Can intuition be taught? YES

Art Papier MD apapier at LOGICALIMAGES.COM
Mon Aug 19 22:19:40 UTC 2013


I have to concur with Dr. Morris.  Larry Weed has tirelessly called
attention to the limitations of the human mind and the complexity, ambiguity
and uncertainty inherent in medical diagnosis.  Larry has written eloquently
in Medicine in Denial about the need for a system of knowledge that will
bring science, rigor and measurement to our decisions.   We need to off load
complexity from ad hoc human decisions into a universal knowledge system and
tools that are structured to discover relationships and new knowledge.
Moving the complexity of system 2 thinking through tools into system 1, and
aiding system 2 thinking with tools that clarify and make obvious patterns
...needs to be our goal.    

A patient presents with fever and necrosis of the ears.  To an emergency
physician that has seen this pattern, or read about it, one immediate
question to the patient should be "Do you use Cocaine?".  If you are a
physician that has never read about Cocaine Levamisole Toxicity (or
forgotten that you read about it) or have never seen it personally there is
no amount of intuition that will allow you to see the pattern of findings
and then ask the patient "Do you use Cocaine?".    Cocaine is being cut with
Levamisole an anti-helimintic deworming agent for sheep.  It is banned for
use in humans by the FDA because it causes severe vasculitis.  Patients do
not come to their doctors and just offer, "I use Cocaine".  One point is
that there are thousands of scenarios like this where you need to know the
questions to ask.and that you cannot ask what you do not know..   Not only
are there thousands of diagnoses, there are thousands of questions to ask
the patient.   No one, not even the most seasoned, best read diagnostic
expert can memorize all the questions and diagnoses they tie to.  Yet our
patients expect our clinicians such as our emergency physicians to do so.
There was simply too much to memorize even back in the dark ages of the
1980's when I went to medical school.  Now it is obviously impossible to
memorize every question for every problem and every differential diagnosis.
Thankfully our current generation of students and residents know this.  They
have grown up on computers and mobile devices and are typically comfortable
accessing knowledge at the point of care, in front of the patient.
Unfortunately many of our colleagues responsible for curriculum design do
not understand technology and they are wed to the idea of the all-knowing
physician diagnostician.  They continue to create online books and
interactive programs to try to instill knowledge in the brain.  Beyond ACLS
and emergency situations where memorization is essential, the brain is the
problem!  We should emphasized training in decision support tools and using
professional information and have open book exams for medical students. At
the same time we need to develop better CDS.    We need CDS that also
reminds the users about the questions and gives system problem based
workflows.  Putting a bunch of findings in and getting a laundry list of
obscure and rare diagnoses has not worked because the input is often wrong
and the output taxes system 2.    So we do need better tools but that does
not mean that we should see the problem as solvable through enhanced memory
based training.   We should model excellent information use,  and test to
it.  Count me in the tools camp along with Dr. Morris.  Best to this
listserv and the excellent conversation.

 

Art Papier MD

Chief Executive Officer

3445 Winton Place . Suite 240 . Rochester NY 14623 

(585) 427-2790 x230 .  <mailto:apapier at logicalimages.com>
apapier at logicalimages.com 


 www.visualdx.com

www.skinsight.com

Logical Images

Art Papier MD

Associate Professor Of Dermatology and Medical Informatics

 

From: Alan Morris [mailto:Alan.Morris at IMAIL.ORG] 
Sent: Monday, August 19, 2013 4:50 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Can intuition be taught? YES

 

I support education, training, simulator experience and good teaching.  The
emphasis on these and other mechanisms for achieving better human
performance, however, avoids what I consider the central challenge:
overcoming the human decision-making limitations that make human performance
fall far short of a desired goal (for example, 95% compliance with credible
evidence-based decisions).  Science requires replication to advance our
understanding.  This has been a central theme since Francis Bacon and the
enlightenment - and is replayed in E.O. Wilson's "Consilience."  I think we
should be discussing tools to enable human decision makers to achieve this
goal, in addition to our treatment of the different mechanisms of training.
In the end, and regardless of mechanism, non-replicable behavior will
continue to impede medical advances and provide a barrier to realization of
patient-clinician encounter scale  medicine as a true science.

Have  a nice day.

 

Alan H. Morris, M.D.

Professor of Medicine

Adjunct Prof. of Medical Informatics

University of Utah

 

Director of Research

Director Urban Central Region Blood Gas and Pulmonary Laboratories

Pulmonary/Critical Care Division

Sorenson Heart & Lung Center - 6th Floor

Intermountain Medical Center

5121 South Cottonwood Street

Murray, Utah  84157-7000, USA

 

Office Phone: 801-507-4603

Mobile Phone: 801-718-1283

Fax: 801-507-4699

e-mail: alan.morris at imail.org

e-mail: alanhmorris at gmail.com

 

From: BRIAN GOLDMAN <drhbg at ROGERS.COM>
Reply-To: Society to Improve Diagnosis in Medicine
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, BRIAN GOLDMAN <drhbg at ROGERS.COM>
Date: Monday, August 19, 2013 1:38 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG"
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Can intuition be taught? YES

 

Intriguing discussion.  Medicine tends to prize left brain functions:
language, logic, critical thinking, numbers, and reasoning.  Intuition is
more of a right brain function, along with recognizing faces, expressing
emotions, music, reading emotions, color, images, and creativity.  Of those,
recognizing the strained expression on a patient's face or the fear of death
in their eyes help me intuit life threatening distress. The methods being
discussed so far to teach intuition strike me as left brain strategies.  I
think the most constructive things we can do is foster the proclivity to
intuition already possessed by the learner.

 

Brian Goldman, MD, MCFP(EM), FACEP
Mount Sinai Hospital, Room 206
600 University Avenue
Toronto, ON M5G 1X5
416-822-5044 phone
416-586-4719 fax

 

  _____  

From: Valerie Thompson <valerie.thompson at USASK.CA>
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG 
Sent: Monday, August 19, 2013 2:52:24 PM
Subject: Re: [IMPROVEDX] Can intuition be taught? YES

 

The study was by Gary Klein and is described in his book "Sources of Power".
It is worth noting, though, that even the most experienced firefighters did
not rely on intuition alone- they would simulate the consequences of the
course of action they were considering and modify and abandon it as
required.  A recent study also shows that although experts are better making
intuitive judgments that their less experienced counterparts, they made even
better ones after a period of reflection (Moxley et al).  Also, if you
haven't already read it, Daniel Kahneman and Gary Klein offer an interesting
hypothesis about situations in which intuitions (including clinical
intuitions) are likely to be reliable and when they are not:

Moxley, J. H., Ericsson, K. A., Charness, N., & Krampe, R. T. (2012). The
role of intuition and deliberative thinking in experts' superior tactical
decision-making. Cognition, 124,  72-78. doi:
10.1016/j.cognition.2012.03.005

Kahneman, D., & Klein, G. (2009). Conditions for intuitive expertise: A
failure to disagree. American Psychologist, 64(6), 515-526. doi:
10.1037/a0016755.

Prof. Valerie Thompson
Department of Psychology
University of Saskatchewan
9 Campus Drive
Saskatoon, SK, Canada.  S7H 3K3

On 19/08/2013 11:03 AM, Kuhn, Gloria wrote:

I would be most interested in learning more about the study you mention.
Can you give us the reference for it?

I am finding this whole discussion thread fascinating and absolutely agree
that situational awareness could be described as a form of intuition and
could be taught.

Gloria Kuhn

 

From: Amy Reinert [mailto:amy.reinert at GMAIL.COM] 
Sent: Monday, August 19, 2013 11:22 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Can intuition be taught? YES

 

As an experienced teacher of the development of intuition in a variety of
contexts, I want to offer a few points for this discussion.

 

Krippner described intuition as a shift in attention from observances and
interactions with every day reality to awareness of more subtle aspects of
situation, self, or environment.  His description is one of many, but one
that I find helpful when teaching intuitive development. Because intuition
is difficult to define, it is also difficult to study. Despite the fact that
when we talk to each other about intuition we tend to agree about what
intuition is, we generally do so without actually describing what it means
to us individually.  Therefore, when proof is offered that intuition is or
is not anything in particular, careful attention must be paid to the
definition of intuition stated in that particular context. There are some
good studies out there about intuition as a phenomenon, but few about it in
the ontological sense. Because it is a subjective experience, it is nearly
impossible to distinguish between intuition and desire, belief, impulse, or
attachment to particular outcomes. Worldview heavily influences this, and
such distinctions are particularly difficult among individuals who have very
little experience in accessing intuition or accepting it as a valid way of
knowing. 

 

One of the best studies on intuition that I have read involved the use of
intuition in professional environments. It focused on the accuracy of
intuition when used solely as a decision making tool-- and allowed
participants their own perception of their individual intuition, rather than
impose a possibly limiting definition. The findings were that individuals
who were inexperienced in their profession, as well as those who were
inexperienced at utilizing intuition in decision making were highly
inaccurate (made incorrect decisions) when relying on intuition alone.
However, very experienced professionals were able to use intuition
exclusively in certain situations with a high degree of accuracy. An example
used in the study was that fire chiefs with 20+ years of experience tended
to know exactly the right moment to pull a fire crew from a building before
the building collapsed or the fire took an otherwise difficult turn. They
did this without stopping to consciously process all of the factors
influencing the situation, but rather reported that they could "feel" when
the call needed to be made.

 

Humans, like all animals, have ways of monitoring the environment that are
not cognitively based, and are still poorly understood. In my experience,
understanding the mechanisms of the process is not necessary for the
development of intuition as a useful skill--and this can indeed be taught.
As a most basic rule while training in the use of this skill, when
intuition, or the "gut check," differs from reason in a given situation, it
is a warning flag to step back and reassess what is known about the
situation, and to look for missing pieces of information. When this happens,
it is likely that the individual has picked up some bit of data that is
sitting there the mind, but not yet integrated into the cognitive processes
involved in action. 

 

If anyone is going to be at the September conference and wants to take a
moment to run through or learn about some basic development skills, I would
be happy to oblige. Teaching this skill is one of my joys in life because it
is so helpful in improving professional skills, as well quality of life. 

 

--Amy

 

Amy Ruzicka, Ph.D.

 

On Sun, Aug 18, 2013 at 8:17 PM, David Gordon, M.D. <davidc.gordon at duke.edu>
wrote:

Sandra,

 

I am fascinated by your comment that intuition can be quickly transferred to
others because I have regarded it as something that requires personal
experience (as opposed to vicarious experience) to develop. By what means
was the experience of this senior emergency medicine physician transferred?
Lecture? Small group discussion? Role modeling?  Is this a published study?

 

Also, from your background, do you regard intuition as a general or
situational ability - as Gloria Kuhn alluded to? I can imagine an expert
clinician bolstering the learner's intuition for diagnosing chest pain but
this wouldn't seem to carry over in the diagnosis of abdominal pain.

 

-David

 

David Gordon, MD
Assistant Clinical Professor
Division of Emergency Medicine
Duke University

 

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  _____  


From: Sandra Tice [sandra.tice at MIPCORP.COM]
Sent: Sunday, August 18, 2013 5:30 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Can intuition be taught? YES

Research has shown that intuition is not innate -- it is a learned skill,
which means that it can be taught to others.  It is automatic thinking that
has become a part of a physician's unconscious mind through years of
experience.  Automatic unconscious thinking is often called intuition or
wisdom - the expert clinical reasoning that is required to accurately
identify and correctly use relevant knowledge, information, data and cues
from tacit interactions to consistently make the right judgments and
decisions.

Not only can intuition be taught but we have been capturing and documenting
it so that it can be read, learned, improved and quickly transferred to
others.  This has been tested in medicine by a physician with over 35 years
of experience in emergency medicine who transferred his intuition to
residents and medical students.  Within several days, they were diagnosing
patients as if they had many years of experience.  Their average diagnostic
accuracy immediately improved by roughly 20% and the time required to
accurately diagnose a patient dropped from over 1 hour to less than 5
minutes.

 

Sandra Tice

Cognitive Scientist & Managing Partner
Direct Phone: 773-975-6555
MIP Corporation

www.mipcorp.com <http://www.mipcorp.com/> 

 

From: Lorri Zipperer [mailto:Lorri at ZPM1.COM] 
Sent: Friday, August 16, 2013 2:06 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] Can intuition be taught?

 

Forwarded by the moderator

 

From: Peggy Zuckerman [mailto:peggyzuckerman at gmail.com] 
Sent: Friday, August 16, 2013 12:26 PM
To: Society to Improve Diagnosis in Medicine; John Brush
Subject: Re: [IMPROVEDX] FM: Crowd Wisdom .... lack of dx error in the
curriculum

Intuition is just that.  One can learn to respond to one's intuition,
usually by practicing doing just that.  Just asking, "Why does that still
worry me?  What am I not getting?" etc.  We as a species learned to avoid
being eaten by accepting that intuition, which is probably endless amounts
of data being processed in the background.

A great book to give a non-medical perspective this is "The Gift of Fear",
which reminds us that our fear responses are often overridden by our
socialized responses, leaving us vulnerable to danger.  We all have said
something to the effect, "I just knew something was wrong, and didn't
respond soon enough." This applies to avoiding the odd situation on the
street, as well as in the medical setting.

Peggy Zuckerman 

On Fri, Aug 16, 2013 at 11:01 AM, John Brush <jebrush at mac.com> wrote:

There are others on this listserv, who are much more qualified than me to
answer the question: "Can intuition be taught?"
My two cents: I suspect that intuition is a form of intelligence that is
innate, but can be shaped, honed, improved, and recalibrated. Intuition is a
talent that can be developed through deliberate practice.
I also think that metacognition can be taught. The goal of education in any
domain should be to encourage students to be more thoughtful - to actively
and critically think about what they are doing. Students need a vocabulary
and some background to get them started, though. I think our goal should be
to make this educational process more explicit. What are the core
competencies of good medical reasoning, and how can we effectively,
reliably, and efficiently teach those competencies?
John


On Aug 16, 2013, at 9:08 AM, Graber, Mark wrote:

Garry's comments raise a very important and fundamental question in our
field that someone out there may know the answer to. If not, add it to the
growing list of research priorities:

In the traditional paradigm, the expert evolves from years of training and
experience, the 'right' education as Garry phrases it.  The expert becomes
so because they've made all the errors there are to make, or have seen them.
The opposing view is that we can shortcut this process if we teach
principles of metacognition, present all the cognitive biases and their
antidotes, and teach error prevention strategies.  Robin Hogarth has a book
"Educating Intuition" and Mark Quirk makes many of the same points in his
"Intuition and Metacognition in Medical Education."

The question boils down to whether you believe that you really CAN educate
intuition, or do you have to acquire it the 'old fashioned' way, through
experience.

Mark Graber

 

 

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