Sunday, November 13, 2011

Improving healthcare with the assistance of the primeval snout

It's true that clinicians greatly benefit by technology that helps them make decisions, but clinical decision making involves both analytical processes as well as inductive (intuitive) processes of reasoning. Clinicians can learn analytical (hypotheticodeductive) processes from a textbook, but inductive learning in clinical practice is almost entirely experiential. 

Experiential learning requires time and repetitive (iterative) instructions, much like machine learning by a computer program. We are very good at teaching clinicians how to use EBM, but we often find it hard to teach them how to "use their gut", which is another way to describe inductive reasoning. Even though clinician-educators emphasize analytic reasoning when we teach students, in our own practices we often depend more on inductive logic to make decisions, as  Abraham Verghese wrote in “The Tennis Partner”: ‘I taught students to avoid the augenblick diagnosis, the blink-of-an-eye label, the snap judgment. But secretly, I trusted my primitive brain, trusted the animal snout. I listened when it spoke.’

So what is this process of diagnostic reasoning that occurs almost at the speed of light, ‘the blink-of-an-eye label’? Does it really work?

One way to demonstrate this is to show physicians a picture of an easily identified skin rash, such as shingles, and ask them to identify the rash and provide a diagnosis. Fresh medical students often cannot reach a diagnosis quickly, because they lack the experiential knowledge -- they can’t see the pattern that allows them to reach the obvious conclusion. Most experienced physicians will correctly identify the rash in milliseconds, but they may not be able to rationally describe the process that led them to the diagnosis ‘in the blink of an eye’. This is a classic example of the so-called ‘augenblick diagnosis’, a form of inductive reasoning.

If you've read "Blink" by Malcolm Gladwell, you know all about inductive reasoning and augenblick diagnoses, and how physicians depend on "thin slicing" to make their diagnoses. I’m very interested in learning how we can develop logical representations and models that capture inductive reasoning, and how to convert "instinctive" thought into reproducible (and measurable) actions. I've said before that if we increase the length of an internal medicine residency from 3 years to 4 years, we'll increase experiential learning, and ergo produce better doctors. But the lack of funding for an additional period of learning (and the associated costs of the instructors and facilities) prevents us from changing the educational paradigm. 
We’ve spent billions of dollars to increase the amount of heath IT we use in patient care, in the hope that it will improve healthcare. This strategy may work. But I wonder if we will reap a more generous reward if we spent the same amount of money to enhance the experiential learning of physicians by training them more comprehensively in the use of the primeval snout....

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