problematization

CRITICAL PROBLEMATIZATION: TRANSFORMING INFORMATION

INTO KNOWLEDGE

Suzana Alves da SilvaPROCEP: Teaching and Research Center of Pro-Cardiaco

[email protected]

quarta-feira, 11 de agosto de 2010

mailto:[email protected]


Problematization It is the act of knowing in concrete

situations

It is the reflection on the content of an act itself in order to act better within the framework of reality

It requires: Critical reasoning of reality Attitude towards the transformation of this reality


Evidence-Based Medicine

“The integration of best research evidence with clinical expertise

and patient values and circumstances”

David Sackett, 1992


Expertise

Patients Evidence

Haynes. ACP J Club 1996.

Model for Clinical Decision


Circumstances

Patients Evidence




Circumstances

Expertise

Patients Evidence




Scientifically Informed Medical Practice and Learning - SIMPLE Model

Suzana Silva, Sicily Conference, Italy 2009 | JECP 2010

“Knowledge does not extend from those who consider they know to those who

consider they do not know. Knowledge is

built in the relationship between human beings and

perfects it self in the critical

problematization of these relations.”

Paulo Freire




Critical Problematization






Paulo Freire





Clinical Action






Paulo Freire





Clinical Action

Scientific Evidence






Paulo Freire


EBCP is ...

“The systematic extension of EBM into the fabric of clinical actions arising from patient-practitioner relationships.”

Peter Wyer


Paulo Freire. Pedagogy of the Oppressed. 1974

“The process of problematization implies a

critical return to action. It starts from action and returns to it”


Randomized Controlled Trials

Observational Studies

All the rest Cl

inic

al D

ecisi

on M

akin

g

Research and Practice

Info

rmat

ion

< 20%

> 80%

David Eddy. Evidence-Based Medicine: A Unified Approach. Health Affairs 2005.


.... .

... ..

.

Suzana Silva, EBCP Newsletter, McMaster University 2008

Randomized Controlled TrialsSystematic Reviews

Logarithmic Transformation“Things must be as simple as possible, but not any simpler”

Einstein

Therapeutic Interventions





Einstein



TherapyDiagnosis

PrognosisHarm


Einstein


The Epistemological Crisis

Silva and Wyer, Where is the wisdom? II, JECP 2009!

XVII XVIII IX XX

Knowledge is gained from experience.

Theory of Tabula Rasa and Posteriori

Reasoning.

The concept of Weak and

Strong Verification

Theory is considered true if it works in

practice

Socio-Cultural context. Tacit knowledge


Integration of Knowledge

Silva and Wyer, Where is the wisdom? II, JECP 2009

Clinical Research

Basic Science

Clinical Expertise

Evide

nce H

ierarc

hy

JAM

A 1992

Oxford Classification

Guidelines




Clinical Research

Basic Science

Clinical Expertise

Clinical Knowledge“Problematization” - Constructivism

Scientific KnowledgePos-Positivism - Pragmatism

InformationPositivism

Evide

nce H

ierarc

hy

JAM

A 1992

Epist

emolo

gical

Hierarc

hy

JECP 2

009

Comple

xity


Guidelines




Clinical Research

Basic Science

Clinical Expertise

Clinical Knowledge“Problematization” - Constructivism

Scientific KnowledgePos-Positivism - Pragmatism

InformationPositivism

Evide

nce H

ierarc

hy

JAM

A 1992

Epist

emolo

gical

Hierarc

hy

JECP 2

009

Comple

xity

Wis

dom


Guidelines


What does it mean?Evidence Assimilation


Evidence Assimilation

Patient-Practitioner Relationship and Practice Circumstances

Action

System

Bas

ed le

vel

Policy l

evel

Indivi

dualize

d Car

e


Evidence Assimilation

Patie

nt-P

ract

ition

er R

elat

ions

hip

and

Prac

tice

Cir

cum

stan

ces

Action

System

Bas

ed le

vel

Policy l

evel

Indivi

dualize

d Car

e


Silva, Charon, Wyer. JECP 2010. In press.

Patie

nt-P

ract

ition

er R

elat

ions

hip

and

Prac

tice

Cir

cum

stan

ces


PProblem

PProblem

AAction

CChoices

CChoices

TTargets

UtilityTherapeutic InterventionsDiagnostic InterventionsPrognostic Interventions

Share consideration of Share consideration of Share consideration of Revised Estimate

PerformanceDiagnosisPrognosis

Share consideration ofShare consideration ofShare consideration ofRevised Estimate

FrequencyDiagnosisPrognosis

Share consideration ofShare consideration ofShare consideration ofRevised Estimate

FrequencyDiagnosisPrognosis

Share considerati

on of

Share considerati

on of X Estimate

Silva, Charon, Wyer. JECP 2010. In press.

Patie

nt-P

ract

ition

er R

elat

ions

hip

and

Prac

tice

Cir

cum

stan

ces


T h e n e w e ngl a nd j o u r na l o f m e dic i n e

n engl j med 361;3 nejm.org july 16, 2009 245

original article

Disclosure of APOE Genotype for Risk of Alzheimer’s Disease

Robert C. Green, M.D., M.P.H., J. Scott Roberts, Ph.D., L. Adrienne Cupples, Ph.D., Norman R. Relkin, M.D., Ph.D.,

Peter J. Whitehouse, M.D., Ph.D., Tamsen Brown, M.S., Susan LaRusse Eckert, M.S., Melissa Butson, Sc.M., A. Dessa Sadovnick, Ph.D.,

Kimberly A. Quaid, Ph.D., Clara Chen, M.H.S., Robert Cook-Deegan, M.D., and Lindsay A. Farrer, Ph.D., for the REVEAL Study Group*

From Boston University School of Medi-cine (R.C.G., T.B., L.A.F.), Boston Univer-sity School of Public Health (R.C.G., L.A.C., C.C., L.A.F.), and Harvard Medi-cal School Genetics Training Program (R.C.G.) — all in Boston; the University of Michigan School of Public Health, Ann Arbor ( J.S.R.); Weill Cornell Medical Col-lege, New York (N.R.R.); Case Western Reserve University School of Medicine, Cleveland (P.J.W., M.B.); Columbia Uni-versity School of Medicine, New York (S.L.E.); the University of British Columbia, Vancouver Hospital and Health Sciences Centre, Vancouver, BC, Canada (A.D.S.); Indiana University School of Medicine, Indianapolis (K.A.Q.); and Duke Univer-sity, Durham, NC (R.C.-D.). Address re-print requests to Dr. Green at Boston University School of Medicine, 715 Alba-ny St., L-320, Boston, MA 02118, or at [email protected].

*Members of the Risk Evaluation and Ed-ucation for Alzheimer’s Disease (REVEAL) Study Group are listed in the Appendix.

N Engl J Med 2009;361:245-54.Copyright © 2009 Massachusetts Medical Society.

A bs tr ac t

BackgroundThe apolipoprotein E (APOE) genotype provides information on the risk of Alzheimer’s disease, but the genotyping of patients and their family members has been discour-aged. We examined the effect of genotype disclosure in a prospective, randomized, controlled trial.

MethodsWe randomly assigned 162 asymptomatic adults who had a parent with Alzheimer’s disease to receive the results of their own APOE genotyping (disclosure group) or not to receive such results (nondisclosure group). We measured symptoms of anxiety, depression, and test-related distress 6 weeks, 6 months, and 1 year after disclosure or nondisclosure.

ResultsThere were no significant differences between the two groups in changes in time-averaged measures of anxiety (4.5 in the disclosure group and 4.4 in the nondisclo-sure group, P = 0.84), depression (8.8 and 8.7, respectively; P = 0.98), or test-related distress (6.9 and 7.5, respectively; P = 0.61). Secondary comparisons between the non-disclosure group and a disclosure subgroup of subjects carrying the APOE !4 allele (which is associated with increased risk) also revealed no significant differences. How-ever, the !4-negative subgroup had a significantly lower level of test-related distress than did the !4-positive subgroup (P = 0.01). Subjects with clinically meaningful chang-es in psychological outcomes were distributed evenly among the nondisclosure group and the !4-positive and !4-negative subgroups. Baseline scores for anxiety and de-pression were strongly associated with post-disclosure scores of these measures (P<0.001 for both comparisons).

ConclusionsThe disclosure of APOE genotyping results to adult children of patients with Alzhei-mer’s disease did not result in significant short-term psychological risks. Test-related distress was reduced among those who learned that they were APOE !4–negative. Persons with high levels of emotional distress before undergoing genetic testing were more likely to have emotional difficulties after disclosure. (ClinicalTrials.gov number, NCT00571025.)

Copyright © 2009 Massachusetts Medical Society. All rights reserved. Downloaded from www.nejm.org by PETER C. WYER MD on July 16, 2009 .

Prognosis Utility

Persons with high levels of emotional distress before undergoing genetic testingwere more likely to have emotional difficulties after disclosure.


Diagnostic Test Utility


Diagnostic Test Utility

Heart failure therapy guided by N-terminal BNP did not improve overall clinical outcomes or quality of life compared with symptom-guided treatment.


What is the accuracy of BNP test for establishing or excluding CHF in patients admitted in the emergency room with non

specific dyspnea?


Into Policy and PracticeAssimilating Information

I am going to give examples that pertain to practice in the level of System and Individual Care. The third dimension is Policy and will be delt with by Holger who will discuss the interplay of value issues and scientific evidence within the GRADE system


Early Goal Direct Therapy

Recommendation to monitor ScvO2 to guide treatment of severe sepsis in the emergency room

Guides therapy and enables early intervention

Convenient, accurate and easy-to-use

Continuous ScvO2 monitoring is also available with integrated Oligon antimicrobial†† material

Rivers 2001


Cartesian Reasoning

•Should Pre-Sep catheter be available in the emergency room and used to guide therapy in patients with sepsis?

René Descartes

Linear system: one thing leads to another


The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis*

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


Constructivist ReasoningTheory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care




Scan

Identify

Assessment

Implement

Monitor

Steps




Scan

Identify

Assessment

Implement

Monitor

What is the actual effectiveness of care?

Steps Problematization




Scan

Identify

Assessment

Implement

Monitor


What should be done that is not been done?





Scan

Identify

Assessment

Implement

Monitor



What are the barriers?





Scan

Identify

Assessment

Implement

Monitor




What are the strategies to modify it?





Scan

Identify

Assessment

Implement

Monitor





What are the outcomes?





Scan

Identify

Assessment

Implement

Monitor






Steps Problematization Evidence Need




Scan

Identify

Assessment

Implement

Monitor






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

Catheter? ATB? Fluids?

Number of personnel needed? etc

Does this strategy modify behavior?

What are the main important outcomes?

Steps Problematization Evidence Need


Medicine of complexity

“I woke up with palpitations and chest pressure this morning. It lasted for about 10 minutes. I just want to get it checked out, that’s all.”

This is how a 31 year old construction worker, who has come to the emergency department during lunch break describes his problem. His physical exam, EKG and initial lab test including cardiac markers are normal. His dad had a heart attack in his sixties. He has no other risk factor besides being a smoker.

Evidence Assimilation in Individual Care


Chest Pain Unit• Low risk patient

• Follow the algorithm for low risk chest pain which includes repeated cardiac markers at 3 and 6 hours after admission + echocardiogram

• Non-invasive test for stratification: GATED-SPECT Cintigraphy or Treadmill Test

Cartesian Reasoning





+

Cartesian Reasoning





+

+

Cartesian Reasoning





$$$$$$ - Low Patient Satisfaction - Overwhelming

+

+

=

Cartesian Reasoning


Chest Pain UnitConstructivist Reasoning

Patient Priorities Practitioner Priorities




Am I having a Heart Attack?




Am I having a Heart Attack?Diagnosis Frequency





If I come back to work what is the probability of something

bad happening?






bad happening?Prognosis Frequency







What is this patient pre-test probability for ACS?








Diagnosis Frequency








Diagnosis Frequency

Will the algorithm for low risk chest pain help me out

excluding ACS for this patient?








Diagnosis Frequency


excluding ACS for this patient?Diagnosis Performance








Diagnosis Frequency



If this patient in fact has ACS what will be the probability of a bad outcome in the next few days?








Diagnosis Frequency



If this patient in fact has ACS what will be the probability of a bad outcome in the next few days?

Prognosis Frequency




1%

0,1%

Pre-Test Probability of ACS

Probability of a Bad Outcome if the patient has ACS

Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006.




1%

0,1%



1 out of10.000


Within 1 month

Will have a heart attack




1%

0,1%



1 out of10.000


Within 1 month


100% of patients > 40 y/o3% with multiple risk factors




1%

0,1%



1 out of10.000


Within 1 month



Is there any other th

ing

going on behind this

chest pain?




1%

0,1%



1 out of10.000


Within 1 month




ing


chest pain?

Is this patient adherent and will follow the recommendation?




1%

0,1%



1 out of10.000


Within 1 month




ing


chest pain?


Where does he live? Is it

close to the hospital? Is

there anyone living with

him?




1%

0,1%



1 out of10.000


Within 1 month




ing


chest pain?





him?Will h

e be able to come

to an outpatient stress t

est

within 1 week from now?




1%

0,1%



1 out of10.000


Within 1 month




ing


chest pain?





him?Will h

e be able to come

to an outpatient stress t

est

within 1 week from now?

Will an outpatient stress

test benefit this patient?


“It’s not a heart attack (or a what-you-call-it), see you later.”

“But it is something, you know, there is something going on”

Patients rarely knew to whom they had been talking, either by name or designation

Lack of information was a main concern

Johnson et al. Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units. J Adv Nurs 2008

Patient’s OpinionBased on ESCAPE Trial, Goodacre et al. BMJ 2007.


Where is the Wisdom?

David Eddy. Evidence-Based Medicine: A Unified Approach. Health Affairs 2005.Wyer, Silva. Where is the Wisdom I. JECP 2009.Sival, Wyer. Where is the Wisdom II. JECP 2009.

TS Eliot. The Rock.Acknowledgement to Peter Wyer

“Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in

information?”


[email protected]

The cases presented here were used only for didactic purposes and should

not be used as a prescription or reference for practice.




Obrigada!

Gracias!

Merci!

Thank You!

Danke!

ありがとう

[email protected]

The cases presented here were used only for didactic purposes and should

not be used as a prescription or reference for practice.




problematization

Documents

clinical decisionquartafeira

paulo freirequartafeira

critical return

peter wyerquartafeira

sicily conference

informed medical practice

process of problematization

human beings