased case volume.
- Despite this, medicine continues to operate under outdated assumptions about how long clinicians can go without performing critical procedures before their proficiency suffers.
Distinguishing Between Skills Fade and Imposter Syndrome
- Many clinicians fear they are losing their abilities, but how can they differentiate between real skills fade and mere loss of confidence?
- Without clear guidelines, clinicians may either underestimate or overestimate their deficits, leading to patient safety risks or unnecessary anxiety.
- Addressing this on a systemic level could help remove the stigma and provide clear pathways for skill recovery.
- Gender and personality may also influence self-awareness of skills fade.
- Some clinicians recognize their decline and seek retraining, while others may overestimate their abilities after a break.
- Without standardized processes, skill degradation remains a hidden risk.
The Difference Between Teaching and Training
- Teaching and training are not the same.
- Teaching introduces concepts, while training reinforces them through repetition until they become second nature.
- Many experienced clinicians struggle to articulate procedural steps because they operate on an automatic level, making them less effective at training beginners.
- Medicine needs to integrate cognitive science principles to ensure clinicians not only learn but retain skills under pressure.
Aging and Skill Retention
- Aging affects psychomotor skills, reaction times, and visual perception.
- In surgical settings, data suggests that experienced consultants maintain an edge over trainees for a period, but beyond a certain point, age-related decline becomes a factor.
- The exact point at which this occurs varies by individual, making it difficult to create universal guidelines.
What Needs to Change?
- A structured return-to-practice program should be implemented to support clinicians after extended absences.
- Recertification requirements should be shortened to ensure competency remains high.
- Medicine must shift from viewing skills fade as a personal issue to addressing it as a systemic responsibility.
- Implementing evidence-based training methods would reinforce long-term skill retention and ensure patient safety.
Final Thoughts
- High-risk fields like aviation prioritize continuous retraining—why doesn’t medicine?
- Addressing this issue could improve patient outcomes, boost clinician confidence, and create a safer, more competent workforce.
- Skills fade is inevitable but manageable.
- Instead of placing the burden on individuals, healthcare systems must adopt structured solutions.
Podcast Transcription
Iain Beardsell:
Welcome to the St Emlyn’s podcast. I’m Iain Beardsell. And I’m Liz Crowe. And we’re at TacTrauma24 in Sundsvaal, Sweden, and another amazing guest, Nathalie Pattyn. Natalie, I tell you what, you’ll do this much better. Introduce yourself for our listeners, please.
Nathalie Pattyn: My resume is a testimony to the fact that I don’t like to choose because, in parallel with medical school, I did a master’s in psychology and a PhD in neuroscience regarding cognitive performance of jet fighter pilots and astronauts. Whereas in clinical medicine, my specialty is emergency medicine, and I’ve been a military physician for my whole life.
Iain Beardsell: And you did an amazing talk today, all about skills fade, which has an, let’s say, older gentlemen, I find a particularly interesting topic, as I find myself struggling to remember things and keep doing them. But you actually talked about skills fade in emergency physicians across all age ranges.
Could you tell us a bit about your work and how it might affect the day to day ability of doctors, nurses, and anyone [00:01:00] working in emergency care?
Nathalie Pattyn: Actually, that topic,chose me because I was confronted with it after long deployment. So it shows up in the literature regarding military medicine, considering low workload deployment.
Because if civilians imagine, military deployments for physicians, they imagine war casualties and high workload. Whereas the reality, more often is that you find yourself on low workload deployments, where actually you lose your clinical skills. My longest deployment was 15 months to Antarctica, and that was overwintering in an Antarctic station. And before leaving, I had six months of clinical training in all aspects of medical specialties I might need. We’re talking dentistry, we’re talking general practice, we’re talking minor surgery, even introduction to anesthesia, to do it all by yourself in such a remote location. And that made me feel very confident [00:02:00] and able to tackle whatever medical issue would come my way.
However, after those 15 months, when I came back, let’s say to my normal clinical practice, I felt very vulnerable and totally not up to speed. And what struck me was, in Belgium at least, there are no regulations regarding getting back to practice after you have detrained. There is no formalisation of it, there are no criteria for it.
And so what actually triggered me to investigate this further was the incredible feeling of vulnerability that gave me and of not being able to do my job. And I thought, what do women do after maternity leave? And it’s a topic that has popped up, in literature, not maternity leave, nobody gives a damn about that, but surgical skills decay during the COVID pandemic, and all of a sudden people were like, hang on, if we don’t operate for [00:03:00] that long, that is not good.
And you actually have data showing that senior consultants actually lose the performance edge they had over training residents because of that detraining period. Whereas you might think that experience has consolidated those skills enough to prevent that kind of decay. And when I did my training in the U. K. prior to the Antarctic deployment, I find that the U. K. has, let’s say, the most sensible policy regarding it. It’s also the medical system where you have regulations in place for supervision during practice after a period out of practice. And there is an NHS document, which is, 10 years old now, which is a very extensive review on skills feed all sorts of clinical practice.
Because in emergency medicine, we’re mainly looking at procedural memory, because semantic knowledge, the kind of, knowing, what dose of [00:04:00] adrenaline to give in function of the age of a child, that is something you can read up on. However, performing an intubation in a three year old, you can read up on the procedure, that won’t make you feel more comfortable to actually perform the skill when you need it. And that’s the real issue there.
Liz Crowe: How would you differentiate between imposter syndrome and actually being de skilled? Like how can you know, actually I do have the skills I don’t have the confidence or actually I need to do more training around this.
Nathalie Pattyn: Well, that is a great question because that is exactly why we need those regulations to actually take that incredibly uncomfortable feeling of people going back to practice, for example, after sick leave, after maternity leave, after other professional occupations.
Because now, if you don’t have those regulations in place, it feels like a personal failure, especially because since there are [00:05:00] no regulations, there is also no systemic solution to it. So actually, you have to find one for yourself. And for example, what I did is I contacted a former supervisor of me, and I asked her, “Can I come back and work under your supervision for a month?”
Knowing that this is what I’ve been doing, and that you actually need to check on me and allow me to have more of that practice, supervised practice. She was perfectly okay with it, but the people around, it was in an intensive care unit, and because of my age and apparent experience and the knowledge I displayed, people didn’t integrate the fact that I was there on supervised practice, because it doesn’t fit. No, it’s not part of, let’s say, the way we conceive medical practice.
Liz Crowe: But that means that you have to have a level of insight, or a level of concern. How much could that be [00:06:00] gendered? Or how much of that could be personality, that I could just assume that I’ve been a clinician for 30 years, I’ve taken six months off, therefore surely I’m still amazing.
Or, I’ve been an amazing clinician, but I had this deep fear after taking four months off. Like how do you differentiate that? How do you work that out? Because I would imagine when you first approached the supervisor, she probably tried to talk you out of it, didn’t she?
Nathalie Pattyn: No, not at all.
Liz Crowe: Ah, interesting.
Nathalie Pattyn: I chose her well.
Liz Crowe: Because I’m imagining lots of people would think this is a waste of time. You’re a very skilled clinician. Surely you don’t need this. Nobody can de skill that quickly. But what your research is saying is actually you can.
Nathalie Pattyn: Yes, and that is why we need evidence base to demonstrate that in terms of skills feed, if you look at the literature, the primary field that has looked at it is aviation, because you have very stringent regulations in aviation. For example, for specific qualifications like [00:07:00] night flight or multi engine flight, if you haven’t done any in flight training, let’s say three months and not only just being logged as a pilot or a co pilot.
No, having done that many takeoffs and that many landings, then you have to recertify with a qualified instructor. And that period is as small as three months. Now, if you dig into the literature, you notice that those three months is actually educated guess figure. There’s no hard data for it.
But what we look at in medicine, if we look at certification for all our alphabet courses, we’re talking years. And especially if you look at the scarcity of, for example, pediatric resuscitation, which is one of the very few fields of emergency medicine where you do have data on skills fade, because it’s so scarce, pediatric cardiac arrest is luckily, very rare. And so there is an evidence skills fade. But what I’m saying is, the [00:08:00] skill fade we see in years is the tip of the iceberg. Actually, when we feel we are de skilled, it’s actually way beyond the point where we actually are performing well enough to meet the normal clinical standards we have in our society.
So we are effectively talking months and that is what our data show.
Liz Crowe: So you’re saying by the time you have a concern, you’ve been dangerous for quite a period of time. Can I ask then, is there any data around skill fade and just aging? So you might still be performing those skills, But is there a cognitive decline?
Do we have any evidence of that?
Nathalie Pattyn: It’s complicated. And that’s why there is no, like hard, clear evidence pointing to one direction or another. For example, if you look at, and now this has been investigated,in, surgical skills, for example, if you look at surgical skills, then you notice that [00:09:00] there is.
And there’s not enough data to draw a clear curve with a dose response effect. But up until some point, there is an advantage from consultants over residents. And then past a certain point, age becomes actually, a deleterious factor. Nobody can pinpoint that because obviously there’s a large inter individual variability. And especially when it comes to psychomotor skills, and especially when it comes to, vision accuracy, not only the type that you can easily correct, but the way contrast, or for a pilot, the way contrast at night, which we know decreases with age.
And those things are not well investigated in the applied settings. Because obviously it’s very difficult and that’s something we encountered as well. To put together the methodology to investigate the seven skills we want to investigate. It took us two years of trial and error.
Liz Crowe: I guess the other thing that I really loved [00:10:00] that you said today in your talk is teaching is not training.
Can you just explain that for us, please?
Nathalie Pattyn: That’s something that I find especially in the medical field is often confused for several reasons. First is because as medical doctors, we have very few knowledge of cognitive processes. If we do, it’s because we read up on it, let’s say out of interest, but it’s not taught to us.
And the way we learn, especially with regard to skills, is there is a cognitive stage where you process the information, and then there is an associative stage where you try to integrate movement, motor actions with the sensory input and make it smooth and actually learn to associate the variations of your actions with their consequences.
And then there’s the automatic stage where these things do not take up like conscious, processing power [00:11:00] anymore.
And teaching is with regard to a technical skill, is the first two stages. So the cognitive stage and the associative stage. Training is making it more and more automatic and thus stress resilient. But in medical field, we are not very patient with our teaching. And especially, and that’s something that is acknowledged in the cognitive literature, when you yourself, as a trained professional, are in the automatic stage, you might not be the best person to teach a skill, because you might not even be able to revert to the cognitive stage because and I can think of a lot of actions. For example, the my first mid exam I had in my specialty of emergency medicine. One of my theoretical questions was to describe the sequence of intubation, like the equipment I would need. And then the sequence of actions with the anatomical landmarks that I would pass.
And of course, I knew that. But [00:12:00] I wasn’t that great at intubating because I hadn’t done a lot of it. Now I feel perfectly comfortable intubating, but if I had to answer that question again, I would need to think really hard about it, not to miss an explicit step. Which means that if I had to teach someone the basics of intubation now, I would really need to prepare that because I can’t roll it off my tongue right now.
And because we don’t know this distinction between these different phases, we are poor at applying it and thus making our teaching evidence based.
Iain Beardsell: A lot of times, Natalie, you’ve said that evidence is lacking and clearly you’re gathering some evidence. Where do you think this will take us in the future?
Is this going to mean that there’ll be certain skills we’ll need to demonstrate more often? Will there be maybe changes in what we expect of different people at different ages? Or is this going to be the unspoken thing that actually we know about but we can never do anything about because we’re not really sure what to do?
Nathalie Pattyn: The latter [00:13:00] is the situation we’re at today. And so I think it can only improve from now, at least in the system where I work. So the idea is to have enough evidence so that we bring a systemic response to what is now an individual problem. What you see with a lot of things in society right now, and let’s take, for example, health and well being of healthcare professionals.
It’s you should get enough sleep, you should take care of, your nutrition, you should make sure you exercise. And then you look at people’s work schedule and you’re like, that is a clear example of a double bind, because if I work 12 hour days, how do I spend time with loved ones? How do I exercise?
How do I take the time to cook nutritional meals? And how do I not sleep deprive myself doing that? And so the skills maintenance issue is actually quite similar because it’s in the [00:14:00] interest of patients, it’s in the interest of society, it’s in the interest of healthcare in general to have healthcare professional performing at the best level they can, whereas now ensuring that standard of practice very often relies a lot on individual responsibility rather than a systemic answer to the problem.
So my goal would be to gather enough evidence to force systems into creating that systemic answer.
Liz Crowe: Thank you so much, Natalie. I’m sure you won’t mind if people reach out to contact you.
Iain Beardsell: I know this is an area of research that you’re interested in gathering more information from in a multinational way and we’ll make sure all the links to your work are available on the blog post. Thanks again for your time.
Further Reading – Handbook of Mental Performance

This extensive overview of mental performance optimization techniques, written by Nathalie and Robin Houffa, offers both a state-of-the-art reference resource and a comprehensive tool for those engaged in managing and implementing mental performance programs and is free to read under a creative commons licence.
The book is written by a combination of academic and operational experts from a wide range of high-performance domains, including the military, space programs, academia, executive coaching, and elite athlete coaching, who complement scientific analyses and overviews of current knowledge with their own experience. Divided into three parts, the book begins by providing a broad conceptual framework through which to embed the latter technical content. Part two looks specifically at the interventions, knowledge, skills, and techniques needed to improve mental performance for both individuals and teams. The final section pulls together the theory of the previous parts, taking a more practical approach by covering implementation, methodological plans on how to appraise new techniques, lessons learned based on the practical experience of the authors, and considerations regarding the necessary learning environment for mental performance improvement.
Pairing an overview of all available neurological, cognitive, and psychological interventions aimed at improving mental performance with a review of their implementation, this is a go-to guide for practitioners involved in managing mental performance and program managers looking at the implementation of a mental performance policy across a wide range of domains. It will also be of interest for courses on performance psychology and human performance in both an academic and professional environment.
The Guest – Dr Nathalie Pattyn

Nathalie Pattyn, MD, MPsy, PhD, received a degree in medicine from the Université Libre de Bruxelles (magna cum laude, 2001), a Master in Clinical Psychology from the Vrije Universiteit Brussel (cum laude, 2004), a PhD in Psychological Sciences from the Vrije Universiteit Brussel (2007) and a PhD in Social and Military Sciences from the Royal Military Academy (2007).
She also holds a postgraduate degree in Aerospace Medicine; a postgraduate degree in Emergency Medicine; a postgraduate degree in General Practice ; a postgraduate degree in Disaster Medicine ;and a Master in Global and Remote Healthcare.
She completed her Junior Officer Course with the Belgian Defense College in 2005, and her Staff Officer Course in 2008. She has a mixed clinical, research and operational background, having been deployed as a medical officer in various Middle Eastern and African countries, and having completed missions in Antarctica for a total duration of more than two years.
Her longest deployment was 15 months to the Halley VI Research Station in Antarctica, where she worked as the station physician while setting up a new biomedical research laboratory for the European Space Agency. She is currently still working as an emergency physician and a flight surgeon.
Her research interests include the psychophysiological measures of performance in elite populations; and Human Factors approach to isolated and confined environments, ranging from space to submarines.
In 2010, she founded a research unit within the Royal Military Academy, dedicated to the multidisciplinary study of human performance in operational environments. This led her to be the project manager for designing a tailored Human Performance Program for the tier one unit of the SOF community in Belgium.
She is currently an Associate Professor in Physiopathology at the Vrije Universiteit Brussel and in Human Performance at the Royal Military Academy.
Tactical Trauma 2024

Huge thanks to Fredrik Granholm and all at Tactical Trauma 24 for their very warm welcome and for letting us record this series of podcasts. This is a fantastic conference, and we would highly recommend you check it out when they advertise their next event.
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Thank you for addressing this important issue in our continuing professional development. The construct of skill fade is likely to be multi-faceted. There are both subjective and objective components. It may be an internal experience or be externally visible. There are cognitive, affective and psychomotor components. Our own insights will vary. What defines skill-fade is also likely to be related to personality factors, peer expectations, as well as institutional standards. An important question is at what point does skill-fade become clinically significant? This is quantifiable if we compare outcomes high volume cardiac medical or surgical centres with low-volume ones. However, in EM there are few procedures that a practitioner can come even close to volume as our specialised colleagues. Measuring outcomes with these numbers is not statistically meaningful. This makes determining the ideal volume or frequency of any chosen intervention difficult.