Title: Practice
1- Practice
- Illusion of knowledge
- Mastery
- Enjoyment and pleasure
- Guidelines
2- Hugh H. Macaulay, III, MD
- Occupational Medicine Consulting
- Englewood, CO
- hhm_at_occmedconsult.net
3- Colorado Medical Treatment Guidelines
- A Practitioners Perspective
4- Practice of medicine
- Illusion of knowledge
- Mastery and Enjoyment
- The Guidelines
5- What is the Practice of Medicine?
6Free Dictionary
- Noun1.practice of medicine - the learned
profession that is mastered by graduate training
in a medical school and that is devoted to
preventing or alleviating or curing diseases and
injuries
7 8(No Transcript)
9(No Transcript)
10(No Transcript)
11- Medical Practice is a journey
12The illusion of knowledge
- information and accuracy
- belief that our basic understanding is actually a
deep understanding
13(No Transcript)
14- http//www.youtube.com/watch?featureplayer_detail
pagevIGQmdoK_ZfY
15(No Transcript)
16(No Transcript)
17(No Transcript)
18- The illusion of knowledge When more information
reduces accuracy and increases confidence - Organizational Behavior and Human Decision
Processes, Vol 103, pp 277-90, 2007 - Drs. Hall and Ariss, Department of Psychology,
Princeton University - Basketball wagers based on statistics and then
with knowing the teams
19- Dr. Daniel Simons, Department of Psychology,
University of Illinois notes - There is a phenomenon in cognitive science
popularly known as the Illusion of Knowledge,
which says that we have the tendency to think we
have a better understanding than we actually do.
- One element of this illusion, Simons says, is our
belief that our basic understanding is actually a
deep understanding.
20- Our over-confident brains can leave us with a
false sense of security about daily decisions. - The illusion of knowledge is necessary to
prevent us from having to face our own
incompetence.
21(No Transcript)
22 23- "A little learning is a dang'rous thing Drink
deep, or taste not the Pierian spring There
shallow draughts intoxicate the brain, And
drinking largely sobers us again. - Alexander Pope, An Essay on Criticism
- Fir'd at first sight with what the Muse imparts,
In fearless youth we tempt the heights of Arts,
While from the bounded level of our mind Short
views we take, nor see the lengths behind But
more advanc'd, behold with strange surprise New
distant scenes of endless science rise! So
pleas'd at first the towering Alps we try, Mount
o'er the vales, and seem to tread the sky, Th'
eternal snows appear already past, And the first
clouds and mountains seem the last But, those
attain'd, we tremble to survey The growing
labours of the lengthen'd way, Th' increasing
prospects tire our wand'ring eyes, Hills peep
o'er hills, and Alps on Alps arise!"
24- Eugen Herrigel, German philosopher and author
(Zen and the Art of Archery) - "practice, repetition and repetition of the
repeated with ever increasing intensity are its
distinctive features for long stretches of the
way. This brings mastery and understanding of
self and the art.
25George Leonard
- Mastery comes from the process of getting there.
Mastery is practice. Mastery is staying on the
path. Masters dont devote themselves to their
particular skill just to get better at it. The
truth is, they love to practiceand because of
this, they do get better - One becomes so engrossed in the process that
everything else falls away. Time of best work.
During this time (the flow) enjoyment comes from
the practice itself. Enjoyment is an intrinsic
value. Pleasure is extrinsic. Enjoyment is
active pleasure is passive.
26- Malcolm Gladwell in his book Outliers highlighted
the notion that become expert if anything, you
must devote at least 10,000 hours to it. - Robert Greene said 20,000 hours.
- Fuse The Intuitive With The Rational Mastery
27- "The moment is the hard work. It is the simple
joy of being absorbed us something use of doing
forgetting about everything but the task at hand
and one day, to your surprise, discovering that
you are better at it then used to be, even if you
still have a long way to go"
28Mihaly Csikszentmihalyi
- "Repression is not the way to virtue. When people
restrain themselves out of fear, their lives are
by necessity diminished. Only through freely
chosen discipline can life be enjoyed and still
kept within the bounds of reason."
29- Enjoyment is intrinsic pleasure is extrinsic.
- This is at the heart of mastering anything. If
you do not learn to love practice, you will not
get very far--or if you do, it will be more of a
forced march than a rewarding journey
30Mental state in terms of challenge level and
skill level,
31- We have talked about
- The nature of practice
- The illusion of knowledge
- Mastery
- The flow with matching of skills and challenge
- So, how does this apply to me? Im a doctor and
treat and heal my patients. I know what I am
doing.
32In the case of lumbar fusion, there was nearly a
20-fold range in ratesSpine. 2006 Nov
131(23)2707-14.United States' trends and
regional variations in lumbar spine surgery
1992-2003.
33There was a nearly 8-fold variation in regional
rates of lumbar discectomy and laminectomy Spine,
2006 Nov 131(23)2707-14.United States' trends
and regional variations in lumbar spine surgery
1992-2003.
34- A murderer is condemned to death. He has to
choose between three rooms. The first is full of
raging fires, the second is full of assassins
with loaded guns, and the third is full of lions
that haven't eaten in 3 years. Which room is
safest for him? - A woman shoots her husband. Then she holds him
under water for over 5 minutes. Finally, she
hangs him. But 5 minutes later they both go out
together and enjoy a wonderful dinner together.
How can this be? - Can you name three consecutive days without using
the words Wednesday, Friday, or Sunday?
35(No Transcript)
36(No Transcript)
37- Whoa dude, I came here to learn about this
guideline stuff.
38(No Transcript)
39- The Guidelines of Colorado
40(No Transcript)
41(No Transcript)
42(No Transcript)
43(No Transcript)
44(No Transcript)
45- OK, bucks saved, but how can I practice using
these things.
46Amenhotep I 1500 BC
47Ebers papyrus
Bricks and herbs for asthma
treatment of cancer.
48Edwin Smith papyrus
49Edwin Smith papyrus
- The world's earliest known medical document
- 17th century BCE,
- describes anatomical observations and the
examination, diagnosis, treatment, and prognosis
of numerous injuries in exquisite detail. - Imhotep is credited as the founder of Egyptian
medicine and the original author of the papyrus,
although internal evidence suggests it was
written and edited by at least three different
authors, the last of which stopped mid-word. It
is a compilation of 48 battlefield injury cases
and the treatments that the victims had received.
- The treatments are rational, and magic is
resorted to in only one case. - The document lists 48 traumatic injury cases and
its treatments. The document starts with the
injuries on the head and then works its way down
the body all the way to the feet, as in any
modern medical document. - It predates Hippocrates by over a thousand years.
50Hippocrates 460 to 370 BC
51Hippocrates
- first physician to reject superstitions and
beliefs that credited supernatural or divine
forces with causing illness. - Hippocrates was credited by the disciples of
Pythagoras of allying philosophy and medicine. - He separated the discipline of medicine from
religion, believing and arguing that disease was
not a punishment inflicted by the gods but rather
the product of environmental factors, diet and
living habits. Indeed there is not a single
mention of a mystical illness in the entirety of
the Hippocratic Corpus. However, Hippocrates did
work with many convictions that were based on
what is now known to be incorrect anatomy and
physiology, such as Humorism.
52Hippocrates
- Ancient Greek schools of medicine were split
(into the Knidian and Koan) on how to deal with
disease. - The Knidian school of medicine focused on
diagnosis, but was dependent on many faulty
assumptions about the human body Greek medicine
at the time of Hippocrates knew almost nothing of
human anatomy and physiology because of the Greek
taboo forbidding the dissection of humans. - The Hippocratic school or Koan school achieved
greater success by applying general diagnoses and
passive treatments. Its focus was on patient care
and prognosis, not diagnosis. It could
effectively treat diseases and allowed for a
great development in clinical - Now, the physician focuses on specific diagnosis
and specialized treatment, both of which were
espoused by the Knidian school. - This shift in medical thought since Hippocrates's
day has caused serious criticism over the past
two millennia, with the passivity of Hippocratic
treatment being the subject of particularly
strong denunciations for example, the
Hippocratic treatment has been called a
"meditation upon death".
53Galen 129 to 216
54Galen
- mainstay of the medieval physician's university
curriculum - suffered greatly from stasis and intellectual
stagnation. - Medical students continued to study Galen's
writings until well into the 19th century - Brain controls all the motions of the muscles by
means of the cranial and peripheral nervous
system - In order to diagnose, one must observe and reason
55Vesalius 1514 to 1564
56Vesalius
- In the 1530s, however, Belgian anatomist and
physician Andreaus Vesalius took on a project to
translate many of Galen's Greek texts into Latin.
Vesalius's most famous work, De Humanis Coporis
Fabrica, was greatly influenced by Galenic
writing and form. Seeking to revive Galen's
methods and outlook, Vesalius turned to human
cadaver dissection as an evolution of Galen's
natural philosophy. - ethic to provide the most accurate form of the
human body. - Galenic tradition relying on his own
observations - Created a new scientific method
- His desire to strive for the truth is most
evident through his ability to correct his own
claims and to continually reshape his thoughts on
the human body. - Through his attention to detail, he was able to
provide clear descriptions and unprecedented
anatomical drawings that set a new standard for
future medical books
57Sir William Osler 1849 to 1919
58Sir William Osler
- Perhaps Osler's greatest contribution to medicine
was to insist that students learned from seeing
and talking to patients and the establishment of
the medical residency program. The success of his
residency system depended, in large part, on its
pyramidal structure with many interns, fewer
assistant residents and a single chief resident,
who originally occupied that position for years. -
- Soon after coming to Baltimore, Osler insisted
that his medical students get to the bedside
early in their training by their third year they
were taking patient histories, performing
physicals and doing lab tests examining
secretions, blood and excreta instead of sitting
in a lecture hall, dutifully taking notes. He
diminished the role of didactic lectures - established the full-time, sleep-in residency
system whereby staff physicians lived in the
Administration Building of the Hospital. As
established, the residency was open-ended, and
long tenure was the rule. Doctors spent as long
as seven or eight years as residents, during
which time they led a restricted, almost monastic
life. - Osler's contribution to medical education of
which he was proudest was his idea of clinical
clerkships--having third and fourth year students
work with patients on the wards. He pioneered the
practice of bedside teaching making rounds with a
handful of students, demonstrating what one
student referred to as his method of
"incomparably thorough physical examination."
59Dr. William Osler
- The practice of medicine is an art, based on
science. Medicine is a science of uncertainty and
an art of probability - Our main business is not to see what lies dimly
at a distance, but to do what lies clearly at the
hand.
60Flexner Report 1910 consequences
- 6, and preferably 8, years of post-secondary
formal instruction, nearly always in a university
setting - Quality of medical education is invariably high
- Medical training adheres closely to the
scientific method - Medicine in the USA and Canada becomes a highly
paid and well-respected profession - The extent of price discrimination in American
medicine declined in the aftermath of the Report - "An education in medicine," wrote Flexner,
"involves both learning and learning how the
student cannot effectively know, unless he knows
how."
61Modern EBM
- In 1996, Dr. David Sackett and colleagues at
McMasters University in Ontario, Canada defined
EBM as - the conscientious, explicit and judicious use
of current best evidence in making decisions
about the care of individual patients
62Archie Cochran
- However, it was only in the second half of the
20th century that a Scottish physician, Archie
Cochran (19091988), decided to assist clinicians
muddling in a vast contradictory mess of
information, by creating an organized critical
summary, by specialty or subspecialty, adapted
periodically, of all relevant randomized
controlled studies - It was not Cochranes contention that clinicians
knowledge was not supported by evidence, but
rather that there is a need to create an
organized, accessible critical summary of these
evidences.
63- EBM integrates best available evidence with
physician knowledge, experience and skills, and
patient values and preferences to make the best
possible clinical decision.
64Three major factors have driven the use of EBM
application
- presence of marked variation in treatments
(implying lack of knowledge and hence lack of
value) - increasing cost of healthcare
- improvement in our ability to measure and analyze
outcomes.
65Three major factors have hindered EBM application
- relative paucity of randomized controlled
clinical trials (RCTs) - dispersal of literature across medical and
surgical subspecialties and basic science - need to make rapid decisions, which precludes an
on-the-spot systematic review
66- The challenge to health care providers is to
provide up-to-date medical care to their patients
while incorporating valid new information. - The ultimate goal should be to help patients live
long, functional, satisfying, and pain- and
symptom-free lives. - To do this requires a balance of competence and
compassion. - The advancement of medical practice relies on
research
67- A significant portion of clinical decision making
is still based on personal and anecdotal
experience.
68- There is significant tension between evidence and
clinical expertise - Without clinical expertise, practice risks
becoming tyrannized by external evidence, for
even excellent external evidence may be
inapplicable to or inappropriate for an
individual patient.
69Clinical Practice Guidelines
- Physicians must assess critically any guidelines
- Evaluate the composition of the panel
- Did the panel select an area or question that is
defined clearly? - Did it perform a thorough search for the
evidence, and how did it determine whether to
include the evidence? How did it categorize the
evidence? - How did it summarize the evidence and come to its
recommendations?
70John Hardwig (1941 )
- The reasons why we continue to use treatments
that do not seem to work are multiple. - clinical experience
- overreliance on surrogate outcome
- adherence to tradition
- inability to stand idle and do nothing
71- Cool, so what happened in Colorado that is so
great that we have to deal with them down here.
They dont even talk right.
72(No Transcript)
73(No Transcript)
74(No Transcript)
75(No Transcript)
76(No Transcript)
77(No Transcript)
78(No Transcript)
79(No Transcript)
80- Multidisciplinary Task Force
- Occupational medicine
- Physiatry
- Chiropractor
- 3 specialist physicians
- Ancillary care(physical therapy, occupational
therapy, other) - Administrative
- Nurse case manager
- Claimant attorney
- About 20 participants
81- The emphasis is on quality of care and function
- Encouragement of active participation and
treatment - Use of the Guidelines allows quicker provision of
care and payment - Encourages the biopsychosocial model
82Some Conditions
- Repetitive strain/motion conditions
- Carpal Tunnel
- Low back pain management
- Injections
83Life Under the Guidelines
- Not bad
- Easy approval
- Guidelines not mandates
- Accepted by the medical and legal communities
- Good resource of information
- Defines care
- Comparison with non-occupational care of that ilk
- Level II certification and impairment ratings
84- Paraprosdokians
- Knowledge is knowing a tomato is a fruit Wisdom
is not putting it in a fruit salad. - You're never too old to learn something stupid.
- If youre not part of the solution, youre part
of the precipitate