Hi Neal,

This is one of the best example of systems I have come across. Will it be ok with you if I use it in teching med students (with all due credit to you)?

Thanks again for tailoring the concepts to such a simplistic level.

Best wishes

Ambuj Kumar
University of South Florida


----- Original message -----
> 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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