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>>it would be remiss of me not to share this scintilllating talk by Prof Pat Croskerry, Professor in Emergency Medicine at Dalhousie University, Halifax, Nova Scotia on the subject of clinical decision making and diagnostic error. http://runningahospital.blogspot.com/2010/11/risky-decision-making.html Thanks Ash. Actually the importance of this applies to all decision making of course, not just the diagnostic process. We see it all the time in decisions about prescribing decisions.If the group will indulge me a little, take this example:- 1. Spring 2006. Systematic review in BMJ outlines increased cardiovascular risk applies not just to COX II NSAIDs (notably rofecoxib), but also to some other "non-selective" NSAIDs.No change in England prescribing data following that paper. 2. Autumn 2006, UK medicines licensing body advises increased CV risk applies to non-selective" NSAIDs, ibuprofen at 1200mg per day or less and naproxen at 1000mg per day appear not to have increased CV risk. No change in England prescribing data. 3. November 2007, National Prescribing Centre (UK, i.e. me and mine) publish summary of evidence and local workshops commence. 4. In the following THREE years, further research is published which has conformed the 2006 BMJ paper, and nationally our commonest prescribed NSAID diclofenac has fallen from 46% of all NSAIDs to 36% of all NSAIDs. Naproxen rose from 8% of all NSAIDs to 17% of all NSAIDs. In themselves these are hardly startling figures - but the average hides the outliers. Naproxen varies between 13% and 25% depending on which region you live in. Diclofenac between 22% and 40%. There's been no change in ibuprofen. Drill down further and in some PCTs ibuprofen and naproxen together account for two-thirds of prescriptions. In others, they're only a third. We've had a paper describing this NSAIDs case study accepted. This variation in clinical care is of course well described and Ash, Muir Gray and others have in recent month published an NHS Atlas of variation http://www.rightcare.nhs.uk/atlas/ Where does decision making come in? Well, are UK prescribers unintelligent? NO, the reverse is the case! Are they lazy and not diligent? NO, the reverse is the case, they're fantastically committed and work incredibly hard. Could the problem be that we expect them to be excellent decision makers, and yet don't tell them at all about how humans make decisions, and how the common errors occur? POSSIBLY. What I am convinced of is that simply teaching EBM skills and producing volumes of guidelines are necessary but not sufficient, and we also need to teach people about how they make decisions if we are to help people to change practice in the light of new evidence. We had several hours going over the NSAID data one day in the summer of 2007. After all the slides had been presented and the discussion completed, I still needed to sit on my own for at least half an hour going backwards and forwards looking at the evidence and the prescribing data to overcome my ingrained thinking which was screaming at me "That can't possibly be true, can it?". Changing what we've routinely prescribed for yeas is very hard. Helping people do that is very important. [On a personal note, I had orthpoaedic surgery last month at a national centre of excellence. I'm sure the surgery was indeed excellent, time will tell. But my cocktail of medicines for pain relief on discharge (not discussed with me at all) included a month of diclofenac at maximum dose. Our current health secretary espouses as part of the current NHS reforms an approach to patient involvement in decision making as "No decision about me without me". There is some way to go, clearly.] We had Pat Croskerry over a year ago and he features in the individual decision making section of our previously trailed film which is again here:- Low resolution version High resolution version Duration (m,s) Introduction <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/introduction.ph p> (11,540KB) Introduction <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/introduction_hi _res.php> (26,474KB) 2:04 Evidence-based medicine <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/ebm.php> (49,223KB) Evidence-based medicine <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/ebm_hi_res.php> (114,172KB) 9:15 Information mastery <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/info_mast.php> (58,780KB) Information mastery <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/info_mast_hi_re s.php> (136,627KB) 13:05 Individual decision making <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/individual.php> (71,763KB) Individual decision making <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/individual_hi_r es.php> (166,447KB) 13:30 Group decision making <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/group.php> (35,940KB) Group decision making <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/group_hi_res.ph p> (82,721KB) 7:45 Patient decision aids <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/pda.php> (32,261KB) Patient decision aids <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/pda_hi_res.php> (76,016KB) 6:16 Summary and credits <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/summary.php> (22,424KB) Summary and credits <http://www.npci.org.uk/therapeutics/mastery/mast3/movie/summary_hi_res. php> (51,336KB) 5:25 I agree, he's a complete star. Decision making is the most important topic, way more important than everything else including even EBM, in medicine, nursing, pharmacy.................. Best wishes Neal Neal Maskrey National Prescribing Centre, Liverpool, UK.