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Practice

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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?

6
Free 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

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  • Shamanism Remains

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  • Medical Practice is a journey

12
The illusion of knowledge
  • information and accuracy
  • belief that our basic understanding is actually a
    deep understanding

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  • http//www.youtube.com/watch?featureplayer_detail
    pagevIGQmdoK_ZfY

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  • 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.

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  • Mastery

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.

25
George 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"

28
Mihaly 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

30
Mental 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.

32
In 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.
33
There 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?

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  • Whoa dude, I came here to learn about this
    guideline stuff.

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  • The Guidelines of Colorado

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  • OK, bucks saved, but how can I practice using
    these things.

46
Amenhotep I 1500 BC

47
Ebers papyrus
Bricks and herbs for asthma
treatment of cancer.
48
Edwin Smith papyrus
49
Edwin 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.

50
Hippocrates 460 to 370 BC
51
Hippocrates
  • 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.

52
Hippocrates
  • 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".

53
Galen 129 to 216
54
Galen
  • 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

55
Vesalius 1514 to 1564
56
Vesalius
  • 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

57
Sir William Osler 1849 to 1919
58
Sir 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."

59
Dr. 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.

60
Flexner 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."

61
Modern 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

62
Archie 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.

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  • EBM integrates best available evidence with
    physician knowledge, experience and skills, and
    patient values and preferences to make the best
    possible clinical decision.

64
Three 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.

65
Three 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.

69
Clinical 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?

70
John 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.

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  • 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

82
Some Conditions
  • Repetitive strain/motion conditions
  • Carpal Tunnel
  • Low back pain management
  • Injections

83
Life 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

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  • 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
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