traditional expert-based information delivery systems using an expert, being an expert
TRANSCRIPT
Traditional Expert-Based Information Delivery Systems
Using an Expert, Being an Expert
Roles of Experts
Consultation CME Review articles Practice guidelines Decision analysis
Using an Expert/Being an Expert
Definition of an expert
• Subspecialist or primary care clinician with special interest
• Anyone/anything you go to for an answer to a question
Using an Expert/Being an Expert
“Never ask the barber whether you need a haircut”
“So many specialists fall into the habit of looking where the light is -- that is, offering solutions only in territory familiar to them. . . Wonderful examples exist of otherwise excellent researchers who are unable and unwilling to recognize evidence contrary to their beliefs.”
Usefulness Score
Work: Low
• Significant potential for usefulness
Relevance: Varies Validity: Expert dependent
• If either relevance or validity is zero, usefulness is zero
Types of Experts
Content Expert
Clinical Scientist
YODA
Content Expert
Experienced, particularly diagnosis and procedures, not
necessarily therapy
Not trained in clinical epidemiology (validity)
Traditional education favors DOEs (relevance)
May not be current, may rely on anecdotes
Risky extrapolation: Information is only as current as the
last consultation
Clinical Disagreement Between/Within Experts
Same film: disagree 29% of time
Previous read: disagree with self 20% of time
Studied with venograms, fundi, MRI, angiography,
mammograms, pathology (melanoma diagnosis)
• March 97 Bandolier on the Web: “Histology as Art Appreciation”
“Never ask a barber . . .”
Chalmers: Recommendation highly correlated with
training and source of income
Management of acute GI bleed
• Surgeons: surgery- 50%; conservative- 15%
• Internists: surgery- 15%; conservative- 50%
Clinical Scientist
Good at evaluating evidence; up-to-date, don’t
have to be content experts
• Separation of therapeutics
• Medical Librarian, PharmD
YODA: Your Own Data Analyzer
Content expert and clinical scientist Consider POEMs first, even if this information
conflicts with DOEs or clinical experience When POEMs not available, use best DOEs with an
open mind Demonstrate appropriate validity assessments Not to be confused with YUCKs
YUCKYOURUNSUBSTANTIATEDCLINICALKNOW IT ALL
Experts gone wrong: YUCKs
YUCKYour Unsubstantiated Clinical Know-it-allMaladaptive
• Rigid, DogmaticAll personality types, but people who see
things in Red and Green can fall into the YUCK trap
The Golden Question: “That’s interesting . . . Is there any evidence that . . . ?”
If it’s not a valid POEM, it’s just not necessarily so
Making the Most of a CME Presentation
Dilbert’s Take on CME
Continuing Medical Education
People remember 90% of what they do, 75%
of what they say, but only 10% of what they
hear
How to make the 10% count
Do We “Get” Something From CME?
Is post-test performance improved? (DOE)
YES
Beware “Chinese-Dinner Memory
Dysfunction”
Are patient outcomes improved? (POEM)
No . . .Multiple RCTs have failed to find a
benefit from traditional lecture format (passive)
Maybe . . . with active (hands-on) workshops
combined with close follow-up
Usefulness
Validity: Depends on the speaker
Relevance: Depends on POEM:DOE ratio
Work: Higher than it seems
• NBA analogy (only last two minutes count)
• Tracking down validity of new POEMs
Role of the Speaker
Present a good mix of POEMs highlighted by clinically relevant DOEs
Augment POEMs with clinical experience Identify Level of Evidence (LOE)for listener
Role of the Listener
Identify, before the talk begins:
• What you want to learn
• What are the POEMs you need to know?
Actively evaluate information (CME worksheet) When a change-inducing POEM is presented,
validate:
• By questioning the speaker
• By cross-checking with other sources
Identifying “Common” POEMS
Will this information have a direct bearing on the health of my patients (is it something they care about)?
Is the problem common to my practice? Is the intervention feasible? If true, will it require me to change my current
practice?
Newer Models for CME
Practice-based small group CME Educational prescriptions Point of care Sources Team-based learning Audience response systems CME worksheet Social media