A quote from Steve Gilman ( posted by Arin Basu in a different context for a
different forum):
"Much that you learn will be learned at a level below consciousness. Use
this. Even as you guide your thoughts consciously, allow for the intuitive.
This interplay between the conscious and unconscious is where the art of
thinking really blossoms."
Copyright Steve Gillman.
Article Source: http://EzineArticles.com/616048
Just a lame attempt on my part to summarize this rich discussion. Also the
line marked copyright makes me wonder about its true place in a web based
meta-cognitive future.
:-)
On Fri, Mar 25, 2011 at 3:36 PM, Maskrey Neal <[log in to unmask]>wrote:
> Imagine the first time you sat in a car as the driver. Whilst you may
> have acquired some knowledge about the functions of the steering wheel,
> gear stick and all the rest of the pedals and knobs, you could possibly
> get yourself to the corner shop safety, never mind the opposite side of
> country.
> But after 20-60 hours of instruction and practice you could actually
> drive competently - but you had to think about what you were doing.
> Another few years and you can drive to work in the morning and when you
> get there you can't actually recall lots of the journey. You stopped at
> all the red lights, didn't hit any cars or pedestrians, but for most of
> the journey you were actually driving on automatic pilot.
>
> I think that's conscious purposeful learning (system 2) becoming
> automated unconscious system 1 decision making. So I disagree Jim.
> Conscious decision making routinely becomes unconscious decision making
> if its repeated. One of the characteristics is its faster.
>
> Learning clinical skills is exactly the same process. You'll see the
> cognitive dance going on everywhere you look, whether in your schools or
> your clinics.
>
> Most of the time driving on automatic pilot you're fine, nothing bad
> happens, and you can problem solve, compose the shopping list etc etc
> whist on the way to work so its efficient use of time. Something
> unexpected happening in the traffic toggles you back to conscious
> decision making. But rarely, and especially if you have an accident
> whilst on automatic pilot, you'll definitely wish you'd have been
> concentrating more on the driving than the shopping list.
>
> Maybe, just maybe, if we can teach Ben's calibration and reflection, and
> probably most importantly just get people thinking about thinking (Ash's
> metacognition) so they're actually aware of how they're learning new
> stuff and why they find that difficult, and aware of how they're making
> decisions and the common cognitive and affective biases we might have a
> few less accidents. We need to find that out.
>
> Certainly the variation in clinical practice, the difficulties we all
> see in getting good quality evidence into routine practice, and the
> patient safety data says we ought to try something new, because what
> we're doing so far isn't actually having the required impact - despite
> sterling work including traditional approaches to teaching EBM.
>
> You probably all think I'm a bit crazy. But I remember as a young,
> enthusiastic but pretty naive GP trainer driving way across Yorkshire on
> a rainy winter Saturday to see and hear a young psychologist called
> David Pendleton tell us about how important it was to teach consultation
> skills and for him to show us some of the very first video recorded
> consultations. The video recorder was the size of a small car and I
> can't over emphasise the radical nature of what he was enthused about. A
> camera recording actual consultations! Within the holy sanctum of the
> doctor patient relationship! Of course we were sceptical (at best, I'm
> ashamed to say), but where are we with consultation skills teaching and
> video recording now?
>
> I think the list's probably heard enough from me for a bit now. I know I
> rant a bit about this. Let's continue off list if individuals find it
> useful.
>
> Best wishes and thanks for all the stimulation
>
> Neal
>
> Neal Maskrey
> National Prescribing Centre
> Liverpool UK
>
>
>
> -----Original Message-----
> From: Evidence based health (EBH)
> [mailto:[log in to unmask]] On Behalf Of Jim Walker
> Sent: 24 March 2011 20:13
> To: [log in to unmask]
> Subject: Re: Clinical Decision Making and Diagnostic Error
>
> The non-conscious system is massively parallel and processes something
> on the order of 10,000,000 bits of information per second, the conscious
> between 16 and 32 bits.
> So the conscious is something like the tip of a fully integrated
> iceberg, dependent on the pre-processing of disparate inputs by the
> non-conscious system for the highly (and necessarily) filtered
> information which it manipulates.
> So while the conscious can direct the attention of some aspects of the
> non-conscious system to some extent, there is no theoretical or empiric
> reason to think that the conscious system can "train" the
> non-conscious--or that we would benefit if it could. (Interesting how we
> identify with the conscious but not with the non-conscious.)
>
> Jim
>
> James M. Walker, MD, FACP
> Chief Health Information Officer
> Geisinger Health System
>
>
> >>> "Djulbegovic, Benjamin" <[log in to unmask]> 3/24/2011 3:31 PM
> >>>
>
> Hi Amy,
> I am at the moment reading some papers by Read Montague (from Baylor)...
> He has written some interesting stuff...
> Best
> ben
>
> From: Dr. Amy Price [mailto:[log in to unmask]]
> Sent: Thursday, March 24, 2011 3:13 PM
> To: Djulbegovic, Benjamin; [log in to unmask]
> Subject: RE: Clinical Decision Making and Diagnostic Error
>
> Dear Ben ,Neal and all,
>
> I am interested in the fMRI data identifying discrete brain areas for
> systems 1 and 2. I am particularly intrigued by how/when they link and
> if the unconscious bias might be trained . Do you have authors names,
> links or papers you could share. I am looking at this area in regards to
> addiction and collaborating with others who are identifying genomics.
> Presently exploring QEEG to see if this uncovers anything of interest...
>
> Best regards,
> Amy
>
> From: Evidence based health (EBH)
> [mailto:[log in to unmask]] On Behalf Of Djulbegovic,
> Benjamin
> Sent: 24 March 2011 02:55 PM
> To: [log in to unmask]
> Subject: Re: Clinical Decision Making and Diagnostic Error
>
>
> Neal,
> Thanks for these insights - it is a really interesting thought about the
> fMRI data identifying discrete brain areas as location of system 1 and
> system 2 (at the moment, I am too reading on this fascinating stuff, and
> after you pointed this out, I wonder what would Hammond say about the
> empirical data that seems to be falsyfying his thesis?)
> Regarding which reasoning system gets its more right than wrong, I think
> we are saying the same thing, except (that in my reading of Hammond he
> seems to be saying) that when we get it wrong, the consequences of
> relying on intuition vs. logic are of the magnitude order less
> significant? (We are, of course, talking about decisions related to
> human affairs and social policies, not to the stuff in the realm of the
> quantum physics!)
> Best
> ben
>
> From: Evidence based health (EBH)
> [mailto:[log in to unmask]] On Behalf Of Maskrey Neal
> Sent: Thursday, March 24, 2011 2:04 PM
> To: [log in to unmask]
> Subject: Re: Clinical Decision Making and Diagnostic Error
>
> Ben
>
> Good to hear from you. Spring's arrived in England and it's lovely, but
> it sure ain't Florida!
>
> My reading is slightly different. From that, neither system 1 nor system
> 2 are superior, but system 1 is our "default". If we are talking about
> errors of commission, then then Pat Coskerry shows these occur
> predominately in system 1 due to the common cognitive and affective
> biases. My own personal dramatic memories are fortunately few in number,
> but when I got it wrong the usual contributing factors were availability
> bias and affective - notably work overload and sleep deprivation. And
> I'm sure Hammond isn't right about us never being spectacularly wrong in
> system 1. In system 2 the common problem is omission - if a common
> medical emergency presents it isn't optimal to have to spend lots of
> time working out the diagnosis and treatment plan. Broadly speaking, as
> Pat Croskerry says, we're safer in system 2 - but we're a lot slower.
>
> The MRI emission data identifies particular and quite different areas of
> the brain being used live with system 1 and system 2 decision making and
> that's harder to explain as a continuum - happy to debate. We've
> obviously "cartooned" some of this necessarily in these brief,
> awareness-raising group discussions and one of the facets we've not
> mentioned is the frequent live toggling in decision making between
> system 1 and system 2.
>
> The key trick is to train people to step back and re-examine the
> issue...both from logical (system 2) and affective side (system 1)...a
> tough to do when decisions have to be made in a short time-frame...
>
> Absolutely. The next step is to prove teaching these approaches changes
> behaviour, and then that change in behaviour improves the processes used
> in decision making if that's possible. Showing improved outcomes or less
> errors or both would be ideal, but if we're honest the definitive
> literature showing "teaching EBM" or for that matter teaching anatomy or
> teaching genetics improves outcomes isn't massive either. The quick
> "could this be anything else" or "are there any other / better treatment
> options" or "did I check for contraindications / interactions"
> calibration at the end of the consultation is simply plain old fashioned
> good medical practice, so if this is well presented its (a) an
> interesting subject to teach and learn, and (b) some of the content has
> excellent face validity for students. Likewise the more leisurely
> reflection - but then maybe the St Pete police would want drivers to be
> concentrating on the road!
>
> I keep hearing about on going research which might move all of this
> forward, and there's certainly lots of interest. Fabulous.
>
> Best
>
> Neal
>
> Neal Maskrey
> National Prescribing Centre
> Liverpool UK
>
> ________________________________
> From: Evidence based health (EBH)
> [mailto:[log in to unmask]] On Behalf Of Djulbegovic,
> Benjamin
> Sent: 24 March 2011 11:02
> To: [log in to unmask]
> Subject: Re: Clinical Decision Making and Diagnostic Error
>
>
> Neal, a challenge is, of course, to know when to use our intuitive
> (system 1) vs. logical (system 2) inferential process...Kenneth Hammond,
> who has promoted idea of a continuum between system 1 and system 2
> (instead two sharply demarcated systems), has made a point that if we
> rely on the system 1, we will often be more wrong than right, but never
> spectacularly wrong. On other hand, reasoning based on system 2 (this
> would include EBM) would be more often right, but when it is wrong it
> can be phenomenally wrong (as our models of the world can be hugely
> mistaken)... A practical/educational corrolary from this is "rely on
> EBM, but if it does not agree with your intuition, don't go there
> go/re-examine your decision..." The key trick is to train people to
> step back and re-examine the issue...both from logical (system 2) and
> affective side (system 1)...a tough to do when decisions have to be made
> in a short time-frame...My own approach has been to ask
> students/residents/fellows is a) to review mentally all patient'stories
> ("cases") at the end of the day and focus on any possible
> oversights/errors that may occurred that day (e.g. while driving back
> home), b) ask yourself " if I were the patient, would I like to be taken
> care by thy guy/girl like me?"
>
> I have been doing this for years- wish I can report that I found the
> "solution"...unfortunately, I still find myself much deficient as I try
> to answer these questions...but resoluted to do better next day...
>
> ben djulbegovic
>
>
>
>
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