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