Apologies for posting again on the same thread.
There's a huge amount of complex scientific information relating to any
given clinical situation or topic and it would be unnecessary and
impossible (not least because of the time factor) to activate all of
that learning in order to arrive at a (sometimes provisional) diagnosis.
So I'd agree entirely that creating mental short cuts and heurisitcs are
a necessary part of the development of medical expertise. This
psychologial process of creating mental rules of thumb is of course not
unique to medicine - it's a fundamental part of being a human being.
However, could it be that part of the reason clinicians struggle to
accept or implement evidence in clinical practice (and we can all think
of many many examples where this is still the case), is because they are
using the same psychological processes of 'short cuts' when they are
making decisions about management options? Gabbay and le May BMJ 2004
are the most recent to demonstrate that instead of persuing critical
appraisal as part of the 5 steps of EBM, or reading summaries of
evidence compiled from trusted sources such as Cochrane, Clinical
Evidence or (in the UK at least) NICE - clinicians base their management
decisions on what colleagues told them or brief reading in magazines. In
other words it seems they (we) take short cuts to the evidence, and then
use mental rules of thumb in reaching management decisions.
Many health care systems are active in implementation - "doing things"
to the system or individuals in order to better implement clinical and
cost effectiveness decisions. Guidelines would be the most common
example. That seems to create an overall median effect size of 10 %
(Grimshaw J, et al. Journal of Continuing Education in the health
professions 2004; 24: S31-S37). Of course, no one is going to abandon
the implementation interventions, but just to do that and not to
consider how humans acquire and process information in the real world
(brief reading and talking to each other) and then try to do something
about that as well seems a little perverse.
I promise I'll be quiet now, for a little while at least.
Neal Maskrey. Medical Director, National Prescribing Centre, 70 Pembroke
Place, Liverpool L69 3GF. Tel: 0151 794 8135. e-mail:
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From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Djulbegovic,
Sent: 14 August 2006 21:53
To: [log in to unmask]
Subject: Re: Commentary About EBM from Peru
What has been missing in this discussion is explicit consideration of
TIME factor. If we have all time (and resources) in the world available
to us, then arguably any of us could come up with the advice which is in
the best interest of patients. The problem is, as the folks of this
discussion group know it too well, that we have to give our advices and
make decisions in the framework of LIMITED TIME (fraught with
uncertainties and lack of reliable information). As two Nobel laureates
(Simon and Kahneman) showed, under circumstances such as a typical
clinical encounter we have to act (and interact) within a framework of
"bounded rationality", to use "satisficing" rather than "maximizing"
strategy. The challenge is to identify these "boundedly rational rules
of thumb" that can be easily transportable to different setting (and are
still associated with attributes of a "good" decision).
Benjamin Djulbegovic, MD,PhD
Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute at the University of
South Florida Department of Interdisciplinary Oncology, MRC, Floor 2,Rm#
12902 Magnolia Drive
Tampa, FL 33612
e-mail:[log in to unmask]