Epistemological Crisis in Medicine

INFORMATION-KNOWLEDGE-WISDOM The Epistemological Crisis in Medicine

Peter Wyer MD Associate Clinical Professor of Medicine Columbia University College of Physicians & Surgeons Chair, Section on Evidence Based Health Care, New York Acadmy of Medicine

Let’s Play A Game

JEOPARDY

Who Was Paolo Freire?

An Internationally Renowned Brazilian Educator

Cases Heard at Signout Case 1 “Paciente masculino admitido no departamento de emergencia por dor abdominal, aguardando TC de abdomen. Sea TC nao mostrar diverticulite, admitir o paciente na Rota 3 para investigacao de Sindrome Coronariana aguda”

Case 2 “Paciente masculino, 57 anos, alcoolatra, admitido 5 vezes no departamento de emergencia para investigacao de dor toracica Rota 3. Nenhum achado significativo em nenhuma destas admissoes. Diagnostico final: hematoma subdural cronico. “

TASKS

1. Assume the cases took place in Rio 2. Choose the case you most relate to 3. Treat it as the ‘answer’ in a jeopardy game: You Can’t Change It 4. Devise the ‘question’ for which these summaries constitute the ‘answers’ 5. Add details, including of context and circumstances in such a way that the summary makes sense 6. Revise the original summary in narrative form

Case 1 Revised Narrative Group 1:

Group 2:

Group 3:

Group 4:

Case 2 Revised Narrative Group 1:

Group 2:

Group 3:

Group 4:

Case Follow Up

Case 1 Follow-Up-Review of Facts Information from clinical information system 75 yo male, CC abdominal pain, PMH: - Multiple w/u abd pain – CT, +US for GS assessed to be silent - Depression-1st Admission 8 mo ago - No CP, no exercise related sx other than occasional cough, EKG nl

Case 1 Follow-Up-Review of Patient • • • • •

Verified information in medical record system Verified absence of symptoms suggestive of ACS Asked the patient why he came to the ED Verified absence of ongoing abdominal sx Discharged the patient home from the ED

Case 1 Follow-Up-Interview With Original Resident • Verified resident aware of the medical information • Queried the basis for the plan • “The attending wanted it”

Case 2 Follow-Up-Review of Facts • 57 yo alcoholic-homeless; HIV +; cocaine user; history of old MI on perfusion imaging • History unreliable-7 admissions for CP in last 9 months • Chest pain inconsistently described in past • No CP today-c/o ‘don’t feel good’ and headache • ETOH level very high, patient alert, coherent • Disheveled-old laceration nose • Admitted falling down a few times in last 1-2 months

Case 2 Follow-Up Outcomes • Patient’s mental status began to deteriorate.

• Subdural hematoma drained at bedside in ED via burr hole • Largely recovered baseline mental status • Continues to be admitted for chest pain • ACS workups continue to be negative

Case 2 M&M Presentation • Presenter trained in EBM-asked to make the presentation ‘evidence based’ • Reviewed (inapplicable) prediction rules for (acute) minor head trauma • Neither the prediction rules in question nor the ACS pathway to which the patient had been admitted X7 in the last 10 months were applicable to the patient’s actual problem

WHAT HAVE WE DONE? We have rehydrated dessicated case presentations

“Where is the wisdom we have lost in knowledge; where is the knowledge we have lost in Information” T S Eliot- The Rock 1934

CANDIDATE REMEDIES • Information • Knowledge • Wisdom

CANDIDATE REMEDIES: Information • Information does not tell you when or how to use it

CANDIDATE REMEDIES: Knowledge • The intern in the first case got it right-his attending did not • 5 attendings in the second case admitted the patient to an erroneous pathway and the EBM-trained conference presenter invoked inapplicable rules

CANDIDATE REMEDIES: Wisdom

"Repetimos que o conhecimento não se estende do que se julga sabedor até aqueles que se julga não saberem; o conhecimento se constitui nas relações homem-mundo; relações de transformação, e se aperfeiçoa na problematização crítica destas relações.“ Paolo Freire

A lesson in distributed cognition

Interpretations-Wallace Model • Attentional deficit-’worst first’ (inattentional blindness) • Time constraints (Rate distortion theorum) • Escape from complexity (Policy/ideology)

Attentional Psychology Not Enough • Narrative Process Model-Charon • Attention-Representation-Affiliation • Affiliated action=phronesis=critical problematization

Tool of Representation • • • •

Therapy Diagnosis Prognosis Harm

We have lingered in the chambers of the sea By sea-girls wreathed with seaweed red and brown Till human voices wake us, and we drown.

The Love Song of J Alfred Prufrock T.S. Eliot

SUMMARY • Evidence based medicine is about patients, not about evidence • The epistemological crisis in medicine and healthcare must be addressed if the practical challenges are to be solved • Scientifically informed, effective care,requires “critical problematization” across all parties • This means “education for critical consciousness”