Stephen

Thanks for posting the papers. I'd seen the Reyna and Lloyd 2006 one before, but not the one from this year looking at decision making by intelligence agents. I think the 2014 one was more worrying than the 2006!

I think it's FANTASTIC that we're now having regular discussions on this group re decision making and that some of the key theories and the language of decision making  have already become normal traffic. 

Indulge me and I will set out where I think we are. As briefly as possible. 

1. The results of the Reyna and Lloyd paper fit broadly with the rest of the literature on the acquiring and use of expertise (we mentioned the Dreyfuss brothers from 30 years ago in the RealEBM paper on the advice from a proper student  of decision making, and it still seems very relevant even if its referred to as Fuzzy trace theory) , but the groups studied in that paper are arguably very small to be drawing big conclusions - 9 medical students, 3 expert cardiologists etc - and in addition the gold standard decision making is judged as being right / wrong on the basis of being consistent with guidelines. This seems inherently flawed as an outcome when the desired approach is to include values and preferences of patients in the decision making. I was very impressed with the JAMA paper which said the appropriate metric for lipids was the proportion of patients who had had an informed discussion about their CV risk, rather than the % of some target group on a statin. 

I read a lovely piece of writing from a GP registrar at the weekend describing a patient with panhypopituitarism (which she'll never see again in her next 100 lifetimes in general practice). The gold standard, "guideline" approach would be refer to endocrinologist, but that's not what the patient was willing to accept. The patient was only willing to consider some empirical treatment and limited biochemical monitoring. This is tricky ground, but with pragmatic patient-centered approach confidence was gained by patient and interestingly also by the doctor - and gradually over time  a more conventional treatment and monitoring arrangement is arrived at. That's the essence of decision making in medicine - two people (at least) and usually over more than a single encounter. 

So that's three important limits to the current descriptive decision making literature - generally it concentrates on the clinician decision making alone against some arbitrary gold standard, its at a single point in time, and it ignores the obvious issue that there's a joint decision to be made by two people who have different knowledge, backgrounds and decision making approaches from each other.

2. More optimistically, I'm pretty sure that teaching clinicians the basics of bounded rationality and  dual process theory helps them with two approaches which help their decision making. I'd be pretty sure that our work which is being independently analysed now will show it helps with metacognition and calibration - and that it helps clinicians help understand others and their decision making (patients, when they make a different decision to them, and colleagues). Interestingly, we don't know for sure yet, but it looks like knowing a bit about oneself and one's own decision making means doctors feel better about their work. I'll get my limitations in straight away, it's small numbers (but a start). 

3. And of course on top of the basic theories there is the acquisition of expertise stuff as set out in the introduction to the Reyna and Lloyd paper, the learning styles literature, the risk tolerance / risk adverse spectrum (and I for one am not convinced that clinicians are always risk adverse if that's their trait and always risk tolerant if that's their trait), to say nothing of the massive effects of affective biases and cognitive biases (the latter being context specific, at least on occasion), and finally and not least the management of information overload so the knowledge inputs are optimised. 

4. So we are miles away from an intervention or interventions which will help us decode decision making, never mind an intervention to "fix" decision making. Indeed it seems to me that it's unlikely we can fix such a complex problem, and that's what complexity theory tells us. But some things are better than others when faced with a complex problem - we don't throw in the towel when we have a child to raise for example! So a grand unifying curriculum is possible - I'd profer communication skills, linked better to numeracy, basic clin epi, information mastery, shared decision making and some basic decision making theory for starters. It'll have to be a spiral curriculum to encompass the expertise acquisition issues....... 

Enough for now. 

Best wishes


Neal
Professor Neal Maskrey
Consultant Clinical Adviser, Medicines and Prescribing Centre
National Institute for Health and Care Excellence
Level 1A | City Tower | Piccadilly Plaza | Manchester M1 4BT | United Kingdom
Tel: 07770535128
Visiting Professor of Evidence-informed decision making, Keele University, Staffordshire. ST5 5BG





-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Marcus, Stephen (NIH/NIGMS) [E]
Sent: 05 July 2014 04:50
To: [log in to unmask]
Subject: Re: RealEBM paper

Colleagues,

My first post. Hopefully attachments can be sent.


Fuzzy Trace Theory ‎can help us in EBM understand ‎the implications of our work.

Stephen


Sent from my BlackBerry 10 smartphone.
From: Amy Price
Sent: Friday, July 4, 2014 8:48 PM
To: [log in to unmask]
Reply To: Amy Price
Subject: Re: RealEBM paper


Hi Ben,

I have seen the theories published and narratives written but not with supportive data. I am  looking at the correlations and asking questions . This is beautifully written , a classic paper on decision making in everyday clinical life  thank you Best Amy

From: "Djulbegovic, Benjamin" <[log in to unmask]<mailto:[log in to unmask]>>
Reply-To: "Djulbegovic, Benjamin" <[log in to unmask]<mailto:[log in to unmask]>>
Date: Friday, July 4, 2014 at 8:44 AM
To: <[log in to unmask]<mailto:[log in to unmask]>>
Subject: Re: RealEBM paper

Amy,
I may not have explained a gist of our findings well: performance on highly analytical tasks ( which must rely on the use of system 2/type 2 processes) correlated better with intuitive-experiential thinking than with analytical thinking. I have never seen similar results reported in the literature ( neuroscience or otherwise) and if you have, please let me know. ( obviously, I would love to see our study repeated, but at this point, this is very intriguing twist to the way we conceptualize physicians' thinking and decision-making).
Thanks
Ben
Ps BTW, we also detected a number of other correlations that were rather unexpected such as negative correlation between age and satisficing, but that discussion would need much more space than it would be appropriate for this medium.

Sent from my iPad
( please excuse typos & brevity)

On Jul 4, 2014, at 8:15 AM, "Amy Price" <[log in to unmask]<mailto:[log in to unmask]>> wrote:

Hi Ben, Rakesh,

These are the typical differences between novice and expert learners and the brain areas that are activated as a result. Above all physicians are people why not look to neuroscience

Best
Amy

From: "Djulbegovic, Benjamin" <[log in to unmask]<mailto:[log in to unmask]>>
Reply-To: "Djulbegovic, Benjamin" <[log in to unmask]<mailto:[log in to unmask]>>
Date: Friday, July 4, 2014 at 7:55 AM
To: <[log in to unmask]<mailto:[log in to unmask]>>
Subject: Re: RealEBM paper

Very nice, Rakesh
The problem is that we still know so little about the ways physicians think. In the recent paper on evaluation of physicians' cognitive styles (http://www.ncbi.nlm.nih.gov/pubmed/24722474), we found that trainees showed a tendency to engage in analytical thinking, while attendings (older, more experienced physicians) displayed inclination toward intuitive-experiential thinking. The trainees, however, performed worse on conditional inference task.
The findings again raise the issue of nature of medical knowledge with a number of implications for teaching ( of EBM).
Best
Ben


Sent from my iPad
( please excuse typos & brevity)

On Jul 3, 2014, at 11:14 PM, "Rakesh Biswas" <[log in to unmask]<mailto:[log in to unmask]>> wrote:

Thanks Huw for this excellent description of what may constitute an 'ideal evidence based patient encounter.'

To further attempt to expand on it, perhaps after the initial encounter and  listening carefully to symptoms, wishes and views, asking questions, examining and doing tests driven by 'intuitive' 'system 1' processing, healthcare can tremendously benefit from a workflow where this is routinely followed by an IT enabled system 2 processing. A workflow that for each patient may routinely include:

a) Searching for current best evidence for diagnosis and further management of the  'particular patient's' described condition.

followed by

b) Matching the available 'particular patient' data to generalizable patient data/current best evidence available online

and finally

c) Coming up with a contextually matched patient management plan for shared decision making.

I guess the above is 'old hat' theoretically but implementation leaves a lot more to be desired (not that we aren't trying). :-)

Here's some more literature :http://www.biomedcentral.com/1472-6947/4/19 on 'particular patient' based reasoning if one would have the stomach for it (one relatively easier way to grasp this article is to just click on the figures and go through them).

best,

rakesh


On Wed, Jul 2, 2014 at 4:37 PM, Huw Llewelyn [hul2] <[log in to unmask]<mailto:[log in to unmask]>> wrote:
I agree with everyone that compassion and sensitivity to a patient’s wishes is central to medical practice and that Neal’s account of his late mother’s illness typifies this.  However, I would like to draw attention to another neglected aspect of EBM.  I think that ‘Real EBM’ also involves:

1.      listening carefully to symptoms, wishes and views, asking questions, examining and doing tests guided partly by diagnostic hypotheses and partly by checklists, all driven by 'intuitive' 'system 1' thought based on an amalgam of personality, personal experience, didactic and problem-based learning, imagination from medical theories, observational studies, RCTs, meta-analyses and guidelines from diverse sources such as NICE, etc.

2.      suggesting diagnoses and justifying each one with the relevant ‘patient’s evidence’ in the form of the ‘relevant’ symptoms, physical signs and test results from (1)

3.      suggesting treatments and further tests also with further justifying ‘patient’s evidence’ from (1) that include the patient’s wishes and desires
The ‘patient’s evidence’ referred to above is the ‘particular’ evidence based on ‘particular propositions’ or ‘facts’ obtained from the ‘particular’ patient in terms of symptoms, views and feelings, physical signs and test results (as opposed to ‘general evidence’ based on ‘general propositions’ based on research observations on groups of patients).  This ‘patient’s evidence’ has not been part of ‘traditional’ EBM.  If it is written alongside a diagnosis or decision as taught in the Oxford Handbook of Clinical Diagnosis, the ‘particular evidence’ helps others to understand one’s reasoning.  It also allows a diagnosis and decision based on this ‘particular evidence’ to be checked against published guidelines.  Finding such a published guideline that arrives at the same diagnosis and decision based on similar findings and based (to some degree or other) on research evidence that supports a diagnosis or decision might be regarded as ‘validating’ it e.g. in accordance with the Bolam test in British Tort Law if the authors (e.g. a NICE committee) can be regarded as a reasonable body of opinion! (see also my post on the 19th May beginning "Dear Rakesh and everyone".) With best wishes Huw Dr Huw Llewelyn MD FRCP Aberystwyth University ________________________________
From: Evidence based health (EBH) [[log in to unmask]<mailto:[log in to unmask]>] on behalf of healingjia Price [[log in to unmask]<mailto:[log in to unmask]>]
Sent: 02 July 2014 06:32

To: [log in to unmask]<mailto:[log in to unmask]>
Subject: Re: RealEBM paper

Hi Rinku,

This was a title for a paper Neal  Maskrey is  working on writing. The other is my response as the concept resonated deeply in me. To me choosing kindness and to remain kind in adversity is greatness and something I work to grow better at, I believe there is healing in kindness  and power in gentleness that is chosen.
Best
Amy

Amy Price
Empower 2 Go
Building Brain Potential
Http://empower2go.org
Sent from my iPad

On 2 Jul 2014, at 01:11 am, "Rinku Sengupta" <[log in to unmask]<mailto:[log in to unmask]>> wrote:

Hi Amy
''Small is beautiful'' - please send in the whole link-seems like something to look into 'deeply'-a very intersting choice of words below-especially- the ability to be/remain kind amongst adverse conditions-evidence based or not.
Thanks
Rinku
Dr Rinku Sengupta
MBBS DGO MRCOG PGCERT MED ED
MEDICAL OFFICER(voluntary)
Dept Of Obstetrics and Gynaecology
Matri Bhavan Hospital
Kolkata
India
00 913324174046


On Wednesday, 2 July 2014, 2:03, Amy Price <[log in to unmask]<mailto:[log in to unmask]>> wrote:


“Small is beautiful: a study of evidence-based medicine as if people mattered” (Copyright reserved!).NM  I love this concept, kindness, asking questions that matter  and being fully present are choices  that are within our power to make. I would add that helplessness is something clinicians face often and it is the most difficult of all as it can kidnap strength and empathy making it important to remember  self kindness and compassion as well so there is space to give to others who have misplaced hope and strength.  Thank you all for being a wonderful, diverse  and kind strength giving group.

Best
Amy

From: "Djulbegovic, Benjamin" <[log in to unmask]<mailto:[log in to unmask]>>
Reply-To: "Djulbegovic, Benjamin" <[log in to unmask]<mailto:[log in to unmask]>>
Date: Tuesday, July 1, 2014 at 7:40 PM
To: <[log in to unmask]<mailto:[log in to unmask]>>
Subject: Re: RealEBM paper

Neal,
It is so satisfying that your mom had a long, meaningful and fulfilling life surrounded by her family who has supported her to live consistently with her outlook at the world...but, as you so eloquently analyzed it, her medical management was completely consistent with the precepts of EBM...no doubt there will never be "idiot-proof" guidelines, and as saying goes " a good doctor knows how to treat, better one when to treat/order dx test, and best one when NOT to administer Rx/order test"...but your and your colleagues piece is ultimately about the nature of medical knowledge and expertise ( in the context of more humane and compassionate care)...
EBM has started its revolution by challenging knowledge of experts....telling us that we should never stop asking a question "how do experts know?" But, more often than not we- particularly trainees- continue to invoke authority in answering questions asked about patient management.
Thanks for opening this interesting tread Ben

Sent from my iPad
( please excuse typos & brevity)

On Jul 1, 2014, at 3:40 PM, "Neal Maskrey" <[log in to unmask]<mailto:[log in to unmask]>> wrote:

Well, thanks Ben and everybody. Most encouraging.

Just to interject a note of caution, when faced with an 84 year old woman with new atrial fibrillation after a recent myocardial infarction, an unexplained recent episode of iron deficiency anaemia (too ill post MI to investigate), a recent stroke (full recovery in 3 days), long standing osteoporosis, impaired renal function and long standing heart failure controlled with an ACEi……………how does evidence in the form of rules, guidelines, technology assessment or anything else help us?

We know (or could find out) what the data look like for most of the treatments we’d consider for most of these conditions individually but there were few people in the RCTs aged 84, never mind one of those co-morbidities and certainly not all of them. We have no idea from the evidence what is the best treatment for those conditions in combination. The research data might or might not be deliberately flawed, but really in such circumstances it’s only a guide at best.

Whether its rules or evidence, we are indebted to and need to rely to two things. The expertise of the clinician who has seen some people with some of these diseases in combination and has that experience and expertise to offer. And, even more importantly, the values and preferences of the patient (see the RealEBM paper for the principles).

In this particular case, the patient was not the slightest bit interested in the AF and stroke prevention, one of the medical imperatives. She dismissed the offer of AF decision aids. Her agenda was she felt lousy most days, she needed kindness and help with daily living, she wanted her medicines reviewed so she didn’t have to take any medicines other than those which kept her symptoms down, and she definitely didn’t want warfarin (even if someone was willing to give it to her) because her husband had been on that and it was awful trying to get INR control and there was no way she could get to the clinic to have her blood taken anyway because her son would have to take her and she didn’t want to be any more of a burden.

The above is a real patient. She recovered pretty well and lived almost independently with no further acute serious illness in what she called her luxury penthouse apartment on many fewer medicines, loved and cared for by her large extended family, and definitely taking nothing for her stroke prevention for 4 years, dying peacefully 2 months short of her 89th birthday. She happened to be my Mum.

The genius of Sackett, Guyatt et all still shines through.
Clinical expertise, needs and wishes of the patient, explicit use of evidence (definitely not rules). All focussed on the best care for individuals. No matter what “the rules” say.
Andy Hutchinson reminded me today about EF Schumacher and his 1973 book “Small is Beautiful: a study of economics as if people mattered”.  We laughed and said we need “Small is beautiful: a study of evidence-based medicine as if people mattered” (Copyright reserved!).

Nothing has changed since the BMJ in 1996. Just that we need more than the industrial scale production of guidelines, protocols and SOPs, all of which which are necessary but which are not sufficient for the present, never mind the future.

And at the risk of being accused of self-publicity see http://blogs.bmj.com/bmj/2014/07/01/neal-maskrey-the-importance-of-kindness/

Best to all


Neal
Professor Neal Maskrey
Consultant Clinical Adviser, Medicines and Prescribing Centre National Institute for Health and Care Excellence Level 1A | City Tower | Piccadilly Plaza | Manchester M1 4BT | United Kingdom
Tel: 07770535128
Visiting Professor of Evidence-informed decision making, Keele University, Staffordshire. ST5 5BG



From: Djulbegovic, Benjamin [mailto:[log in to unmask]]
Sent: 01 July 2014 16:35
To: Neal Maskrey; [log in to unmask]<mailto:[log in to unmask]>
Subject: RE: RealEBM paper


Well done Neal and colleagues. Nothing to disagree with. However, I found the following sentence a key to the possibility of resolving the dilemmas identified in your paper (“Evidence based medicine: a movement in crisis?”)

“Given that real evidence based medicine is as much about when to ignore or over-ride guidelines as how to follow them, those who write guidelines should flag up the need for judgment and informed, shared decision making.”

This really bring us back to the seminal 1992 JAMA paper, which introduced EBM and highlighted the role of experts (and nature of expertise); should we trust experts with their tacit knowledge based on private evidence not accessible to others, or should we insist on explicit, public type of knowledge that can be understood by all people who share a common set of the tools (and values)? The public scrutiny and demand for accountability currently heavily favors “rules” over “judgments” …. I am skeptical that we will see fundamental changes any time soon even if successfully enact all initiatives outlined in Box 3 of the paper… This, of course, is not to say that we should not try, but as they say “it is complicated”☺ Best ben


From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Neal Maskrey
Sent: Friday, June 13, 2014 2:16 PM
To: [log in to unmask]<mailto:[log in to unmask]>
Subject: RealEBM paper

http://www.bmj.com/content/348/bmj.g3725

Trish is up a mountain so I’ll post that this is published online in the BMJ today.

The amazing Trish G who led all this magnificently, lots of big brains……….and little me.

The BMJ seems to have website problems today; I can only get this via Explorer and not on the iPad (yet?). Be gentle dear friends, be gentle.

And of course, thanks as ever for all the stimulation…………

Best to all

Neal
Professor Neal Maskrey
Consultant Clinical Adviser, Medicines and Prescribing Centre National Institute for Health and Care Excellence Level 1A | City Tower | Piccadilly Plaza | Manchester M1 4BT | United Kingdom
Tel: 07770535128
Visiting Professor of Evidence-informed decision making, Keele University, Staffordshire. ST5 5BG


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