Problematization

PROBLEM DELINEATION AND CRITICAL PROBLEMATIZATION

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

Four Dimensions of Health Care Policy (Guidelines)

Implementation

Delivery

Evidence From Research

Paolo Freire

"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

Cartesion Thinking vs Problematization

Case 1: Surviving Sepsis Guideline • Practice category 1: “initial resuscitation” • Considered ‘early goal directed therapy’ protocol • Looked at individual components separately

including monitoring SvcO2 via a special device

• Research on bundle components very indirect • Gave 1C recommendation to EGDT Intensive Care Med 2008;34:17-60

Alan E. Jones, MD; Michael D. Brown, MD, MSc; Stephen Trzeciak, MD, MPH. Critical Care Medicine 2008

Case 2: Implementation of EGDT • Major NYC medical center • Well championed effort • Strong interest in institution across service lines • Broke down because of resistance to use of special

catheter for SvcO2 and associated monitoring requirements

Case 3: a patient with atrial fibrillation • Major NYC medical center ED • 65 yo female presents in paroxysmal a fib • Family insists: “shock her-the drugs never work” • Would like to be D/C after cardioversion • Institutional culture favors drugs and admission • Chief resident later does search for evidence on

comparative efficacy of anti-arrhythmic drug classes in achieving conversion

Constructivist Remedies

The SIMPLE Model of Constructed Action and Evidence Assimilation

Silva, J Eval Clin Pract. 2010, In Press

Actions, then information ACTION DOMAIN THERAPY

DIAGNOSIS

PROGNOSIS

HARM

Ask

Ask

Ask

Ask

Acquire

Acquire

Acquire

Acquire

Appraise

Appraise

Appraise

Appraise

Apply

Apply

Apply

Apply

PACT: A Tool of Representation • Therapy • Diagnosis • Prognosis • Harm

Knowledge Transfer or Evidence Assimilation

Monitor Knowledge Use

Knowledge Inquiry

Synthesis

Adapt Knowledge to Local Context

Products/ Tools

Identify Problem Identify, Review, Select Knowledge

Evaluate Outcomes

no wle dge

Assess Barriers/Facilitators to Knowledge Use

KNOWLEDGE CREATION

Tai lor ing K

Select, Tailor, Implement Interventions

Sustain Knowledge Use

Evidence Based Quality Improvement Steps

Problematization

Evidence Need

What is the actual effectiveness of care?

... what is the expected mortality...?

What should be done that is not been done?

Catheter? ATB? Fluids?

What are the barriers?

Number of personnel needed? etc

Select, tailor, implement

What are the strategies to modify it?

Does this strategy modify behavior?

Monitor

What are the outcomes?

What are the main important outcomes?

Scan Identify, review select knowledge

Identify barriers

The Dimensions of Health Care Policy (Guidelines)

Implementation

Delivery

Evidence From Research

Research for Patient Care • Comparative effectiveness • Practice based and participatory research

shape the research questions & methodology As Iain Chalmers: “…. research should address health problems of importance to populations and the interventions and outcomes considered important by patients and clinicians.” e.g.: The research priorities of patients with osteoarthritis of the knee favoured more rigorous evaluation of physiotherapy and surgery and assessment of educational coping strategies. 9% wanted more research on drugs: 80% of RCTs on patients like this are drug evaluations

help with data collection, tools development, selection of outcome measures Most rheumatoid arthritis patients, when asked, indicated that fatigue was the dominant symptom of concern – not pain, as researchers had assumed In the UK, researchers seeking funding for RCTs must demonstrate that patients have been given an opportunity to provide input on the outcomes to be measured in the trial Canada is developing a core set of validated patientreported cancer care outcomes

SUMMARY • Scientifically informed, effective care,

requires “critical problematization” across all parties • If the problem is wrong, the question is wrong; if the question is wrong, evidence based methods and resources are misguided • Pedagogical tools to guide problem delineation are a needed component at all faces of evidence-based research and practice