According to my watch, it is 531 in the hall.
So this tells me a lot.
I can't think of anyone better to give a guest lecture on knowledge and to actually think there's an awful lot about knowledge interaction.
I'm going to resist telling all sorts of anecdotes about the medical doctor.
Yeah, it works right across the board. And he's a real think outside the box.
And I collect think people who think outside the box.
And that's the main reason I brought him in.
He's a very clever professor, which he is, but because he is going to encourage us to think outside the box tonight, you can fill in the gaps.
I haven't said about the relevant things you think I need to know before you get into this amazing lecture, which I've seen twice before.
And I'm looking forward to seeing you again. Yeah, thanks.
I think I've got a microphone on here and we. Okay. Can you hear me?
Yeah, great. Okay. Well, thank you for the thank you for the invitation.
I'm going to we're through about four days of stuff.
Perhaps if I just stand at this side for at least for the moment in about in about an hour.
So I'm not going to fill in any more gaps about me because it's more about how we go about making decisions.
So what would be really great would be if you could dig out a piece of paper and a pen.
And if anybody needs any paper, here's some paper, pass it backwards.
This isn't going to be hard stuff. I know some of you have been working incredibly hard on this course this week and it's day four and 530 at night.
So this is going to be more on the entertainment and the things than on the education and the things.
But I hope you'll find it interesting and I hope there's a few things to think about.
It's just more fun if you join in, so be prepared for a bit of interactivity rather than just PowerPoint and me talking.
So let's start with familiar territory. Here's the socket definition from 1996.
I think this is heading for 30,000 citations.
So so there must be something in it. Now, I came here in 1994 when Dave Sackett was still here.
We had a party at Martin Dawes house with a swimming pool.
I remember that was the that was that was the greatest thing.
No, it wasn't Paul Glacier. It was here. And it was his first time as a group chief.
So it was that long ago.
And the point about this definition is that evidence based medicine started out all about making decisions for individual patients.
Interestingly enough, it's my emphasis in red.
But this word, the task set was better decision making for individuals, interestingly enough.
Did we answer that question? Well, three bits in the prologue.
So we were trying to drop in to the traditional clinical expertise alongside what would the patient consent to,
even if we didn't do a tremendous amount at that time about getting values and preferences explicitly in the way that we might try and do nowadays,
and we try and draw up in this evidence.
The task was to do that better, to have better consultations.
That was the challenge from that IBM editorial from 1996.
Did we answer that? Well, I'll steal this analogy from from Don Berwick.
This is a bridge in Honduras. Honduras is that little country in Central America.
They get a lot of rain. In Honduras, there are lots of rivers.
And in the 1930s, they need to build bridges because canoes weren't really cutting it for the economy.
And they built this bridge and the bridge was fantastic.
It stood up to all sorts of weather.
The traffic went backwards and forwards every day until in 1998 they got a Category five hurricane smack on the nose of Honduras,
one of the worst hurricanes that's ever been on the planet.
And this is the serious, but it was absolutely awful.
Tens of thousands of people died, hundreds of thousands made homeless.
The economy was decimated for a decade, but the bridge stood.
The civil engineers are doing a fantastic job. The.
There wasn't any malpractice and. In the construction, the bridge stood up to Hurricane Mitch.
The only problem was the river moved.
So the bridge answered the first problem. Now we've got a different problem, and we need to look again at what the challenge is.
And one of the first things the evidence based medicine movement did was start collecting all this fantastic research,
or some of it was fantastic and some of it wasn't very good.
And collecting it together into evidence summaries, some of which were called guidelines, and some were done very well.
Some were doing okay and some weren't doing very well at all.
But instead of answering the complex question of how do we do consultations which incorporate those three elements,
what we did was answer a simpler question, which was how do we collect the evidence together into evidence, summaries and guidelines?
And we did that quite a lot.
So we're now over 230 guidelines that nice where I used to work.
And we've developed a different problem now.
We have guideline overload and information overload, and all of this is based upon what's best for the population,
not what works best for the individual at this moment in time sitting in front of us.
With that clinical problem today. So that's prologue bit number one.
Prologue bit number two features this famous American ice skater called Dorothy Hamill.
Dorothy Hamill is advertising a drug called roughly Cox IB roughly Cox.
It was a sort of designer, non-steroidal anti-inflammatory drug,
which was produced in the hope of reducing one of the major side effects of all steroid pills, and that is gastric ulceration and bleeding.
And indeed, the original research that was published showed that there was a reduction in
the rate of GI complications with roughly Cox slip compared to competitors.
There was also a signal and the major randomised controlled trial that it might increase cardiovascular events by a small but absolute amount.
So the advertising budget in the states where they have direct to consumer advertising
was bigger than Budweiser or Pepsi advertising 160 million on television largely.
And people were going to their doctors and saying, Can I have this new drug called Raphe Cox?
But they stopped doing that when the makers withdrew roughly Cox from the market because it increased the rate of cardiovascular events.
Anybody have a guess at how many premature or avoidable cardiovascular events
were estimated to have occurred in the United States associated with what the.
Cox it. What do you think? Hundred thousand, high or low, higher, about 140 to 160000 with a 40% mortality rate.
This was jumbo jets crushing a phenomenal thing.
They they the total in the UK is estimated to be much less than that, but still a couple of thousand.
And in my time at the US Prescribing Centre we wrote a summary which said You use these things cautiously.
There might be a little bit of a signal here. I'm not claiming that we did anything, but the context is that.
And of course with that people started to look at the more traditional and say it's particularly a known site called diclofenac.
Diclofenac has a molecular structure very similar to Raphe Cox,
even it has a Cox two selectivity identical to Raphe Cox, and this is the prescribing of diclofenac.
So as this work is being analysed, almost half of all the prescriptions written by every GP in England for an end side was diclofenac.
Yeah, point is 0506 here.
This is 2013. Over here this line worn is the time when the systematic review was published in the British
Medical Journal saying diclofenac increased cardiovascular events by three per thousand per year.
You might want to think about your prescribing as does apparently the evidence isn't isn't fantastic as
it as as it does with other insights apart from ibuprofen and approx and ibuprofen at standard doses,
approximate 1000 milligrams a day doesn't appear to increase the cardiovascular rate.
Note the dramatic effect friends on the prescribing of diclofenac once that signal is published and one of
the world's leading scientific journals and line two as where every prescriber gets a letter from the MHRA,
the UK drugs regulator saying You might want to think about your prescribing of nonsteroidal
anti-inflammatory drugs and think about using ibuprofen and naproxen rather than things like diclofenac.
This is the point at which me and mine wound up prescribing advises to go about talking to people in GP practices and in local groups.
Note how long it takes for things to start dwindling downwards in terms of the use of diclofenac
and note the fact that Northeast bit of England gets the message quite early and leads the pack.
The West Midlands thinks about it for a bit and comes down quite nicely.
South East Coast does almost nothing for about three years and then starts to get hold of it.
What do you think happened? Point for time, point for a lawsuit?
No, actually we started having cough points for prescribing so GP's got money for doing the right thing and at point five.
The money got taken away. So it's a bit you look at that sort of data and you think these people aren't very bright, are they?
Don't you think having that and that the natural reaction. These people are, you know, pretty uncaring and they're not committed.
They're not working hard enough, doing the right thing for their patients.
You look at that prescribing data and you think these people need a good slap.
But of course, I do it one more time. It's great, isn't it?
But of course, that's not the case. It's just a bit more complicated than telling people what to do.
Changing what you do is particularly difficult, and we've,
in the last 12 months have the new nice guidelines for atrial fibrillation, which says don't use aspirin on it.
So just for people with stroke and of course,
everybody's brain says that can't possibly be true because I've used aspirin for years for that indication, in essence at heart.
So we might want to think about prologue number three, which is Joan, how many people do see patients?
Hands up. Okay. So the rest of you will have to imagine that you see patients.
So Joan's 84. She's had a couple of heart attacks.
She's she's had well-controlled heart failure. She's at the far end of the survival curve.
She's a survivor with heart failure. She's had heart failure for about eight years now and is still pretty much symptom free.
We think she's got osteoporosis because she's had a couple of low impact fractures.
She's fractured f and she's broken her wrist. She she gets bouts of gout occasionally.
Hannah Renal function isn't great, but then nobody's renal function is greater.
84 Her EGFR runs in the sort of mid-twenties.
There's a list of of medicines here and she now has a new problem.
She's developed atrial fibrillation. Her risk for stroke is is certainly getting towards the top end for the technical people here
at the shard vascular I've calculated for you is five and risk of bleeding is is is three.
So what do you think we should do for Joan those of you who who do this what
what's the what's the thing that you'd want to cover in this consultation?
It's a stroke thing, isn't it? Really?
Atrial fibrillation increases your risk of having a stroke phenomenally if you have a stroke due to atrial fibrillation.
But a bit of clot forms in the heart and flies through the bloodstream to the brain.
It's a really serious, horrible thing to happen and potentially preventable by anticoagulation.
Yeah. So I do this in a workshop of clinicians and I say, okay, you might want to discuss these sorts of numbers with Joe.
So if there's a thousand people like Joan, how many will have a stroke in the next year?
If there's a thousand people like Joan, how many will have a major bleed in the next year?
Because if we anticoagulant her, her risk of having a complication,
a bleeding from the gut of perhaps into the back of the eye or someone else's is goes up because we've, in effect, thin the blood.
And how do those numbers change if Joan is anti coagulated?
Anybody want to have a guess? Um, it's the thousand people like Joan.
How many will have a stroke in the next year? So people with a childbirth score of 550?
Yeah. Anybody else? I've done this in workshops with loads more clinicians.
The numbers that people estimate ranged from 1 to 100.
I've done it with the staff from a stroke unit, a regional stroke unit, and their numbers weren't as high as 2 to 300.
Interestingly, if you see lots of strokes, you think the risk is much higher than if you don't see lots of people with strokes.
But it would be good to actually know those numbers and to be able to have a conversation with her about the risks and benefits and and the options.
But it would be good if we knew pretty closely what those numbers were.
But we but we don't really, really need to.
So that's three things. We have to work out what the evidence is, find it and apply it to people like Joan, not just create it into guidelines.
And then we have to work out why is it that we find it so hard to change clinical practice,
to make different decisions from the ones that we're used to making?
Yeah, that's the that's setting it up, everybody.
Okay, so this is where you need your piece of paper and a pen.
Everybody ready? A list of words follows.
Look at them once, but don't reread them. When you've read the list, close your eyes.
Nothing horrible happens. There's no time came. The sailing, the closing, the eyes is just a signal for me.
So I know we can move on to the next bit. Everybody okay? When you've read the list, close your eyes.
Pretty much everybody there. Write down as many words as you can remember.
Come on. We've got some of the most intelligent lifeforms on the planet. Come on.
Anybody. Anybody need more time to copy from their neighbour?
So who's got 20 words? Oh, okay.
Four ish. Three, four, five. Yeah, that's that.
That's the. That's the norm. And anybody think they're doing quite well compared to the peer group?
Seven, eight? Yeah, one or two. Okay. Just take a look everybody at the list again.
Just take a look and see if any of you have misremembered a word.
Hands up. If you've misremembered the word straight off. Yeah, that's quite, quite.
Now, that's interesting, isn't it? How easy it is to mix things up.
Second thing, how many people are A's and B's?
People predominantly remembering words from the start of the list.
How many people are D's? And these people predominantly remembering words from the back end of the list
and how many people are all over the place and no true pattern splits out?
If you have a big enough sample, it's about a third, a third and a third.
So that's interesting as well.
You have an an in built propensity for remembering things from the start of something or from the end of something or scattered all over.
But the whole point of this is that nobody can remember everything.
You're cognitive ability is bounded.
It's not infinite. And if you think that this is a bit harsh, those of you who do clinical work.
Yeah. The list of potential drugs that interact with warfarin runs to four slides.
I've not put it up. I'm not going to ask you to write it down.
But somehow clinicians find their way through this and we don't get as many complications from this sort of stuff as you would think.
Although Warfarin sits up there as one of the top causes of iatrogenic admission to hospital
admission caused by taking a medicine or something caused by something that's been done to them.
So. So that's the first thing. Who's bought a car in the last three years?
Okay, since you're close to me, tell us what you did to help you make a decision for buying a car.
Well, actually, it was my husband of one car. Okay? He didn't do his homework anyway, near enough.
So what I did after he did what he paid for the car, evidently he bought it while I was overseas.
Okay. I went on to all the other car websites. Yes. How many kilometres they had, how old they were.
Okay. So this would be a summary sort of website of what car website or consumer.
Okay, yes, same sort of thing. I went to the choice that was the RACV, you know, country.
Okay. If you want this type of car. Yeah.
Okay then I'll look at the insurance. Yeah.
How much would you pay for that. Okay. And it was on to that you didn't even want to come.
Okay. I've not had that one before.
Somebody else. Who else wants to tell us about what they did about buying a car?
Go for it. Let's go over here. Well, only we want to spend all night because we want to get to other stuff as well.
But please tell us it's on. Oh, I used Auto Trader K the filters to tell you what time the vending machine was.
So I don't know what time you what time of transmission.
Yeah. How did you just just let me interrupt you for a minute, okay?
Far away. What about how did you decide what what variables you were going to put in?
So you were looking at price and safety. How did you decide on those things?
Because you obviously made the same choice around the things. My experience with my previous two cars, I was looking for something, um, no similar.
Yeah. Yeah. So, yeah, I ended up actually being the same car.
Yeah. You used. Yeah. Okay. I had a different idea of how.
Oh, yeah, yeah. Okay. Anything else?
Did you do anything else in terms of helping you make a choice?
Oh, no, I pretty much set it all and all of this.
All choices. Yeah. To set on the filters, outcomes, the results.
And that's not too far away. I'll go and look at that one. Yeah, exactly.
Brilliant. Thank you very much. That's pretty typical.
Um, we select a few things that are important to us size, cost, colour, various bits, safety, fuel consumption is a common one.
I've never had anybody say they weren't to the Society of Automotive Engineers website and
read the systematic review on engine testing theory and this third edition 700 pages.
You made a perfectly good decision without ploughing through the technical engineering jargon.
People don't go for laminated glass design considerations for vehicle door systems.
Fast track the 40 minute PowerPoint presentation.
Yeah, we truncate staff, we make quicker decisions.
We don't go to these detail things.
And arguably, it wouldn't have helped you to make a better, quicker, easier, safer decision about which car to buy.
If you had read 700 pages on mechanical engineering about car engines, you see my point and we can get by without the 700 pages.
So Herbert Syme, one Nobel Prize for describing the fact that your rationality is bounded,
that it is simply not possible for you to read, learn, hear, learn, see, learn, store it away.
Recall it in context. Just that the point.
Which you might need it most of the time.
You make a good enough decision. You collect sufficient information to reduce your uncertainty to the point at which you're able to make a decision.
That's an important phrase. So you're looking to reduce uncertainty to the point at which you are able decision.
And once you reach that point, you can stop and make a decision.
It's called Satisficing.
And if you do this work with general practitioners, they can get through the week with saying for every problem that they face, barring one or two.
And then they do the alternative. They temporise or do some investigations and they'll say We'll give it a few
days and then they'll go away and they'll do some more information collecting.
That's called maximising. That may be from other people.
It might be from the Internet these days. In times past, it might have been from books.
So Satisficing is the normal way we go about making decisions.
Maximising is a is a rare approach.
And this this Herbert Simon work is counter to the notion that all we need to do to make better decisions is to have all of the information.
And that's palpably not true. And it has implications for fields of artificial intelligence, which was part of Herbert Simon's work.
But we don't need to go there now. If you look at how this blends into clinical practice,
this is a quick bit of work published in The Lancet by a couple of junior doctors who looked
at the patients that they'd admitted under their care in the previous 24 hours on call.
So it was 18 patients with 44 diagnoses.
So lots of them were like Joan with more than one thing wrong with them.
They they calculated that if they were to set out to read the relevant guidelines
pertinent to those 44 diagnoses published only in the last three years in the UK,
just by relevant Royal Colleges and nice they would have to read 3679 pages and at 2
minutes reading each page the physician on call would need to read for 122 hours.
So there's a different way of getting through this. This is not simply more knowledge equals easier decision making.
This clearly something going on as you saw with the diclofenac stuff when we do john gabbay and Andre Lima,
his mind line stuff and those of you who've been on the course this week will have heard about my lines already,
I think from about a systematic review. This is the this is the quote that I like to put up.
Clinicians rarely access appraise news, explicit evidence directly from research or other formal sources.
Rare exceptions are where they need to go and maximise gap in them.
They didn't write that, but that's what they meant. Instead, they rely on what we call mind lines.
So in contrast to guidelines, mind lines, patents, pictures in our heads, these are collectively reinforced,
internalised, tacit, so not necessarily written down anywhere guidelines informed by brief reading.
Think about where you got your information from your cars, brief reading, but mainly their interactions with each other and with opinion leaders,
patients, pharmaceutical reps and other sources of largely tacit knowledge that builds on early training.
So patterns are ingrained and then we use the patterns.
And that leads me on to the fact that simply constructing guidelines isn't enough.
There's clearly a community of practice involved in mind lines.
Before we get to the consultation with Joan and the individual bits and the complexity of all of this,
three different translations, they all require different methodologies.
We've worked on that long. Not too much on the other two.
So second theory we've done bounded rationality. It's great being a professor of evidence informed decision making.
There's only two things you need to know. One is bound to rationality.
The second is due process theory. Who knows the story of Noah in the Bible?
Come on, don't be shy. I saw you twitch.
Just prepare the brain now. Tell us briefly the story of Noah in the Bible.
Well, as I remember it, something to do with, uh, people being misbehaving generally.
Yeah. No, it's been well behaved. Uh, and therefore, God said to him, you know.
Yeah. Yeah. You'll be safe.
Yeah. Yeah. And the raven went out with a thing in his mouth some time later.
Yeah. 40 days and 40 nights. Yeah. Uh, we would have been flooded, and then.
Yes, he sent out some birds, and then a dove.
And the dove comes back with. With some, uh. What was it?
An olive branch? Yeah. Yeah. And that was the signal that the.
The flood is receding and everybody happy.
Everybody remember the story of Noah now. And it was done by Russell Crowe.
Yeah. Russell Crowe and Jim Carrey.
Do you remember the Jim Carrey film? Yeah. Two of every kind.
Yeah. Okay. Imagine you're working as a doctor in a remote village.
It's the weekend. There's no other health care professionals around.
But you do have a new piece of technology called the Marvel Tron.
The Marvel Tron will save the life of any patient you're treating,
but you have to answer correctly the question the Marvel Tron asks of the attending doctor before it works its magic.
A young child is brought to, you see, seriously ill, and it appears she'll die imminently.
You switch on the Marvel tron and await the question. Now you must write down your answer immediately.
The question is asked or the child will die. Pen and paper.
Ready? Importantly, you'll get no blame if you get the answer to this question wrong.
You'll only be blamed if you don't try and save the life.
This is the Good Samaritan as well as the know her story.
So are you ready? It didn't work according to the Bible.
How many giraffes did no take into the ark? Answer quickly.
Write it down. Charles is dying and answer. Period. Let's cut to the chase because time's getting on.
How many people wrote down to? Yeah, pretty much everybody wrote down to.
So where did you get that evidence from? A Bible.
A Bible story. Somebody told it to you once, a long time ago.
Anybody else? Where do you get it from?
Probably assumed it's in the mail. Mentioned you asked, but you said yeah, yeah, yeah.
Okay. So we just know it. Don't weigh in there somehow.
We know the animals go in two by two. There's even a Disney song.
Yeah. Let's check with the guideline of every clean base that shall take to the by sevens, the male and female and off base that are not clean by two.
So are giraffes, are clean beast, clean base, have cloven hooves and chew the code.
Here is the cloven hoof of a giraffe. Here is the cloven hoof on the desert floor.
Here is the YouTube video of giraffes chewing their codes.
The correct answer is 14, not two, 14, not two.
And at this point,
somebody is going to get their iPhone out and start Googling Bible dot com because your brain is saying that can't possibly be true.
I know that the animals go in two by two. The pattern is imprinted with you.
I promise you the answer is 14.
I've even had an Orthodox Jewish pharmacist get out his iPhone and Google the Torah in Hebrew and he teaches this in the synagogue.
And after about 5 minutes, he said, Gosh, Neal, you're right, even in the tourist 14 and I've been telling everybody it's two by two.
Okay? The point is, once we know something, which once we've had it imprinted several times,
it sticks with us and it's really hard to do something different.
Pattern recognition is actually part of our DNA.
We're all descended from about 5000 ancestors living in Eastern Africa millions of years ago, and their pattern recognition had a survival advantage.
If you could recognise a berry that you could eat from one that would poison you a friend from a foe
or an animal that you could chase and catch and eat from one that would chase and catch and eat you.
There was a survival advantage. And as I'll demonstrate shortly, this pattern recognition is so strong in is that we can't actually turn it off.
So once we've started prescribing diclofenac, it's really difficult to stop it.
Once we have a pattern of behaviour in our minds, it's terribly easy just to go along and it's actually an advantage.
So I was in Amsterdam last week. I'm staying at a hotel.
I'll never stay there before. I don't know how to find my way through that, through the transport system.
Very difficult once I've done it once second time, easy.
Classic example of how easy we can get patterns.
And this is sort of being constructed together into this due process theory.
So in medicine, if a patient presents and the pattern process a function that we have,
it's not an ensemble sight within the brain, it's just the way the brain works.
If we've seen it before and we recognise what it is, this is fast intuitive.
We can't switch it off. We don't have to think about it, it just happens and we can come up with the diagnosis based upon pattern recognition.
If you're an undergraduate training or your GP training or this is an unusual condition that you've never seen before,
then you don't recognise what it is. This this type to decision making process requires effort.
It's uncomfortable, it takes time and it's a struggle.
And some days every surgery runs like this and it feels like a dream.
And some days every surgery runs like this and it's like walking through treacle and sometimes
new information comes in and it will rationally override the first impression we have.
Sometimes, despite new information being available,
the previous patterns that were imprinted this rationally override the new information that comes in.
Think of the MHRA warning about and cites.
It's not the people are lazy. It really tells you they happen to be human beings and they find it difficult to shift patterns.
Okay, so we'll do a bit of this in a second. It's actually geological process theory.
So in an emergency situation,
a trained clinician recognises what the emergency is and provides the lifesaving treatment straightaway fast, quick lifesaving treatment.
And don't think that System two is always going to be better than system one.
Optimal decision making is actually pattern recognition.
With a few stop and start rules some some some alternatives to just going with the pattern that's there.
Good giga insist on lots of work on this from from Berlin but I'm skating over the the academia so let's do a bit of this together.
All together. Big breath in. I want to hear you.
Big breath in. What's the answer to this? Some. That was useless.
We'll do it again. Big breath in. What's the answer to this song?
Thank you. That's better. Okay, so when I put out the first time, you didn't have to count upon your fingers.
I didn't see anybody getting their socks off. It was known to you.
The answer was four before you came in here.
And it's still four now. I promise you, it hasn't changed.
Two and two is still four altogether.
Big breath in. What's the answer to this? Some. Okay.
So that requires system two processing of a fairly simple nature.
But there are some rules of thumb that would help you make a more rapid decision.
So if we said that was about 80 and that was about 60, 80 times 60 is about 4800.
So if I was trying to tell you that the answer was 10,000, you be able to fairly quickly tell me that I was wrong,
providing you knew the rules of thumb, which in this language are called heuristics.
So if you know the tricks, you can you can get that. That's what I mean about stop start rules of thumb type stuff.
Okay, so what's this? Make the diagnosis here.
Big breath in everybody recognise Margaret Thatcher.
So if you're a clinician and a margaret Thatcher walked into your consulting room, you be able to recognise Margaret Thatcher.
Yeah. So how many people have recognised have met Margaret Thatcher?
So this is a pattern recognition, just trash.
Of course you have the pattern recognition.
It's imprinted on you. You've only seen pictures in papers, in magazines, on the television.
Most of those pictures were a long time ago. The funeral was a few years ago.
But she was prime minister, actually. You know, 1990 was when she left office.
And yet a pattern recognition and who as human beings is so brilliant that there is no problem in recognising Margaret Thatcher.
We take it for granted. Actually don't way that we can do that. It's an amazing scale.
And if you don't see a distant relative for ten years but you happen to come across them at a wedding or a funeral or a christening,
you straightaway recognise Aunty Minnie probably from just the way she walks, rather than the fact that you've seen her face.
It's a fantastic bit of human scale to be able to do that pattern recognition.
So if, if I put this up in front of trained clinicians, they'll say it's huge, it's right away.
You don't have to go away and work it out. You know that this is shingles.
Put it up in front of first year medical student. So obviously students, nursing students, anybody really hard to get to grips with that.
No idea what it is unless they've seen it before in a relative.
Um, well, emergency treatment there's a seriously ill adolescent need clinicians.
Okay, so this is, that's that due process theory.
You've just saved a life potentially.
This is meningococcal septicaemia, antibiotics into this seriously ill child as soon as you can please and lots of other stuff as well.
You don't need to go to the books and start working out what this is or googling what this might be.
We know it straight away and it's extremely useful.
Pattern recognition. What's this? Okay.
I'll take you back to him. I'll take you back to medical school.
I'll become the professor of cow ology.
I spent 20 years recognising, treating, investigating, researching that rare but serious condition where a human being has turned into a cow.
No carefully. Students, the brow, the eyes, the jawline, the nostrils, the ears.
And we do lots of stuff in lecture theatres and in small group learning.
And I'd set some tasks to go and do self-directed learning.
And then I take you on to the ward at the John Radcliffe, where a patient had been admitted the previous night under my care.
And you'd say, what a great teacher that prof is.
Because the patient in the bed looks like this, just like the one we learnt about over at the medical school.
No carefully students, I would say the brow, the eyes, the jawline, the nostrils, the ears.
And we do a bit of additional work and we might see two or three patients and I might set the odd test and then we'd come to your final
examination and I'd set you the task of differential diagnosis and provided you could correctly identify the patient that's turned into a cow,
despite it being a slightly unusual setting.
I might let you go off and be a doctor, and there'd be some point to this because a couple of years later you'd be
working in the A&E department and a patient comes in looking a bit like this.
I need to have a look at the patient in the cubicle in the accident and emergency department,
and you'd sort of squint your eyes at that and something might pop up into your brain if you're lucky.
And you might go and talk to the registrar and the consultant and say, that chap over there in that cubicle, I think he might have turned into a cow.
And you'd be right.
And your self-confidence would go up and in your esteem amongst your colleagues would increase and you'd progress through your career.
And then a couple of years later, somebody comes in looking like this.
And gradually, if you keep looking at this person in the cubicle, you might spot that.
That's an ear and that's an eye and that's a jawline and nostrils, another ear hair.
Now I've got it. I've never really seeing the cow on the screen.
Okay. That's how fast the brain can start to recognise patterns.
Importantly, look at the screen and close your eyes. Now open them again.
Now try not to see the cow, because now it's imprinted.
So if I wanted to get you to write out a prescription for a new drug,
I'd get you to try out two or three times when you've written it out three times.
You write outgoing for the first patient. The fifth patient, no problem whatsoever.
The printing happens that that quickly.
So this is how it works in terms of education, since we're an educational centre.
If I asked you to drive me home to the northwest of England tonight and you'd never driven a car before,
I hope you'd say no because you're consciously incompetent.
You know you can't drive a car because you've never had a driving lesson. I would have.
Please say no. But if you had some driving lessons, it would be hard.
You'd have to put some effort in. It would be system two.
It would be slow. But by the time you got to your driving test,
provided you thought about what you were doing whilst you were doing the driving test, you might just be consciously competent.
Now, after lots of practice at driving, system two is gone.
It's a system one with repetition and you can drive a car now whilst working out the shopping list and thinking
about what's happening with the kids and what's going on at work today and all of those sorts of things.
I wasn't thinking coming here today. Now it's time to change gears.
Now I need to press the clutch, etc. Yeah. The problem is that sometimes.
Oh, sorry. Sometimes things change.
Somebody steps out in front of you or the lights alter or the road defines you.
You're using your system well. And at that point, you're unconsciously incompetent.
You think you're okay, but you're not. And if this is a situation that needs repetition, you have to assess that, become aware of it.
That requires effort. Just recognising you need to change requires effort.
And then you have to go back and learn again to write ibuprofen and naproxen diclofenac.
And that's hard because it requires effort. What goes wrong with this pattern recognition?
Steve is shy and withdraw and invariably helpful, but with little interest in people has a need for order and structure and a passion for detail.
Which of these is it most likely that Steve is?
What do you think? Librarian.
Pharmacist. Yeah. Librarian. Pharmacist is what most people are saying.
I know quite a lot of librarians. I know even more pharmacists.
I agree with you. How did you reach that conclusion, though?
Yeah. You created a picture from the text up here.
You don't need a picture. You can create pictures that easily by just reading some text.
And then you apply this picture to the alternatives that are down here and see the one that matches most.
This is a cognitive bias.
It's called base rate neglect because in most countries, in most populations, the numbers of farmers are much greater than any of these options.
So even if a small proportion of farmers had these introverted traits, it's still more likely on the numbers that Steve's a farmer than any of these.
The pattern recognition led you astray, and there's more than 100 of these.
So anchoring sorry, anchoring bias, an early salient feature in a consultation, is something that a clinician might fix on.
And despite continuing queues emerging throughout that consultation, they stick with the first impression that comes to mind.
Ascertainment bias thinking shaped by prior expectations.
So I'm a GP in Scarborough. Years ago I was on call.
It's 3:00 in the morning on a Sunday morning. The night clubs are turning out.
That was quite, quite early for these days, isn't it.
But but the night clubs were turning out at 3 a.m. and there's a guy staggers across the pavement,
trips at the side of the gutter and falls in the road. And I very nearly run him over.
What's the diagnosis? He's drunk. Yeah, he's actually had a stroke.
But I thought because of where I was and where he was, time of day, I thought he was drunk, too.
Recent experience dominates the evidence.
So if you're a doctor and you've prescribed an evidence based treatment for a patient and it's not something you're familiar with,
the patient develops a horrible side effect. How hard is it to then write out the prescription for the next patient for whom it's indicated?
Yeah. Recent experience dominates what the evidence says.
It's just pattern recognition all the time. Well, run, run through all of these.
Let me go with this. This one, the gambler's fallacy.
So I've seen three people recently with chest pain just in the last couple of weeks there.
They've all had heart attacks. I would normally say, you know, two or three of these a year at most.
Here's a fourth patient with crushing central chest pain going down their arm.
They're sweating and they're feeling sick. My brain is saying this can't possibly be a fourth person with a heart attack in two weeks.
That just can't be the case. Whereas, of course, if I stand back and think about it,
the presentation of this patient now cannot possibly be connected with the three other patients who've had heart attacks in the last two weeks.
There can be no connection whatsoever. It can't just be.
Look, I search Satisficing.
So the most commonly missed fracture on an x ray in the A&E department is Sky for now.
Colleagues now note the most commonly missed fracture is the second fracture.
Because you look on the x ray of whatever's hurting, you see a fracture and you say, Great, I found out why this patient's hurting.
And that can have serious consequences if they've got four fractures in one hand, because that needs the hand surgeon now,
because that's an occupationally threatening set of conditions,
whereas a crack in well metacarpal is probably a back slap and see you in fracture clinical Monday.
Completely different situation so lots of these cognitive biases that they all have a basis and pattern recognition.
I know what it is and I recognise that.
Who's this Jesus straight away? Just like warrior Jesus.
Yeah. Representation of D. Nobody's really sure what Jesus looks like, of course.
But traditionally this could be Jesus. Yeah. Okay.
Not Jesus. This is a piece of toast. But the pattern makes you think of Jesus.
Jesus in the Kit Kat bar. Oh, wow.
Got one before. Be careful eating Kit-Kat bars when you're driving a car.
Oh, I'm not sure this is a true story.
I got it from the Internet. I definitely put it just fitted very nicely.
So. So I put it in. Who is this? Not Hitler.
But doesn't it make you think of Hitler? It's this pattern recognition thing.
Once it starts, you can't turn it off. Once you've got the pattern there.
It's really hard. You have to make a conscious effort not to go with saying, Oh, Scott, looks like Hitler.
What you do is, of course, you can see the problem.
Oh, we we've got some repetition. So lots of cognitive biases this lies put in to remind me to mention affective biases.
So they are. The airline pilots talk about being hungry, angry, late or tired?
Tired. That is the connotation here. I don't necessarily read right across from things in the aviation industry to the decision making in medicine,
but I think there is something we could learn from the awareness.
Pilots have self awareness that they need to be particularly careful if they've got one of those.
Certainly as a GP for 20 years.
I'd have all four of those most days and that certainly seems to be true the way things are in clinical medicine at the moment.
Effective bias is each one. Any one of them individually increases your chances of making an error by 30%.
We don't make too many errors, fortunately, but a relative increase of 30% is it's worth thinking about.
So let's go back to Joan as we finish off.
What would be the optimum consultation with Joan?
We'd want to know something about the benefits and risks of anticoagulation.
And when I was at Nice, I actually did some work with a colleague called Andy Hutchinson.
And actually we run the world championships of atrial fibrillation experts
and the shared decision making experts and came up with this sort of graphic.
So at the top, there's a thousand people like Joan, and over the next 12 months, 916 people won't have a stroke, but 84 people will.
So you weren't too far away with 50. It's a ballpark figure.
It's not too far away. That's just the point estimate. So it'll have confidence intervals around it.
It's not necessarily absolutely accurate to four decimal places,
but that's a sort of ballpark figure we could come up with from the best available evidence at the time.
So how do you represent that to Joan?
If you get into the conversation with her about her risks of stroke, do you say great news, Joan?
If there's a thousand people like you over the next year, a thousand people won't have a stroke.
Related, 960 people out of a thousand won't have a stroke related to the atrial fibrillation.
But 84 people will say bad news, Joan.
That's atrial fibrillation. 84 people out of a thousand will have a stroke in the next year,
but 960 won't because how you frame that news and those numbers will make a big difference to how she views it and actually to the way you view it.
And you have a propensity for one way round or the other, and you shouldn't because you're trying to reach an unbiased decision.
You angio because you have a mind line about this.
But Joan has a mind line about this, too, and we don't know what Joan's as yet.
If we add in the anticoagulation. Oh, sorry, 57.
Sorry, go back. 157 people are saved from having an atrial fibrillation related stroke.
If we don't calculate all the thousand, all the thousand have to take the anticoagulation.
Only 57 are helped. And again, there's the framing problem with the how much benefit people get as well.
And then there's the problem that you don't have a crystal ball.
You can only say to Joan what will happen in the population.
You can't say what will happen for her. Phil Hammond said years ago, having a stethoscope is no substitute for a crystal ball.
It would be great if you could say what would happen to her, but you can't.
In terms of bleeding. There's nine people that have a bleed without anticoagulation.
It goes up by another, another 15. Most people don't have bleeds, but nevertheless, that's a significant increase.
So does that solve the problem for you? Now, you know the evidence, does that help you to make the decision for your own?
I would argue not because you can't tell what will happen to her and you don't know
how she feels about this and you have no idea what else is going on in her head.
So that'll go one day of researchers fame and immortal fame.
I would recommend reading anything, but I'll going to go one day, but particularly being mortal.
And he says there's probably four questions we need to ask a bit more often.
What's your understanding of your illness? What are your fears and worries for the future?
What outcomes will be unacceptable to you? And and what are we trying to do here?
What are we trying to do for you? In American speak, it's one of the goals of care.
If time is short and I can't do accents, as you've just discovered, I don't think I'd do the if time is short,
because most 84 year olds know that time is short and don't need their noses rubbing in it.
Yeah, but something along those lines would perhaps be worth exploring.
There's an evidence base for this.
This is a randomised controlled trial of using those sorts of questions to people who've got widespread lung cancer at diagnosis.
So the randomisation is to having that sort of conversation and not having that sort of conversation.
The people who had that conversation had 20% fewer emergency admissions for hospice or hospital care.
Their costs were 20 to 30% lower. The cost of care were 20 30% lower.
Um, they lived on average 25% longer.
And interestingly, of those who die, they looked at the relatives of the people who died and the people who'd had that advanced planning conversation.
The relatives of those people were in much better shape six months after death of their beloved relative.
Um, this is a randomised controlled trial at the end of a GP consultation saying is there anything else
we can usefully talk about today or is there something else we could usefully talk about today?
Anything or something. Something gets you 80% of the hidden agendas.
It gets you where Jonas with this stuff, if you say anything, seems to close it off.
One word is incredibly powerful and we've not explored how to do this fantastically well as an individual.
So how did it go with Joan, do you think?
Well, we started off with a anticoagulation stroke reduction type of conversation, but we didn't get too far.
I don't want any more tablets. I feel ill all the time.
I'm unsteady on my feet. I need help with shopping. I need help getting in and out of the shower in the morning.
She's frightened of falling over and fracturing a hip again. She has a fairly unpleasant experience at the moment.
I can't stand them cooking. She was a great cook, really keen on cooking, as you can say.
How am I going to get a meal? But we persisted.
I don't want water in my house was on water and it was awful.
I'm not interested in your pictures of benefits and risks. I 84 now.
Tell me which of my tablets are controlling my symptoms and let's stop the rest.
I'll take my chances.
Never mind that the guideline says anticoagulant people are risk of stroke because they got atrial fibrillation or prevent lots of strokes.
The population level, it works fantastically at the individual level. It may well not.
And we've concentrated on the population, not the individual. So what happened?
Joan did well. She didn't take her anticoagulant.
Some of her medicines were stopped. She didn't have a stroke because the odds were always in favour of her.
Go with many more green faces than red faces.
She got stronger. She was able to look after self in her own flat with little support.
Five more years of good quality of life and died peacefully, two months short for 89th birthday.
I'm well qualified to tell you Joan story.
Joan was actually my mom and you can see the effect of cardiac actually a longstanding and stage heart disease.
Her ankles are swollen but this is quarter to one in the morning at a party.
Know I know I'm saying mom it's quarter one.
Shall I take you home? Are you going to be ever attacked? And she said, you must be joking.
How often do I get to come to a party like this? Take me over that. I haven't seen Mary for ages.
So. So the epilogue, very quickly for slides, patient centeredness, I think now is an absolute gift.
Every consultation, values and preferences of patients has got to be there.
And whilst we've done some work on consultation skills, most specialists get nothing,
GP's get some process based stuff and it's still nowhere near enough to get that,
to get that to that wonderful expertise that's required to do these sorts of preference sensitive consultations really well.
The bifocal version I think, is a really useful concept.
So we're not ditching the evidence. We want to know what the evidence is for the population.
It's essential both for Joan and for her clinician to know what that evidence is, perhaps in some circumstances.
But sometimes people make decisions without knowing what the evidence says.
They'll just go with a few variables and just make a choice based on while that was quite good, we'll do that again, as we did with the cars.
So we have to have a focus on the individual and the focus on the population.
Both of these, not predominantly this which abmas done more off for the last 20 years.
I think third thing, I think we're all agreed the evidence doesn't make the decision for you.
Decision making is an entity on its own and we have to know the evidence.
But we have to be really good at making decisions too,
and knowing a bit about what's going on in our heads and knowing a bit about what might be going on in the patient's
heads and exploring the two together might be somewhat better than everybody gets aspirin after a heart attack,
let's say. So the final slide is the sort of where we're going to need to go with this.
We need to do a bit more on the curriculum. We need to help people find the stuff that really matters.
We need to understand ourselves. So we need to understand pattern recognition and bounded rationality and how
those two things work together for us and how we can employ those heuristics,
those stop start rules, because we will inevitably make most decisions using system one and pattern recognition.
And then the final bit is they let's work a bit more at the consultation,
the scales in order to have really great, meaningful consultations with people.
That's the sort of curriculum that we need to be heading for, and it's a spiral curriculum.
It's no good talking to medical students about decision making because they're still constructing those a knowledge.
Once you start having to make decisions, you need to know a bit about making decisions.
But before that time, it's too soon.
But an awareness that this is where you're heading, we're expect you to become an expert might be might be really helpful.
I hope that's been helpful. Thank you very much for the invitation to.