---

From: "Djulbegovic, Benjamin" <[log in to unmask]>
To: [log in to unmask]
Sent: Thu, 24 March, 2011 23:49:55
Subject: Re: Clinical Decision Making and Diagnostic Error

perhaps we identify with the conscious but not with the non-conscious because we consider technological and other advances as an integral part of our logical, conscious system...but I don't believe that with all inventions at our disposal we are close to processing 10,000,000 bits of information per second (and without overheating!)
BTW, what is the fastest modern computer in terms of processing power?
ben

________________________________________
From: Jim Walker [[log in to unmask]]
Sent: Thursday, March 24, 2011 4:13 PM
To: Djulbegovic, Benjamin; [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