PROBLEM DELINEATION AND

CRITICAL PROBLEMATIZATION

Peter Wyer MD Associate Clinical Professor of Medicine

Columbia University College of Physicians & SurgeonsChair, Section on Evidence Based Health Care, New York Academy of Medicine

Four Dimensions of Health Care

Policy(Guidelines)

Delivery

Evidence From ResearchImplementation

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

Silva, J Eval Clin Pract. 2010, In Press

The SIMPLEModel ofConstructedAction and EvidenceAssimilation

Actions, then information ACTION ACTION DOMAINDOMAIN

THERAPYTHERAPY DIAGNOSISDIAGNOSIS PROGNOSISPROGNOSIS HARMHARM

Ask

Acquire

Appraise

Ask

Acquire

Appraise

Ask

Acquire

Appraise

Ask

Acquire

Appraise

Apply Apply Apply Apply

PACT: A Tool of Representation

• Therapy• Diagnosis• Prognosis• Harm

Knowledge Transfer or

Evidence Assimilation

MonitorMonitorKnowledgeKnowledge

UseUse

SustainSustainKnowledgeKnowledge

UseUse

EvaluateEvaluateOutcomesOutcomes

AdaptAdaptKnowledgeKnowledge

to Local Contextto Local Context

AssessAssessBarriers/Facilitators to Barriers/Facilitators to

Knowledge UseKnowledge Use

Select, Tailor,Select, Tailor,ImplementImplement

InterventionsInterventions

Identify ProblemIdentify Problem

Identify, Review,Identify, Review,Select KnowledgeSelect Knowledge

Products/Products/ToolsTools

SynthesisSynthesis

Knowledge Knowledge InquiryInquiry

Tailo

ring K

now

ledg

e

KNOWLEDGE CREATIONKNOWLEDGE CREATION

ScanScan

Identify, Identify, review select review select knowledge knowledge

Select, Select, tailor, tailor, implementimplement

MonitorMonitor

What is the actual What is the actual effectiveness of care?effectiveness of care?

What should be done What should be done that is not been done? that is not been done?

What are the barriers?What are the barriers?

What are the What are the strategies to modify strategies to modify it?it?

What are the What are the outcomes?outcomes?

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

Catheter? ATB? Catheter? ATB? Fluids?Fluids?

Number of personnel Number of personnel needed? etcneeded? etc

Does this strategy Does this strategy modify behavior?modify behavior?

What are the main What are the main important outcomes?important outcomes?

Steps Problematization Evidence Need

Identify barriersIdentify barriers

Evidence Based Quality Improvement

The Dimensions of Health Care

Policy(Guidelines)

Delivery

Evidence From ResearchImplementation

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 patient-reported 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