Thinking, Learning & Doing

Slow, deliberative, calculating, and effortful. Fatigues easily.

Fast, intuitive, the channel of expertise as tacit knowledge. Doesn’t fatigue.

Contemplative Thinking

Intuitive Thinking

Type 2

Type 1

Reflective (Mental Dispositions)

Algorithmic (Intelligence)

Intuitive Hunches/expertise

Most thinking is of this kind Pattern Matching

Expert: System 1 Intuitive Thinking

Tacit Knowledge

Novice: System 2 analytical thinking

Tacit Knowledge

Slow answer or Slow operation

action

Fast answer or Fast operation

action

experience

Gary Klein, 2009

Heuristics are intuitive mental tactics for making decisions quickly in the absence of detailed knowledge. Heuristics are part of everyday thinking. The mind does this automatically: 1. Similarity matching 2. Frequency estimation 3. Anchoring and adjustment

Biases are statistically unbalanced mental inclinations. They are automatic and not results of laziness or inattention: 1. Overconfidence 2. Hindsight bias 3. Confirmation bias

The visual system automatically makes assumptions about the environment.

This creates a heuristic interpretation: the visual system constructs the image in the mind. The mechanism is very good, it met survival needs in the evolutionary environment, but it is not perfect. Illusions illustrate the assumptions at work.

Martian face

The illusion disappeared in photos from other angles.

Forgetting

Perception Visual

Auditory Haptic

Input

Long-term Memory Episodic Semantic Procedural

Subconscious

Rule-based

Knowledge-based (Deliberation)

Conscious Thinking Decision-making

Human Thinking

Action

Output

Forgetting

All thinking and perception begins in the subconscious.

STM attention

Schemata (Intuitive)

Expert: System 1 Intuitive Thinking

Tacit Knowledge

Novice: System 2 analytical thinking

Tacit Knowledge

Slow answer or Slow operation

action

Fast answer or Fast operation

action

experience

Gallbladder at Rest

Conditions Conducive to Mistaking CD for Cystic Duct

Class I & III injuries

Gallbladder at Rest

Plane imperceptible. Adhesion of GB to CD.

CHD not seen

Conditions Conducive to Mistaking CD for Cystic Duct

Class I & III injuries

Meta Level (the Control)

Knowledge & Strategies

Goals & Constraints Mental Model

Situation Awareness

Object Level (the Task)

Performance control takes place at the executive (meta) level, where goals, constraints, mental model of the operation and anatomy, and technical strategy are integrated to carry out the task. Feedback is largely via visual perception, which monitors progress and unexpected events.

Judgment error: wrong operation; wrong approach; etc.

Misperception: bile duct injury; vagal nerve injury; incidental splenectomy; recurrent nerve injury; positive margin.

Legal standard of care: Neither poor judgment nor misperception can be assumed to be below the standard. The exact nature of the situation in any specific case may be impossible to determine retrospectively. The plaintiff is obliged to show why the mistake was below the standard given the context in which it occurred..

Before the accident.

Cook R & Woods DD

Hindsight bias: Retrospective analysis suggests that the outcome was predictable.

Cook R & Woods DD

After the accident.

SBAR (or SCAP) Read-back Face-to-face Hand-off IT

Checklists Timeout protocols Standardized orders H&P format

Every transition in care constitutes a gap where information is apt to be lost. Each should be formalized by a checklist or something similar.

Information loss at gaps can be decreased by structured handoff routines and checklists, which serve as memory aides.. HANDOFFS CHECKLISTS & ETC.

Cook R & Woods DD 9/19/2013

The System for Procedures

Operating Room

Interventional Radiology

ICU

Patient Care Wards & Staff

Surgeons

Anesthesiologists Nursing Social Work

Administration

ER

Outpatient Facility

Patient In

Patient Out

Anesthesia1

Patient Surgeon

Prepare

Surgical Ward

Clinic

R.R.

Operation O.R. Nurses

O.R. Nurses

Anesthesia2

O.R. Suite PreOp

Home

Nurses

Nurses

Referring MD

Nurses

Nurses

Surgical Patient Flowchart

9/19/2013

Anesthesia1

Patient Surgeon

Prepare

Surgical Ward

Clinic

R.R.

Operation O.R. Nurses

O.R. Nurses

Anesthesia2

O.R. Suite PreOp

Home

Nurses

Nurses

Referring MD

Nurses

Nurses

1. 2.

3.

4. 5.

6. 7.

8.

9.&10.

11.

·Eleven handoffs ·Eight procedural subsystems

1.

2.

3. 4.

5.

6. 7.

8.

9/19/2013

New technology means new kinds of operations, more complex operations, new instruments, increased supervision, and with the existing system suboptimal experience for competence.

Huge increase in the knowledge on all subjects means it is virtually impossible with the existing system for neophytes to assimilate everything relevant. But knowing what is relevant remains a requirement for competence.

THEN (1960-1970)

Separate services run by Chief Residents.

Supervision indirect. Often off-site (SFGH).

Large volume of cases; multiple experiences with each kind.

Relevant literature hard to access, easy to master.

Evidence-based practice.

NOW (2013)

Attendings in charge at all hospitals.

Supervision direct and continuous.

More kinds of cases; smaller volume of each kind. More complexity.

Relevant literature easy to access, but voluminous.

Evidence-based practice

H&P UGI series Gastrectomy LG LN nodes

Diffuse v intestinal CT scan PET scan EUS H. pylori Stage Superficial Nutrition Neoadjuvant Rx D2 LN dissection Maruyama index Laparoscopic

gastrectomy

1970

Clinically important information that the surgeon must know.

H&P UGI series Gastrectomy LG LN nodes

Diffuse v intestinal CT scan PET scan EUS H. pylori Stage Superficial Nutrition Neoadjuvant Rx D1-D2 LN dissection Maruyama index Laparoscopic

gastrectomy

2013

Clinically important information that the surgeon should know.

“The conscientious and judicious use of current best evidence from clinical care research in the management of individual patients.” Other kinds of evidence were deemed less reliable: intuition; rationalism; pragmatism; authority.

EBM was meant to free practitioners from expert opinion, the prevailing influence.

For primary care MDs the number of relevant original articles was overwhelming. Thus, unbiased summaries (eg, Cochrane reviews) were created.

The alternative solution, further specialization, is almost inevitable in specialties. Specialists are expected to be familiar with all relevant knowledge. How can they do that?

Evidence-based medicine is just a good start.

The structure should anticipate ad hoc and standard events.

Specify questions before learning Sources of information

How do surgeons learn? Testimonials. Information principally obtained from

experiences on the job. Not books; not original literature. Information is principally obtained from

experience and from reading a textbook. Information is obtained from PubMed searches

for relevant articles and from the other sources.

If the learner doesn’t have sweaty palms, he or she is probably not learning. (Tom King)

The learner should do 85% of the talking; the teacher 15%. (Tom King)

“Flip” the learning. Study the assignment before the class. Use class time for clarification and application of the facts. (Khan Academy)

Mass studying can promotes rapid learning, but retention and transfer is less than with spaced learning.

Testing is one of the most effective devices to create learning.

strong

weak

active learning

passive learning

Reductionism increases and reliability decreases as you go down the list.

Passive learning Mind-wandering Auto-distraction O.K. for experts; poor for novices Everybody likes lectures. No stress either way.

Lecture Crutches: 1. Take notes 2. Report what was said

strong

weak

active learning

passive learning

Reductionism increases and reliability decreases as you go down the list.

SHALLOW ENGAGEMENT DEEP ENGAGEMENT

Learner relies on memory and elaboration strategies.

Adequate for traditional classroom teaching, which is satisfied with factual answers and simple applications.

Learners rely on weak learning strategies and memorization.

Relate new material to old. Reconsider previous

conclusions about the subject matter.

Critique and revise. Strong motivation is

required. Learning techniques

important. Sleep

Conscious Mind

Stud

ying

Lear

ning

Shortterm Memory Co

nsol

idat

ion

Longterm Memory

HOT COLD

Retr

ieva

l Subconscious Mind

DISUSE

Forgetting results from disuse. The info enters a section of memory from which it cannot be retrieved. It is not really lost.

Learning and Forgetting Flowsheet

Schoolroom learning is mostly inferior to apprenticeship learning. The practice of medicine is challenging because the context is rich. Didactic teaching and simulation remove context, simplifying the problem.

From the learning standpoint, every patient should be considered to be a lesson.

One should follow a defined strategy for practice-based learning. Nowadays it is the only way to stay current.