Hi Paul
Patient education using cognitive/visual tools is nicely presented in
Doak & Doak Teaching patients with low literacy skills
http://www.hsph.harvard.edu/healthliteracy/doak.html
As the site points out, the title is misleading the book is really
useful for anyone who does do not find algorithms or text very intuitive.
Best wishes
Janet
Paul Glasziou said the following on 14.12.2009 12:00:
> Dear Neal,
> Great discussion. I agree the dual processing theory is helpful, but I
> think its early days in how this might help training.
> In addition to the toggle between system 1 and system 2, research
> should also look at ways of training each system.
> A fascinating example is a randomised comparison of training consumers
> in the "ABCD" rule against paired photos for recognizing melanoma*.
> The "intuitive" (system 1) training seemed to do better than the
> analytic. Clearly it needs repeating, and would be useful to do with
> clinicians too.
> Is anyone aware of other studies comparing system 1 and system 2
> training?
> Cheers
> Paul Glasziou
>
> * Int J Cancer. 2006 May 1;118(9):2276-80.
> Superiority of a cognitive education with photographs over ABCD
> criteria in the education of the general population to the early
> detection of melanoma: a randomized study.
> Girardi S, Gaudy C, Gouvernet J, Teston J, Richard MA, Grob JJ.
> Department of Dermatology Hôpital Ste Marguerite, Assistance Publique
> des hôpitaux de Marseille andResearch unit LIMP EA 3291 Université de
> la méditerranée, Marseille, France.
> Most education campaigns for melanoma (MM) detection in the general
> population have used the "ABCD" algorithm, although recognition of
> objects in the real life is based on a holistic image recognition
> rather than on analytic criteria. The objective was to compare
> analytic (ABCD) and cognitive (photographs) strategies for teaching
> self-recognition of MM. A prospective 4-arm stratified randomized
> trial in 255 individuals compared 3 realistic educative interventions
> by leaflets: 1) ABCD algorithm ("ABCD"), 2) a set of photographs
> chosen to stimulate recognition of MM among benign pigmented lesions
> ("Cog"), 3) photographs + explanations ("Cog-Ex" arm) and 4) no
> intervention ("NI"). A 40-slides test was performed before
> intervention (T0), 1 week after (T1) and after induction of anxiety
> (T2). In the "ABCD" arm, sensitivity slightly improved (80 to 83.8%, p
> = 0.04), but specificity dropped from 65.1 to 56.3% (p < 0.001), with
> no benefit in accuracy as compared to "NI". In "Cog" arm, there was no
> change in sensitivity, but a strong increase in specificity (65.9 to
> 81.1%, p < 0.001) and accuracy (42.1 to 53.1%, p < 0.001). "Cog-ex"
> resulted in similar although lower benefit. Under stress (T2), there
> was a dramatic loss of specificity and accuracy in "ABCD" arm (65.1 to
> 44.1%, p < 0.001 and 40.8% to 35.8%, p < or = 0.001) without higher
> gain in sensitivity, while sensitivity and accuracy increased (p <
> 0.005) after "Cog" leaflet, without decreasing specificity. Finally,
> the "ABCD" message alone does not seem efficacious and is even worse
> in the context of anxiety, whereas a quick look at a few photographs
> is sufficient to improve the ability of the laymen to recognize a MM
> just by optimizing their spontaneous image recognition capacities.
> Education by photographs is a realistic strategy which should replace
> or complete "ABCD" message in the campaigns for self-detection of MM.
> 2005 Wiley-Liss, Inc.
> PMID: 16331608 [PubMed - indexed for MEDLINE]
>
>
> Maskrey Neal wrote:
>>
>> Great quote, Jim!
>>
>> So there’s another list of research questions….for starters….
>>
>> - what initiates a “toggle” from system 1 processing to system 2
>> processing (and the various strategies employed therein)?
>>
>> - does that toggle improve/ worsen or have no effect on decisions
>> made, and especially patient outcomes?
>>
>> - what initiates a toggle from system 2 processing (and the various
>> strategies employed therein) to system 1 processing?
>>
>> - does that toggle improve/ worsen or have no effect on decisions
>> made, and especially patient outcomes?
>>
>> Looking at the literature, most of the problems come from people
>> getting stuck in system 1 without activating system 2. Seems to me
>> that’s largely because system 1 is the system preferred by humans for
>> decision making –it’s a sort of baseline probability effect. So
>> probably (ho ho) the priority is the “debiasing”, but that’s not to
>> say that system 2 always beats system 1 by any means.
>>
>> Good stuff group.
>>
>> Many thanks once again
>>
>> Bw
>>
>> /Neal/
>>
>> Neal Maskrey NPC Liverpool UK
>>
>> ------------------------------------------------------------------------
>>
>> *From:* Jim Walker [mailto:[log in to unmask]]
>> *Sent:* 11 December 2009 21:10
>> *To:* [log in to unmask]; Maskrey Neal
>> *Subject:* Re: using beliefs and narratives to bolster uptake
>>
>> Great example, Neal.
>>
>> I'm suggesting an approach to cognition that goes beyond this to, for
>> instance, study how and why we switch from system 1 to system 2 (and
>> back) with what effects on accuracy and efficiency. Then we might be
>> better able to teach ourselves how make those switches more effectively.
>>
>> 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
>>
>>
>>
>> >>> Maskrey Neal <[log in to unmask]> 12/11/2009 4:09 AM >>>
>>
>> Of course Jim.
>>
>> The example I use when teaching is to show a picture of the classic
>> rash of meningococcal septicaemia and ask the audience "What
>> treatment does this seriously ill child need". In a flash they chorus
>> "Penicillin".
>>
>> Classic dual process theory where system 1 thinking just made the
>> diagnosis and sorted the treatment in half a second or less. Perhaps
>> saving a child's life. So it's really dual dual process theory.
>>
>> Except then system 2 ought to come in and consider alternatives for
>> both the diagnosis - maybe an acute leukaemia, a severe ITP, one of
>> the many other causes of DIC etc. - AND the management - IV fluids,
>> inotropic and respiratory intensive support etc.
>>
>> Think as well as blink. (Pat Croskerry, not me).
>>
>> I really don't know how I survived as a medic for over 30 years
>> without knowing this framework.
>>
>> Bw
>>
>> Neal
>>
>> ------------------------------------------------------------------------
>>
>> *From:* Jim Walker [mailto:[log in to unmask]]
>> *Sent:* 11 December 2009 01:54
>> *To:* [log in to unmask]; Maskrey Neal
>> *Subject:* Re: using beliefs and narratives to bolster uptake
>>
>> Please pardon this perhaps cryptic suggestion:
>>
>> While it is critically important, an exclusive focus on controlling
>> bias may distract us from studying and using the positive aspects of
>> human cognition to improve our decision making, for example, the
>> thoughtful teaching and use of satisficing.
>>
>> Happy holidays!
>>
>> 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
>>
>>
>>
>> >>> Maskrey Neal <[log in to unmask]> 12/10/2009 4:29 AM >>>
>>
>> Good morning - it seems to have stopped raining in Liverpool
>> today..after about a month!
>>
>> Reading Christine's original question, it's an important one for the
>> group. Describing the cognitive and affective biases that affect
>> decision making (judiciously, involving clinical expertise and the
>> patient's individual circumstances and preferences, of course) is one
>> step. But the next steps (I think) are to design a repeatable
>> intervention which both raises awareness of those biases but is also
>> capable of "debiasing" individuals and groups so that they are more
>> open to making decisions on high quality evidence, and of course
>> inherent in this is a tool to measure accurately and reproducibly any
>> change from pre- to post-intervention. Tools to assess basic
>> preferences and susceptibilities of individuals and groups to biases
>> or groups of biases would also be worth exploring, especially if it
>> becomes possible to design effective interventions which help those
>> individuals recognise and reduce such susceptibilities.
>>
>> I've had our information specialist run a literature search for these
>> types of study and we've not seen anything in health care. I'm
>> awaiting a very few papers which might or might not be relevant from
>> other settings - since decision making and biases are important
>> everywhere we can learn from those. Any more help from the group
>> would be much appreciated. But whatever, there's a rich research
>> stream here prime for mining.
>>
>> To that end, I'm trying to pull together a small workshop in London
>> on Monday 15^th March 2010 to explore the triad of information
>> overload/selection : clinical decision making : shared decision
>> making - and out of that I'd expect the research agenda to be
>> clearer. If UK (or elsewhere) members of the group are interested in
>> attending please contact me off list. The workshop isn't finally
>> confirmed yet, but I'd expect it to happen, and we wouldn't charge
>> attenders. You'd need to pay your own travel expenses though.
>>
>> The irony here is that the National Prescribing Centre doesn't have a
>> primary research remit - but as long as we're delivering on our core
>> programme that doesn't inhibit us from in addition stimulating others
>> to produce primary research - which of course then enables our core
>> function. J
>>
>> Best wishes
>>
>> Neal
>> //Neal Maskrey. Director of Evidence Based Therapeutics//// //
>>
>> Please note change of address from 17^th August 2009
>>
>> National Prescribing Centre
>> Ground Floor
>> Building 2000
>> Vortex Court
>> Enterprise Way
>> Wavertree Technology Park
>> Liverpool
>> L13 1FB
>>
>> web: www.npc.co.uk <http://www.npc.co.uk/> and www.npci.org.uk
>> <http://www.npci.org.uk>
>>
>> Please note change of telephone numbers from 17^th August 2009
>>
>> Main telephone number 0151 295 8671
>>
>> Fax line 0151 220 4334
>>
>> Secretary 0151 295 8691
>>
>> Disclaimer: This e-mail may contain confidential and/or proprietary
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>>
>> If any addressing or transmission error has misdirected this e-mail,
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>>
>> ------------------------------------------------------------------------
>>
>> *From:* Evidence based health (EBH)
>> [mailto:[log in to unmask]] *On Behalf Of *write words
>> *Sent:* 04 December 2009 17:55
>> *To:* [log in to unmask]
>> *Subject:* using beliefs and narratives to bolster uptake
>>
>> I'm a freelance journalist, and I'm writing a piece examining
>> pushbacks against evidence-based medicine (for instance, see the
>> latest mammogram controversy in the U.S.)
>>
>> In particular, I'm exploring the role of belief in the uptake of EBM.
>> In my reporting, I've found that new scientific evidence is often
>> rejected when it contradicts strongly held (but erroneous) beliefs.
>> It's not that people don't see the evidence, it's that they don't
>> believe it (or they don't believe that it applies to them).
>>
>> I'm looking for research on the role of belief systems in the uptake
>> of EBM. Has anyone studied ways to defeat scientifically wrong but
>> strongly held beliefs via narrative? The idea being, that in some
>> cases it's not the evidence itself that convinces, but instead, the
>> story or narrative constructed from the evidence. How can new
>> evidence be more effectively communicated when it contradicts
>> established practice?
>>
>> cheers,
>>
>> Christie
>>
>> Christie Aschwanden
>>
>> Freelance writer
>>
>> [log in to unmask] <mailto:[log in to unmask]>
>>
>> www.christieaschwanden.com <http://www.christieaschwanden.com>
>>
>> ------------------------------------------------------------------------
>>
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>>
--
Janet Harris
Course Director, Public Health Management & Leadership
University of Sheffield
Section of Public Health
School of Health & Related Research
Regent Court, 30 Regent Street
Sheffield S1 4DA
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Email: [log in to unmask]
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