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And Clinical Problem Solving Shantou University, Session 6, November, 2010.

Integrative Thinking. And Clinical Problem Solving Shantou University, Session 6, November, 2010. Mihnea Moldoveanu Desautels Professor of Integrative Thinking Rotman School of Management University of Toronto. Two Views of education. “ INFORMATION” (KNOW-WHAT)

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And Clinical Problem Solving Shantou University, Session 6, November, 2010.

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  1. Integrative Thinking AndClinical ProblemSolvingShantou University, Session 6, November, 2010. Mihnea Moldoveanu Desautels Professor of Integrative Thinking Rotman School of Management University of Toronto

  2. Two Views of education “INFORMATION” (KNOW-WHAT) [current state: what do I know/remember?] “Memorize”: Chemistry, biology, Anatomy, Physiology “KNOWING” EDUCATION “BEING, DOING” “Apply”: Deploy knowledge to solve clinical problems. “TRANSFORMATION” (KNOW-HOW) [desired state: what problems can I solve with what I know?]

  3. What Is “Know-How”? SOLVE PROBLEMS FRAME PROBLEMS KNOW-HOW COMMUNICATE AND LEGITIMIZE SOLUTIONS “MAKE IT WORK”: IMPLEMENT SOLUTIONS

  4. Thinking about the way you think about the patient I-Mode (Intelligent) Surveying the predicament Choosing the problem Parsing the problem Thinking about the patient M-Mode (Mechanical) ‘chugging through’ ‘solving the problem’ The patient Intelligence does not equate to computational ability, but to the adaptive deployment of computational ability (!!)

  5. A Starting Point for Integrative Thinking The test of a first-rate intelligence is the ability to hold two opposing ideas in mind at the same time and still retain the ability to function. One should, for example, be able to see that things are hopeless yet be determined to make them otherwise. – F. Scott Fitzgerald Fitzgerald, F.S. 1945. The Crack-Up. New York: New Directions Publishing.

  6. Understanding the Beast: Automatism and Mechanical Routinization of Behavior 1. The common sense view of planning and action Time Time DELIBERATION ACTION PLANNING INTENTION AWARENESS OF COMMITMENT JUSTIFICATION/ INTERPRETATION COMMITMENT INTENTION ACTION 2. The more realistic view…

  7. The unbearable unconsciousness of being…Libet, 1979) ... and electrodes inserted in scalp and hand of subject... Minute clock speeded up by a factor of 30... ...allow researchers to test for difference between neural initiation of action (RP), the registration of conscious wish to initiate action (W) and action itself (S)... ...and note that there is a 300 to 800 millisecond GAP between initiation of action and the registration of a conscious wish to act.

  8. What if mental behavior (aka ‘thinking’) is also largely automatic?

  9. Seeing X as Y is active...

  10. ...and sticky. In fact, downright viscous.

  11. Flipping the Mind’s Eye

  12. We see the world through models... and therefore models are everywhere.

  13. Models in Clinical Practice Condition/Disease Model pa (Condition) Model ph (Condition) Patient Physician Model pa (Physician) Model ph (Patient)

  14. Intervention I: “Modeling and Diagnostic Errors” Patient: 30 yo white female, presenting with intense sustained vomiting after meals, abdominal pains, 10% weight loss over 1year, no GI bleeding, no other symptoms. Physician A (Model I): Anorexia nervosa/bulimia Physician recommendation: Counseling, anxiolytics, starch/pasta/cereal diet (‘easily ingestible’) Patient outcome: Continued symptoms, heightened anxiety, deceptive behavior (hiding drugs) Physician Model IA: Anxiety disorder/phobia, non-compliance Physician recommendation: Internment (psychiatric ward)

  15. Structure of the Interaction Model IA Patient Physician A Model IA Model I Model I Condition

  16. Consider Model II(Celiac Disease: auto-immune disorder gluten intolerance) Physician B (Model II); Prescribes upper GI endoscopy Patient resists (Model IA) Physician insists, discloses Model II Patient complies, Model II is confirmed New diet prescribed Symptoms subside, weight loss recovered

  17. Logical Structure of Intervention Model I Condition Physician A Patient Model IA negative impact Prescription I Model II Condition Physician B positive impact Prescription II Opposite of prescription I

  18. Basic Structure of Medical Inference (NAÏVE) Test Test D1 Condition Patient D2 D2 D3 D3 D3 Differential Diagnosis Physician D4 D5 …

  19. Structure of Clinical Inference (Improved) Condition Patient Physician Differential Diagnoses Depend on Mutual MODELS

  20. Self: Modeling: An Exercise in Applied Physiology MEDICAL STUDENT (SELF) SELF-MODEL

  21. Self-Modeling Exercise SELF (student) BEHAVIORAL GOAL/ STATE/TRAIT (focus, presence, fitness, STM, LTM) MODEL (SELF) (endocrine, neurophysiological, cognitive) CHANGE “DIAGNOSIS” (prescription for change) TEST (try behaviors)

  22. What if language itself is a set of models? Using EIP as an Educational Vehicle

  23. Language Shapes How We Think New cognitive research suggests that language profoundly influences the way people see the world. Do the languages we speak shape the way we think? Do they merely express thought, or do the structures in languages (without our awareness) shape the very thoughts we wish to express?

  24. Language Shapes How We Think Take “Humpty Dumpty sat on a wall…” Even this snippet of a nursery rhyme reveals how much languages can differ from one another. In English, we have to mark the verb for tense; in this case, we say “sat” rather than “sit.” In Indonesian you need not (in fact, you can’t) change the verb to mark tense.

  25. Languages Shapes How We Think In Russian, you would have to mark tense and also gender, changing the verb if Mrs. Dumpty did the sitting. You would also have to decide if the sitting event was completed or not. If our ovoid hero sat on the wall for the entire time he was meant to it would be a different form of the verb than if, say, he had a great fall. In Turkish, you would have to include in the verb how you acquired this information. For example, if you saw the chubby fellow on the wall with your own eyes, you’d use one form of the verb, but if you had simply read or heard about it, you’d use a different form.

  26. In Translation Russian 1. If the action took place but we don’t know if it was completed or not: A. HD is male:  Humpty Dumpty sidelnastene   (see-DEL nah steh-NEH) B. HD is female: Humpty Dumpty sidelanastene   (see-DEL-ah nah steh-NEH) C. HD is neutral: Humpty Dumpty sidelonastene  (see-DEL-oh nah steh-NEH) In this case we just know that at some point in time Humpty Dumpty sat on a wall. We don’t know if HD is still there or gone home. 2. The following verb is the ‘completed form’ of the same verb used above, and the sentence would mean that HD has physically seated itself on a wall. It means that HD has completed the action of sitting down on the wall but we don’t know if HD is still on the wall: A. HD is male:  Humpty Dumpty selnastenu   (SEHL nah STEH-nuh) B. HD is female: Humpty Dumpty selanastenu   (SEH-lah nah STEH-nuh) C. HD is neutral: Humpty Dumpty selonastenu   (SEH-loh nah STEH-nuh) 3. One other ‘completed form’ verb means that HD has spent some time sitting on the wall earlier and is no longer there: A. HD is male:  Humpty Dumpty posidelnastene   (pah-see-DEL nah steh-NEH) B. HD is female: Humpty Dumpty posidelanastene   (pah-see-DEL-ah nah steh-NEH) C. HD is neutral: Humpty Dumpty posidelonastene  (pah-see-DEL-oh nah steh-NEH) Given that the story continues to say that HD fell, if I were telling the story, I’d choose the first or the second verb – either would be fine. The third one would be a bit off because it’s giving away that HD is no longer on the wall, so saying next that it fell off does not flow well.

  27. In Translation Humpty Dumpty sat on a wall… Indonesian Humpty Dumpty dudukdidinding Verb duduk = past or present Turkish Humpty Dumpty birduvarınüstüneoturdu (from Google Translate) Humpty Dumpty (in Turkish tales we call it RafadanKafadan which means not too much boiled egg) RafadanKafadanduvardaoturdu- (this means you saw it yourself. the verb is otur, du is suffix, duvar = wall) RafadanKafadanduvardaoturmuş. (this means you learned it from someone else. miş is suffix -. so we have two past tenses in order to explain if you see it or learn it.)

  28. Language and Attribution of Responsibility Language matters When bad things happen, how do we decide who is to blame and how much they should be punished?

  29. Language and Attribution of Responsibility Subtle linguistic cues influence judgments – even when people have rich established knowledge and visual information about events – with important real-world consequences. It changes the way people construe what happened and how they attribute blame and dole out punishment.

  30. Language and Attributions of Responsibility English describes events in terms of people (agents) doing things, even in the case of accidents Example:“Susan broke the vase”

  31. Language and Attributions of Responsibility Speakers of Spanish or Japanese would be more likely to say: “the vase broke itself.”

  32. Language and Attributions of Responsibility Language matters In a study, English speakers watched the video of Janet Jackson’s infamous “wardrobe malfunction” (a wonderful non-attributable coinage introduced by Justin Timberlake), accompanied by two written descriptions. The descriptions were identical except the last sentence. One said, “ripped the costume” while the other said, “the costume ripped.” Even though everyone watched the same video and witnessed the ripping with their own eyes, not only did people who read “ripped the costume” blame Justin Timberlake more, they also levied a whopping 53% more in fines.

  33. Language and Attributions of Responsibility Non-attribution in language can sound evasive: Example: Reagan’s “Mistakes were made.”

  34. Stop, Think, Reflect, Discuss...

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