<html><head><meta http-equiv="content-type" content="text/html; charset=utf-8"></head><body dir="auto"><div>Agreed. As long as we agree the Art must rest on sound science. That can be best achieved by using replicable decision support tools to enable reproducible s identification decisions and research. </div><div>Alan<br><br>Sent from my iPhone</div><div><br>On Aug 19, 2013, at 16:58, "Amy Reinert" <<a href="mailto:amy.reinert@gmail.com">amy.reinert@gmail.com</a>> wrote:<br><br></div><blockquote type="cite"><div><div dir="ltr"><div>One consideration that this discussion brings to mind, for me, is that the practice of medicine is a human endeavor with two primary components. One part is the science, and the other is interpersonal relationship that exists between physician and patient in the encounter-- even if the encounter is brief. These two components require different skills. It seems to me that too often the interpersonal is undervalued, or even overthrown, in favor of the science, which sometimes leads to neglect of the human to the degree that the person who is the patient is just another piece of data. This can result in physician behavior which is off-putting or intimidating to the patient, who then either withdraws and stops offering information or asking questions, or works in overdrive to try to get the physician to hear them. Kay Toombs' work on this topic offers much that remains relevant. Certainly without mastery of the science, there is no reason for a physician to approach patients. Still, this is about more than a winsome bedside manner. I have a hunch that, all things being equal in terms of clinical knowledge and skill, physicians who excel in quickly achieving rapport with patients make fewer diagnostic errors. Without rehashing the bias discussion in its entirety, I will just quickly note that non-conscious biases likely lead to premature or incorrect conclusions about the patient that have nothing to do with the science. Although certainly there are times when replicable behavior, protocols, and computer aided decision making are helpful and appropriate, it can't be ignored that failures in interpersonal skills can be an obstacle to collecting the right information or asking the right questions in the first place. </div>
<div> </div><div>--Amy</div><div> </div><div>Amy Ruzicka, Ph.D.</div></div><div class="gmail_extra"><br><br><div class="gmail_quote">On Mon, Aug 19, 2013 at 4:50 PM, Alan Morris <span dir="ltr"><<a href="mailto:Alan.Morris@imail.org" target="_blank">Alan.Morris@imail.org</a>></span> wrote:<br>
<blockquote class="gmail_quote" style="margin:0 0 0 .8ex;border-left:1px #ccc solid;padding-left:1ex">
<div style="font-family:Calibri,sans-serif;font-size:18px"><div><div>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.</div>
<div class="im"><div><div>Have  a nice day.</div><div><br></div><div><div></div></div><div><div style="font-size:14px"><div style="font-family:Calibri"><div><font face="Arial">Alan H. Morris, M.D.</font></div><div><font face="Arial">Professor of Medicine</font></div>
<div><font face="Arial">Adjunct Prof. of Medical Informatics</font></div><div><font face="Arial">University of Utah</font></div><div><font face="Arial"><br></font></div><div><font face="Arial">Director of Research</font></div>
<div><font face="Arial">Director Urban Central Region Blood Gas and Pulmonary Laboratories</font></div><div><font face="Arial">Pulmonary/Critical Care Division</font></div><div><font face="Arial">Sorenson Heart & Lung Center - 6th Floor</font></div>
<div><font face="Arial">Intermountain Medical Center</font></div><div><font face="Arial">5121 South Cottonwood Street</font></div><div><font face="Arial">Murray, Utah  84157-7000, USA</font></div><div><font face="Arial"><br>
</font></div><div><font face="Arial">Office Phone: <a href="tel:801-507-4603" target="_blank" value="+18015074603">801-507-4603</a></font></div><div><font face="Arial">Mobile Phone: <a href="tel:801-718-1283" target="_blank" value="+18017181283">801-718-1283</a></font></div>
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<span style="font-weight:bold">From: </span> BRIAN GOLDMAN <<a href="mailto:drhbg@ROGERS.COM" target="_blank">drhbg@ROGERS.COM</a>><br><span style="font-weight:bold">Reply-To: </span> Society to Improve Diagnosis in Medicine <<a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a>>, BRIAN GOLDMAN <<a href="mailto:drhbg@ROGERS.COM" target="_blank">drhbg@ROGERS.COM</a>><br>
<span style="font-weight:bold">Date: </span> Monday, August 19, 2013 1:38 PM<br><span style="font-weight:bold">To: </span> "<a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a>" <<a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a>><div>
<div class="h5"><br><span style="font-weight:bold">Subject: </span> Re: [IMPROVEDX] Can intuition be taught? YES<br></div></div></div><div><div class="h5"><div><br></div><div><div style="font-family:verdana,helvetica,sans-serif;font-size:12pt">
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.<br>
<div> </div><div>Brian Goldman, MD, MCFP(EM), FACEP<br>Mount Sinai Hospital, Room 206<br>600 University Avenue<br>Toronto, ON M5G 1X5<br><a href="tel:416-822-5044" target="_blank" value="+14168225044">416-822-5044</a> phone<br>
<a href="tel:416-586-4719" target="_blank" value="+14165864719">416-586-4719</a>
 fax</div><div><br></div>  <div style="font-family:verdana,helvetica,sans-serif;font-size:12pt"> <div style="font-family:times new roman,new york,times,serif;font-size:12pt"> <div dir="ltr"> <hr size="1">  <font face="Arial"> <b><span style="font-weight:bold">From:</span></b> Valerie Thompson <<a href="mailto:valerie.thompson@USASK.CA" target="_blank">valerie.thompson@USASK.CA</a>><br>
 <b><span style="font-weight:bold">To:</span></b> <a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a> <br> <b><span style="font-weight:bold">Sent:</span></b> Monday, August 19, 2013 2:52:24 PM<br>
 <b><span style="font-weight:bold">Subject:</span></b> Re: [IMPROVEDX] Can intuition be taught? YES<br> </font> </div> <div><br><div>
  

    
  
  <div>
    <div>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:<br>
      <br>
      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<br>
      <br>
      Kahneman, D., & Klein, G. (2009). Conditions for intuitive
      expertise: A failure to disagree. American Psychologist, 64(6),
      515-526. doi: 10.1037/a0016755.<br>
      <br>
      <pre>Prof. Valerie Thompson
Department of Psychology
University of Saskatchewan
9 Campus Drive
Saskatoon, SK, Canada.  S7H 3K3</pre>
      On 19/08/2013 11:03 AM, Kuhn, Gloria wrote:<br>
    </div>
    <blockquote type="cite">
      
      
      <div>
        <div><span style="color:rgb(31,73,125);font-size:11pt">I would be most interested in learning more
            about the study you mention.  Can you give us the reference
            for it?</span></div>
        <div><span style="color:rgb(31,73,125);font-size:11pt">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.</span></div>
        <div><span style="color:rgb(31,73,125);font-size:11pt">Gloria Kuhn</span></div>
        <div><span style="color:rgb(31,73,125);font-size:11pt"> </span></div>
        <div><b><span style="font-size:10pt">From:</span></b><span style="font-size:10pt"> Amy
            Reinert [<a href="mailto:amy.reinert@GMAIL.COM" target="_blank" rel="nofollow">mailto:amy.reinert@GMAIL.COM</a>]
            <br>
            <b>Sent:</b> Monday, August 19, 2013 11:22 AM<br>
            <b>To:</b> <a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank" rel="nofollow">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a><br>
            <b>Subject:</b> Re: [IMPROVEDX] Can intuition be taught? YES</span></div>
        <div> </div>
        <div>
          <div>
            <div>As an experienced teacher of the
              development of intuition in a variety of contexts, I want
              to offer a few points for this discussion.</div>
          </div>
          <div>
            <div> </div>
          </div>
          <div>
            <div>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.
            </div>
          </div>
          <div>
            <div> </div>
          </div>
          <div>
            <div>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.</div>
          </div>
          <div>
            <div> </div>
          </div>
          <div>
            <div>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.
            </div>
          </div>
          <div>
            <div> </div>
          </div>
          <div>
            <div>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. </div>
          </div>
          <div>
            <div> </div>
          </div>
          <div>
            <div>--Amy</div>
          </div>
          <div>
            <div> </div>
          </div>
          <div>
            <div>Amy Ruzicka, Ph.D.</div>
          </div>
        </div>
        <div>
          <div style="margin-bottom:12pt"> </div>
          <div>
            <div>On Sun, Aug 18, 2013 at 8:17 PM, David
              Gordon, M.D. <<a href="mailto:davidc.gordon@duke.edu" target="_blank" rel="nofollow">davidc.gordon@duke.edu</a>>
              wrote:</div>
            <div>
              <div>
                <div><span style="font-size:10pt">Sandra,</span></div>
                <div><span style="font-size:10pt"> </span></div>
                <div><span style="font-size:10pt">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?</span></div>
                <div><span style="font-size:10pt"> </span></div>
                <div><span style="font-size:10pt">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.</span></div>
                <div><span style="font-size:10pt"> </span></div>
                <div><span style="font-size:10pt">-David</span></div>
                <div><span style="font-size:10pt"> </span></div>
                <div>
                  <div>
                    <div>
                      <div>
                        <div><span style="font-size:10pt">David
                            Gordon, MD<br>
                            Assistant Clinical Professor<br>
                            Division of Emergency Medicine<br>
                            Duke University</span></div>
                      </div>
                      <div>
                        <div><span style="font-size:10pt"> </span></div>
                      </div>
                      <div>
                        <div>
                          <div style="margin-top:14pt;margin-bottom:14pt">
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                  </div>
                  <div>
                    <div style="margin-bottom:12pt"><b><span>From:</span></b><span> Sandra Tice [<a href="mailto:sandra.tice@MIPCORP.COM" target="_blank" rel="nofollow">sandra.tice@MIPCORP.COM</a>]<br>
                        <b>Sent:</b> Sunday, August 18, 2013 5:30 PM<br>
                        <b>To:</b> <a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank" rel="nofollow">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a><br>
                        <b>Subject:</b> Re: [IMPROVEDX] Can intuition be
                        taught? YES</span></div>
                  </div>
                  <div>
                    <div>
                      <div>
                        <div>
                          <div><span style="font-size:11pt">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.</span></div>
                          <div><span style="font-size:11pt">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.</span></div>
                          <div> </div>
                          <div><span style="font-size:11pt">Sandra
                              Tice</span></div>
                          <div><span style="font-size:11pt">Cognitive
                              Scientist & Managing Partner<br>
                              Direct Phone: <a rel="nofollow">773-975-6555</a><br>
                              MIP Corporation</span></div>
                          <div><span style="font-size:11pt"><a href="http://www.mipcorp.com/" target="_blank" rel="nofollow">www.mipcorp.com</a></span></div>
                          <div> </div>
                          <div>
                            <div style="border-width:1pt medium medium;border-style:solid none none;border-color:currentColor;padding:3pt 0in 0in">
                              <div><b><span style="font-size:10pt">From:</span></b><span style="font-size:10pt">
                                  Lorri Zipperer [mailto:<a href="mailto:Lorri@ZPM1.COM" target="_blank" rel="nofollow">Lorri@ZPM1.COM</a>]
                                  <br>
                                  <b>Sent:</b> Friday, August 16, 2013
                                  2:06 PM<br>
                                  <b>To:</b> <a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank" rel="nofollow">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a><br>
                                  <b>Subject:</b> [IMPROVEDX] Can
                                  intuition be taught?</span></div>
                            </div>
                          </div>
                          <div> </div>
                          <div><span style="color:rgb(31,73,125);font-size:11pt">Forwarded by the moderator</span></div>
                          <div><a name="140986cac221a78b_14096ac70d956667__MailEndCompose" rel="nofollow"></a> </div>
                          <div><b><span style="font-size:10pt">From:</span></b><span style="font-size:10pt">
                              Peggy Zuckerman [<a href="mailto:peggyzuckerman@gmail.com" target="_blank" rel="nofollow">mailto:peggyzuckerman@gmail.com</a>]
                              <br>
                              <b>Sent:</b> Friday, August 16, 2013 12:26
                              PM<br>
                              <b>To:</b> Society to Improve Diagnosis in
                              Medicine; John Brush<br>
                              <b>Subject:</b> Re: [IMPROVEDX] FM: Crowd
                              Wisdom .... lack of dx error in the
                              curriculum</span></div>
                          <div>
                            <div>
                              <div>
                                <div style="margin-bottom:12pt">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.</div>
                              </div>
                              <div style="margin-bottom:12pt">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.</div>
                            </div>
                            <div>Peggy
                              Zuckerman </div>
                          </div>
                          <div>
                            <div>
                              <div>On Fri, Aug
                                16, 2013 at 11:01 AM, John Brush <<a href="mailto:jebrush@mac.com" target="_blank" rel="nofollow">jebrush@mac.com</a>>
                                wrote:</div>
                              <div>There are
                                others on this listserv, who are much
                                more qualified than me to answer the
                                question: "Can intuition be taught?"<br>
                                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.<br>
                                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?<br>
                                <span style="color:rgb(136,136,136)">John</span></div>
                              <div>
                                <div>
                                  <div><br>
                                    On Aug 16, 2013, at 9:08 AM, Graber,
                                    Mark wrote:<br>
                                    <br>
                                    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:<br>
                                    <br>
                                    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."<br>
                                    <br>
                                    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.<br>
                                    <br>
                                    Mark Graber</div>
                                </div>
                              </div>
                            </div>
                          </div>
                          <div> <br></div>
                          </div></div></div></div></div></div></div></div></div></div></blockquote></div></div></div></div></div></div></div><p></p></div></div></span></div><div class="HOEnZb"><div class="h5">
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<br>Moderator: Lorri Zipperer <a href="mailto:Lorri@ZPM1.com">Lorri@ZPM1.com</a>, Communication co-chair, Society for Improving Diagnosis in Medicine<br>

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<br />Moderator: Lorri Zipperer Lorri@ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine<br />

<br />To learn more about SIDM visit:<br>http://www.improvediagnosis.org/</p>

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