Neil, thanks.
I have wholeheartedly agreed with your emphasis on decision-making all long...In fact, I am a big proponent of dual process theory (and in a small way have been trying to promote it). The problem is: a) that none of the current definition of "rational" decision-making have accepted it (we are still in the EUT world- see attached, written in somewhat different context, but relevant to this discussion nonetheless), b) we simply do not know when to "trust" system I vs. system II. It would be great if you all can identify set of circumstances when we should rely on intuitive reasoning vs. deliberative one. I, for one, think that in the case of life-threatening conditions, regret theory (i.e. non-EUT theory) is more valid than EUT, but many folks don't.
I am truly hopeful you can help move the debate along... too bad I can't be there, but looking forward to reading about the progress...
Best
ben
-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Maskrey Neal
Sent: Saturday, October 24, 2009 1:38 PM
To: [log in to unmask]
Subject: Re: The EBM curriculum - revising the Sicily statement
Hi Ben and group
I think decision making theory is pretty mature. There's a good 30 years of modern research which includes two Nobel prizes (Daniel Kahnemann for essentially dual process theory, most done with Amos Tversky who sadly died before the Nobel prize was awarded) and Herbert Simon for bounded rationality. Our problem is they've worked in economics not medicine and its all a strange world, and makes our brains ache. Well mine anyway.
Dual process theory looks like a unifying model and has supporting evidence from psychology, neuroanatomy, neurophysiology and even genomics. Of course "all models are wrong, but some are helpful." No question in my mind that dual process theory is very helpful, for it explains the transformation Ben describes beautifully.
Let's explore at Sicily, and you can shoot me down!
Bw
Neal
Neal Maskrey
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: Sat Oct 24 18:03:31 2009
Subject: Re: The EBM curriculum - revising the Sicily statement
Paul, thanks
No, I am not giving up, but in the faithful adherence to EBM principles, we simply need to continue to evaluate what works and what doesn't :-) However, I feel that I need to qualify my previous response (although I am sure that the Oxford students are very smart ones and are lucky to be taught be the leading EBM educator and researcher!)
We have recently merged clinical problem solving course with EBM, which is given to 2nd year students. This course revolves around hypothetical cases. When nudged and guided, the students do a great job in all aspects of EBM (in the US, medicine is studied at the graduate level, meaning that most students have already been exposed to statistics, theory of knowledge, took necessary math courses etc so, with a quick reminder they easily get basics of EBM statistics...). However, something breaks in the later years when they have more clinical rotations...It looks like that the EBM lectures have all but forgotten...Most of students (and residents and fellows- this is what continue to surprise me) are not even aware that there are questions that needed/could be answered...Undoubtedly, the mind-set is of problem-solving, but the problem-solving that takes form of of the quick action-oriented approach ("I just need to know what I need to do") and not of critical appraisal ("as long as the experts do this, I don't really care if this is necessary good or bad")...This is the reason that I think that EBM has to be embedded in the clinical rotations...for EBM to be relevant, it has to be content-driven...In fact, most people realize this, but no one seem to be able to find time slot in the current curricula i.e. to re-arrange clinical rotations in such manners that training is EBM driven...If we were to do so, then we probably could see no more than 7-10 patients/day, as opposed to 25-30 patients/day (NB individual students/residents are still responsible for no more than 7-10 patients, but the entire team typically cares for 25-30 patients). So, how many patients does the attending on clinical service in Oxford takes care of? What about students/residents (registrars)?
I am not sure if any of this needs to find its way into Sicily statement, but these are observation from "the trenches"...
Best
ben
-----Original Message-----
From: Paul Glasziou [mailto:[log in to unmask]]
Sent: Saturday, October 24, 2009 11:32 AM
To: Djulbegovic, Benjamin
Cc: [log in to unmask]
Subject: Re: The EBM curriculum - revising the Sicily statement
Hi Ben,
Yes - I think the order of teaching things is important, and we shall
certainly look at this (I know Julie Tilson has been working on this
issue).
From failed experience, we also think that some basics should be taught
first (searching, statistics, appraisal, etc) before putting it all
together. In Oxford the basics happen in the pre-clinical years, and by
the clinical years they are able to apply this. So early in year 4 we
give them a similar excerise to your question, and nearly 100% come back
(within a 24-hour turnaround) with good searches, appraisals, and
applications. So I am curious about what your students had done
previously, and what stage of background knowledge they have? (And I
urge you not to give up yet ;-)
Cheers
Paul
Djulbegovic, Benjamin wrote:
> Here is a small uncontrolled observation that may further inform your deliberations. Every time I am on clinical service, I tell students, residents or fellows the following: I have one educational task for each of you. Your job is to identify the issue/question/problem in YOUR patient that you do NOT know the answer to. I want you then to go in the literature and search for the answer (evidence) and report back to the team.
> I have been doing for many years. Do you know how many trainees have done this properly (according to the EBM paradigm)? Zero! (and many of them would refer to the authority in providing their answer since there are some famous people around they can easily ask for the answer). (In the past, when we had more time to teach at bedside, this actually provided the great opportunity for teaching. Not so any more, since the entire patient care and teaching are increasingly compressed in time)
> In my mulling over this, I came to conclusion is that it is the content i.e. background knowledge that matters. People without sufficient background knowledge have difficulties articulating the questions (it has been said that capability to articulate question is one of definition of creativity). This implies that we should teach EBM in the later years of training and not in early years (as it is currently the case, at least in my instutition , but also at several other institutions I know). Perhaps the revised Sicily Statement should take this into account.
> wishing you the most productive conference
> best
> ben
> ps I am so curious to see what will come out of the discussion regarding the need to teach principles of interpretation of medical evidence (critical appraisal) vs. decision-making. The former has been sufficiently well operationalized, but does current state of knowledge allows operationalization of decision-making process? So far, for the most part, teaching EBM has been prescriptive ("how to do" stuff, with the focus on E aspects of EBM). Can we be really prescriptive when it comes to decision-making at this point of time? Looking forward to learning the outcomes of the Sicily meeting discussion with a great interest.
>
> ________________________________________
> From: Evidence based health (EBH) [[log in to unmask]] On Behalf Of Piersante Sestini [[log in to unmask]]
> Sent: Saturday, October 24, 2009 7:46 AM
> To: [log in to unmask]
> Subject: Re: The EBM curriculum - revising the Sicily statement
>
> My understanding is that background knowledge shouldn't be used to make
> practical decisions, but is essential to frame problems and to build
> foreground questions.
> I agree that guidelines can be used to address both kind of questions.
>
> Piersante Sestini
>
> R. Kok wrote:
>
>> My experience in teaching colleagues EBM is that answers to background questions can be very usefull in making practical decisions, especially in learners. However even with back ground questions aggregated evidence, for example guidelines can be very instrumental.
>>
>> Regards,
>> Rob kok
>>
>> ----- Original Message -----
>> From: Piersante Sestini <[log in to unmask]>
>> Date: Saturday, October 24, 2009 10:17 am
>> Subject: Re: The EBM curriculum - revising the Sicily statement
>> To: [log in to unmask]
>>
>>
>>
>>> I agree with your practical points. But just because they are
>>> learners,
>>> they have more background questions that foreground ones.
>>> So first of all they need to learn how to deal with the need for
>>> general
>>> knowledge (that is, background questions), rather than than to dig
>>> just
>>> into foreground questions from the start, as may be could be suitable
>>>
>>> for old hands.
>>>
>>> regards,
>>> Piersante Sestini
>>>
>>>
>>> Martin Dawes, Dr. wrote:
>>>
>>>
>>>> I think we need to be clear what the teaching objectives are for the
>>>>
>>>>
>>>
>>>> learner groups
>>>>
>>>> If we want people to practice EBP then they need to have great E-B
>>>>
>>>> (pre-appraised) resources at their fingertips, plus a raft of other
>>>>
>>>> items - the ready prepared meal approach
>>>>
>>>>
>>>>
>>
--
Paul Glasziou
Director, Centre for Evidence-Based Medicine,
Department of Primary Health Care,
University of Oxford www.cebm.net
ph - +44-1865-289298 fax +44-1865-289287
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