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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