Practice

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• Practice
• Illusion of knowledge
• Mastery
• Enjoyment and pleasure
• Guidelines

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• Hugh H. Macaulay, III, MD
• Occupational Medicine Consulting
• Englewood, CO
• hhm_at_occmedconsult.net

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• Colorado Medical Treatment Guidelines
• A Practitioners Perspective

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• Practice of medicine
• Illusion of knowledge
• Mastery and Enjoyment
• The Guidelines

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• What is the Practice of Medicine?

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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

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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

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• 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.

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• 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

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• "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!"

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• 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.

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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.

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• 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

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• "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"

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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."

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• 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

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Mental state in terms of challenge level and
skill level,
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• 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.

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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.
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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.
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• 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.

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Amenhotep I 1500 BC

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

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Hippocrates 460 to 370 BC
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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.

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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".

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Galen 129 to 216
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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

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Vesalius 1514 to 1564
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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

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Sir William Osler 1849 to 1919
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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."

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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.

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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."

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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

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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.

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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.

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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

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• 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

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• A significant portion of clinical decision making
  is still based on personal and anecdotal
  experience.

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• 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.

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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?

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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

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• 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

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• 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

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Some Conditions

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

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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