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Knowledge Translation: A Cognitive Perspective

Knowledge Translation: A Cognitive Perspective. Jamie C. Brehaut, PhD. Applying Social Science Theory to KT. Theory: “a coherent and non-contradictory set of statements, concepts, or ideas that organizes, predicts, and explains phenomena, events, behaviours, etc…” Without a theory…

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Knowledge Translation: A Cognitive Perspective

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  1. Knowledge Translation: A Cognitive Perspective Jamie C. Brehaut, PhD

  2. Applying Social Science Theory to KT Theory: “a coherent and non-contradictory set of statements, concepts, or ideas that organizes, predicts, and explains phenomena, events, behaviours, etc…” Without a theory… Unclear when an intervention will be effective When an intervention IS effective, unclear whether it will generalize Eccles & Grimshaw (2005) J. Clinical Epidemiology.

  3. “1 of 42 studies included in the review made any mention of theory guiding their intervention” Flory & Emmanuel (2004) JAMA.

  4. Theories on the Implementation of Change Individual professionals: Cognitive theories Educational theories Attitude theories: theory of planned behaviour Motivation or stages of change theories Social interaction and context: Social learning theory Social network and influence theories Theories on patients and factors related to patients Theories on professional development Theories on leadership Organisational and economic context: Theories of innovative organizations Theory of quality management Process re-engineering theory Complexity theory Theory of organizational learning Theories on organizational culture Economic theories Grol, R et al. Improving Patient Care: The implementation of change in clinical practice. 2005

  5. Different Kinds of Individual-Level Theories • Theories describing behaviours target a different level of understanding than do theories describing decisions • Behavioural theories often collapse across instances of the behaviour • Decision-level theories are often trying to understand the variability that occurs across instances of the behaviour

  6. Theory of Planned Behaviour

  7. Behaviour-Level Theory Doesn’t Easily Explain… Real-time changes in a situation that can affect a behaviour Variance between stated plans and actual behaviour Inconsistency in actual behaviour For these, you need decision-level theory

  8. Decision-Level Theories Can inform behaviours, by describing important contextual changes Can explain variance between stated plans and actual behaviour (‘intention-behaviour gap’) BUT… Don’t mesh immediately with behaviour-level ones May be more immediately helpful for application to KT in terms of constructs, rather than whole theories

  9. Areas that may inform KT research Heuristics and biases Knowledge about memory Dual Process theory Feedback Self assessment vs. self-monitoring Affect/emotion

  10. Heuristics and Biases ‘Clinical’ definition of Heuristic: Shortcuts that can be taught to medical students; rules of thumb; parsimonious strategies for thinking/diagnosing/treating; useful ‘tricks of the trade’ ‘Cognitive’ definition of Heuristic: general principles of human reasoning; not specific to experts or to certain domains, unconscious, more or less; associated with quick, intuitive assessments of probability Bias: deviations from a normative standard or ideal. Elstein, A. personal comm., SMDM 2009.

  11. Heuristics and Biases (lots of them) Confirmation bias Diagnosis momentum Feedback sanction Framing effect Fundamental attribution error Gambler’s fallacy Gender bias Multiple alternative bias Omission bias Order effects Outcome bias Overconfidence bias Playing the odds Posterior Probability error Premature closure Psych-out error Representativeness restraint Search satisfying Sutton’s slip Sunk costs Triage cueing Unpacking principle Vertical line failure Visceral bias Yin-yang out Croskerry P. Academic Emergency Medicine 2002; 9: 1184-204.

  12. Three Canonical Heuristics Availability Heuristic: judgements affected by ease of recall, accessibility Representativeness Heuristic: judgements affected by typicality / similarity Anchoring and Adjustment Heuristic: judgements affected by starting points

  13. Under-Use of Warfarin for Atrial Fibrillation Most common cardiac arrhythmia (5% of people > 65) Strong association with stroke (6-fold increase, 1-15% per year)

  14. Warfarin Very Effective in Reducing Stroke Risk Reduces stroke risk by 65% But only given in ~50% of cases for which it would be appropriate to do so WHY? UpToDate (2009).

  15. “…availability heuristic suggests…bleeding events related to anticoagulation…are dramatic and easily remembered and seem to actually reduce warfarin prescribing”

  16. Heuristics Unavoidable? Shepard RN (1990) Mind Sights: Original Visual Illusions, Ambiguities, and other Anomalies.

  17. Reducing Effects of Different Biases Correcting Strategy-based errors: Increase incentives; introduce accountability; provide tools for effortful operations (clinical decision rules, computerized support) Correcting Association-based errors (e.g. availability): Cue decision-maker for neglected information; search for contrary information Correcting Psychophysically-based errors: Re-framing; considering multiple reference points Larrick RP. Debiasing. Blackwell Handbook, 2004.

  18. Implications for KT research • To what extent do (at least somewhat) automatic heuristics contribute to difficult KT problems? • Can efforts to counteract these effects contribute towards more effective KT?

  19. Areas that may inform KT research Heuristics and biases Knowledge about memory Dual Process theory Feedback Self assessment vs. self-monitoring Affect/emotion

  20. Knowledge About Memory • Not like a computer; memory is often reconstructed based on a semantic network, and can make associative errors (e.g. availability) • Salient memories (fatal bleed) likely affected the decision about whether to Rx Warfarin in the new case • NOT specific risk estimates from guidelines • Expertise isn’t primarily general problem solving skills, but accumulation of specific experiences that are context specific • Limits of memory Regehr & Norman. Academic Medicine 1996.

  21. Knowledge About Memory • Not like a computer; memory is often reconstructed based on a semantic network, and can make associative errors (e.g. availability) • Expertise isn’t primarily general problem solving skills, but accumulation of specific experiences that are context specific • E.g. PBL. Original plan was to teach generalizable problem-solving skills, which didn’t work. • Correlations between different measures of a single clinical skill are very low (0.1 – 0.3) • PBL a success for entirely different reasons • Limits of memory Regehr & Norman. Academic Medicine 1996.

  22. Knowledge About Memory • Not like a computer; memory is often reconstructed based on a semantic network, and can make associative errors (e.g. availability) • Expertise isn’t primarily general problem solving skills, but accumulation of specific experiences that are context specific • Limits of memory • In health care, examples abound of not considering limits of memory • Docs and guidelines • Informed consent • E.g. Clinical decision rules Regehr & Norman. Academic Medicine 1996.

  23. The Ottawa Ankle Rules

  24. Memory Test of the OAR According to the Ottawa Ankle Rules, which of the following should be considered when deciding whether to order a FOOT X-RAY SERIES? Select ONLY those indicated by the Ottawa Ankle Rules. • Bone tenderness at the base of the 5th metatarsal • Bone tenderness at the navicular • Inability to bear weight immediately after injury • High risk of fracture (e.g. osteoporosis) • Inability to bear weight in the emergency dept. • Age 55 or older • Cracking or popping sound heard • Pain in Malleolar zone • Recent history of foot fracture

  25. Memory Test Results According to the Ottawa Ankle Rules, which of the following should be considered when deciding whether to order a FOOT X-RAY SERIES? Select ONLY those indicated by the Ottawa Ankle Rules. • Bone tenderness at the base of the 5th metatarsal • Bone tenderness at the navicular • Inability to bear weight immediately after injury • High risk of fracture (e.g. osteoporosis) 78% 94% • Inability to bear weight in the emergency dept. • Age 55 or older • Cracking or popping sound heard • Pain in malleolar zone • Recent history of foot fracture 22% 80% 2% 72% 19% 14% 8% 30.9% Correct Responses Brehaut et al (2005). Academic Emerg Medicine

  26. Implications for KT research • How can interventions be developed that don’t exceed memory limits? • Can a better appreciation of memory-related processes suggest subgroups for targeted intervention? • Can a series of experiences (e.g. vignettes) succeed where presentation of central concepts does not?

  27. Areas that may inform KT research Heuristics and biases Knowledge about memory Dual Process theory Feedback Self assessment vs. self-monitoring Affect/emotion

  28. General Dual-Process Theories • Type 1: • Experiential • Unconscious • Fast • Intuitive • Little cognitive load Type 2: • Rational • Conscious • Slow • Deliberative • Large cognitive load Sladek et al. Implementation Science 2006.

  29. Example: Fuzzy Trace Theory Verbatim memory: literal facts Gist memory: core meaning • Gist information is more easily recalled, lasts longer, more resilient to distraction, stress, fatigue, etc. Implications for medical education • What should be taught • How information should be assessed • Type of decision support in the clinic Lloyd & Reyna, 2009; JAMA

  30. Implications for KT research • Are the behaviours we are targeting with KT Type 1 (intuitive), or Type 2 (deliberative)? • Are there KT interventions that target Type 1 or Type 2 processes more or less effectively? • Intervening on Type 1 decisions with Type 2 interventions? Is this why KT is so hard? Robin Hogarth (2001). Educating Intuition.

  31. Areas that may inform KT research Heuristics and biases Knowledge about memory Dual Process theory Feedback Self assessment vs. self-monitoring Affect/emotion

  32. Audit and Feedback 60 60 • Most effective when: • Immediate • Patient-specific • Frequent • Correct answers 50 50 40 40 30 30 20 20 Number of practices Number of practices Std. Dev = 16.93 10 Your practice Std. Dev = 16.93 10 Your practice Mean = 15.8 Mean = 15.8 N = 247.00 0 N = 247.00 0 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 85.0 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 85.0 Requests per 1000 patients Requests per 1000 patients Grimshaw,J (2008). pers comm.

  33. Hysong (2009) Systematic Review Assessed several constructs, some from Feedback Integration Theory (Kluger and DeNisi, 1996) A&F intervention more likely to work when feedback • provides correct information • is presented multiple ways (graphical, verbal, written) • provides both group and individual data • is delivered publicly • includes normative information • is more frequent Hysong (2009) Medical Care.

  34. Implications for KT Research • To what extent is the level of information detail referred to in theories of feedback even available most A&F tasks? • Can existing approaches to A&F be improved by consideration of feedback theories? • Which ones?

  35. Areas that may inform KT research Heuristics and biases Knowledge about memory Dual Process theory Feedback Self assessment vs. self-monitoring Affect/emotion

  36. 5. Self-Assessment / Self-Monitoring Docs are not good at global self-assessments of skill (Reflection ON practice) Little or no correlation between self-assessment and objective measures of performance Virtually everyone thinks they are doing better than they are, but especially the worst performers (Davis et al 2006 JAMA) Problem for KT researchers, it determines what information they go searching for (“pull”) However, they are much better at knowing when to slow down / refer / look it up (self-monitoring, Reflection in practice) (Eva & Regehr 2008. J Cont Ed in Hlth Prof)

  37. Self-Monitoring Self-assessment r = 0.1 – 0.3 Eva & Regehr (2007) Academic Medicine.

  38. Implications for KT research • It’s not that self-assessment are entirely deluded • Instead, the problem is aggregating across experiences • Psychological principles make it difficult or impossible to provide equal weight to every experience (e.g. availability, self-efficacy, etc., etc.) Are typical KT tools (e.g. guidelines) more likely to instill self-assessment than self-monitoring?

  39. Areas that may inform KT research Heuristics and biases Knowledge about memory Dual Process theory Feedback Self assessment vs. self-monitoring Affect/emotion

  40. 6. Affect / Emotions Affect is generally automatic, and affects many kinds of decisions Serves as attention-grabber, indicator of importance, motivator… And it can be exploited to change behaviours… Weber & Johnson (2009). Annual Review of Psychology.

  41. Serial Position Effect

  42. Affect Serial Position Effect

  43. Redelmeier et al (2003). Pain

  44. Redelmeier data slide Redelmeier et al (2003). Pain

  45. Implications for KT • What role do affective components play in existing KT interventions? • Can affective components be exploited to improve KT interventions?

  46. THANK YOU! Jamie C. Brehaut, PhD Tel: (613)798-5555 ext. 13432 Email: jbrehaut@ohri.ca Thanks to: Jeremy Grimshaw, Ian Stiell, Annette O’Connor, Ian Graham, Kaveh Shojania, Dean Fergusson, Jonathon Kimmelman, Raphael Saginur, Malcolm Man-Song-Hing, Roy Poses, Kelly Carroll, Richard Perez, Ania Syrowatka Funding: CIHR, Ontario Ministry of Health and Long-term Care, Physician Services Incorporated

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