Traditional Expert-Based Information Delivery Systems

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Traditional Expert-Based Information Delivery
Systems

• Using an Expert, Being an Expert

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Roles of Experts

• Consultation
• CME
• Review articles
• Practice guidelines
• Decision analysis

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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

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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.

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Usefulness Score

• Work Low
• Significant potential for usefulness
• Relevance Varies
• Validity Expert dependent
• If either relevance or validity is zero,
  usefulness is zero

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Types of Experts

• Content Expert
• Clinical Scientist
• YODA

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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

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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

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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

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Clinical Scientist

• Good at evaluating evidence up-to-date, dont
  have to be content experts
• Separation of therapeutics
• Medical Librarian, PharmD

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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

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YUCK

• YOUR
• UNSUBSTANTIATED
• CLINICAL
• KNOW IT ALL

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Experts gone wrong YUCKs
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YUCK

• Your Unsubstantiated Clinical Know-it-all
• Maladaptive
• Rigid, Dogmatic
• All personality types, but people who see things
  in Red and Green can fall into the YUCK trap

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The Golden Question Thats interesting . . . Is
there any evidence that . . . ?
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If its not a valid POEM, its just not
necessarily so
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Making the Most of a CME Presentation
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Dilberts Take on CME
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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

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Do We Get Something From CME?
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Is post-test performance improved? (DOE)

• YES
• Beware Chinese-Dinner Memory Dysfunction

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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

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Usefulness

• Validity Depends on the speaker
• Relevance Depends on POEMDOE ratio
• Work Higher than it seems
• NBA analogy (only last two minutes count)
• Tracking down validity of new POEMs

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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

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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

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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?

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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