Hi, Ben.
It may be theoretically impossible, but I feel like I do it. And when I
feel like I am doing it, the process feels different and seems to lead
to different outcomes than when I don't try do it.

Can clinical expertise enable patients to assess what they will make of
and do with evidence (along with being the basis of the clinician's own
decision making)?

Is this the sort of conundrum that prompted the adage, "In theory,
theory and practice are different, but in practice they aren't."?

Cheers!

Jim

James M. Walker, MD, FACP
Chief Health Information Officer
Geisinger Health System
 
 
If the human mind was simple enough to understand, we'd be too simple
to understand it.
                       - Emerson Pugh 


>>> "Djulbegovic, Benjamin" <[log in to unmask]> 7/8/2009 2:15 PM
>>>
Neil, Thank you for this. I am really happy to see that this is finally
happening...for a long time the EBM camp has not talked to
decision-making researchers, and I hope this will finally open the long
neglected discussion between evidence and decision-making (necessary but
not sufficient for decision-making)...This also provides the opportunity
to re-define EBM. Most textbook definitions of EBM still talk about
**integration of best research evidence with clinical
expertise and patient values.** Based on theoretical ground that
Neil alluded to this is not possible. Most decision scientists would
argue that no theory can be both descriptively and normatively (and
prescriptively) valid. Hence, definition of EBM aiming to achieve the
stated goals of **integration of best research evidence with
clinical expertise and patient values" is theoretically impossible:
integration of normative concepts (evidence and patient values) with
descriptive theories of decision making (clinical expertise) to become a
prescriptive theory (improve decision making) cannot be done (at least
at today's level of scientific development and as long as humans think
the way they do...). 

Which is not to say that there is no much to improve how we practice
medicine... but we need to know what we can and cannot do...

ben

Benjamin Djulbegovic, MD, PhD
Professor of Medicine and Oncology
University of South Florida & H. Lee Moffitt Cancer Center & Research
Institute
Co-Director of USF Clinical Translation Science Institute
Director of USF Center for Evidence-based Medicine and Health Outcomes
Research


Mailing Address:              
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12901 Bruce B. Downs Boulevard, MDC02
 Tampa, FL 33612

Phone # 813-396-9178
Fax # 813-974-5411

e-mail: [log in to unmask] 


______________________

Campus Address:             MDC02

Office Address :                 
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CMS3057
Tampa, FL 33612



-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Maskrey
Neal
Sent: Wednesday, July 08, 2009 12:41 PM
To: [log in to unmask] 
Subject: Re: List of biases

Thanks for starting this string Jon. We've discussed the importance of
how human beings, clinicians and patients and both together, acquire and
use information to reach decisions in health care in the past and you've
finally prompted me to tap to this group.

Apologies for the length of this. I've kept it as short as I can,  and
tried though failed to avoid stating the obvious. No doubt you'll tell
me.

Ian Scott has an excellent paper in the 4 July BMJ - "Errors in
clinical reasoning: causes and remedial strategies". For those
interested, two easy-reads as introductions to the topic are Gerd
Gigerenzer's "Gut Feelings" and Stuart Sutherland's "Irrationality: the
enemy within".

I'll summarise. There are essentially two systems we use in acquiring
information and reaching a decision. So this is any decision, including
in health care decisions both diagnosis and management. A system 1
approach involves acquiring a limited number of information items and
using them to make a "fast and frugal decision". The human brain has
limited capacity and we need to truncate the volume of information and
process it in order to be able to make a decision.

System 2  is more systematic with lengthy and detailed collection and
analysis of data. If we were buying a new car we'd almost certainly read
some magazine articles and talk to some people who we trusted for the
knowledge about cars. I'd guess almost no one would go to the systematic
reviews re automotive engineering on the Society of Automotive Engineers
website. And if we did, that might not improve the decision.

System 2 is what we'd expect to underpin health care decisions,
especially those big decisions that don't thankfully have to be made
more than  a few times in a lifetime. Unfortunately the data shows that
clinicians make decisions based on brief reading and talking to other
people (Gabby and le May BMJ 2004). That sounds uncomfortable but
there's some reassurance in that Gigerenzer shows in some settings
system 1 based decision making can out perform system 2 based decision
making.

However, that seems less credible in more complex decisions and the
list of cognitive biases described in the literature looks like
testimony to the fallibility of humans.

Obviously its not a simple as the above and e.g. the recent BMJ paper
describing GP reasoning from Carl Henegan et al provides more complexity
and insights.

So what's to be done. Well, firstly we've recognised the issue.
Secondly, it seems sensible to explore teaching some of this in our
work. Ian Scott summarises the evidence for that and as you'd expect it
looks like its a slim volume as yet. There might be some harms from
taking this too far too soon, but we are all too aware of the greater
harms from the under and over implementation of health care
interventions.

For me this links into where we're going with EBM. I think we're in the
3rd age and tip-toeing into the 4th. EBM v1.0 was conceptual. EBM v2.0
was and is technical development - searching skills, MA stats etc. EBM
v3.0 was and is the industrial age - Cochrane collaboration, teaching
critical appraisal to anyone who shows interest etc. And so I'd profer
that if we want to make EBM really live for people (cf threads on this
group on a number of occasions) EBM v4.0 needs to be Customer Focussed.
The customers are clinicians, patients, commissioners and no doubt
others. And if we want to reach those groups we need to think about they
as humans use EBM outputs as information and how they use those to make
decisions. People need to be careful who they talk to and what they
(briefly) read.

And in order to broaden our understanding of why high quality evidence
still doesn't get incorporated into practice quickly, we need to have a
dialogue with other specialties - sociologists, ethicists and as in this
area the cognitive psychologists.

In summary, we teach health care professionals so they can make
decisions. It seems perverse not to describe to them how they as human
beings make decisions - so they  at least stand some chance of being
aware of some of their own and others potential foibles, doesn't it?

There's a few of us who've produced (at last) 5 papers which include
the above and lots more. They've been accepted by the UK RCGP journal
for GP Registrars InnovAiT and are in press. I'll post links as and when
they appear.

Love to talk to people about this.

Bw

Neal

Neal Maskrey
Director of Evidence Based Therapeutics
National Prescribing Centre
Liverpool
UK



-----Original Message-----
From: Evidence based health (EBH)
<[log in to unmask]>
To: [log in to unmask]
<[log in to unmask]>
Sent: Wed Jul 08 07:38:24 2009
Subject: List of biases

Hi All,

I thought I'd share this fascinating list of cognitive biases found on
wikipedia http://en.wikipedia.org/wiki/List_of_cognitive_biases.

What struck me was two things:

1) The sheer volume of potential cognitive biases

2) We often focus on methodological biases, but irrespective of the
purity of methodology, there is still a mountain to climb when it comes
to overcoming cognitive bias.

Best wishes

jon

PS I feel the need to play a game of cognitive bias bingo!



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