Delineating a Clinical Problem: Asking the Right Question and Asking the Question Right

1. Delineating a Clinical Problem: Asking the Right Question and Asking the Question Right 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

2. The Concept of Clinical Action

3. “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 Silva, J Eval Clin Pract. 2011;17:585

4. The Concept and Role of PACT • 4 subdomains of clinical action always tacitly present within a problem together with other determinants of care • PACT is a tool of representation that allows deconstruction of a problem into actionable components • This facilitates meaningful identification and assimilation of research evidence into the solution

5. The SIMPLE Model Problem delineation “The process of problematization implies a critical return to action. It starts from action and returns to it” Paulo Freire, 1972 Values Priorities Preferences

6. Patient-Practitioner Relationship and and Practice Circumstances Silva, Charon, Wyer. JECP 2010.

7. Patient-Practitioner Relationship and and Practice Circumstances Silva, Charon, Wyer. JECP 2010.

8. The Anatomy of the Question opulation ntervention omparison utcome

9. Why PICO—the 2-PICO Assessment for Directness

10. Example: a Patient with Atrial Fibrillation Uma mulher de 68 anos é trazida ao pronto-socorro por causa do início súbito de palpitações e é encontrada em FA (fibrilação atrial) com freqüência ventricular de 140-160. Seus sinais vitais encontram-se dentro da normalidade e ela não apresenta congestão pulmonar, insuficiência respiratória, angústia ou outros. Sua família afirma que isso já aconteceu antes e "os medicamentos utilizados não funcionaram e eles tiveram de chocá-la." Ela tem história de hipertensão leve, mas não de doença cardíaca estrutural ou de outras comorbidades importantes. Sua família espera que ela possa ser tratada e liberada do Departamento de Emergência. As instalações hospitalares deste hospital habitualmente admitem esses pacientes. Os médicos plantonistas discutem sobre qual droga deve ser utilizada para tratamento e se devem priorizar controle de FC (frequência cardíaca) ou controle do ritmo.

11. Patient-Practitioner Relationship and and Practice Circumstances Silva, Charon, Wyer. JECP 2010.

21. SUMMARY • Scientifically informed, effective care, requires “critical problematization” across all parties and dimensions • The need for information is derived from the problem at all levels • PICO allows connecting questions to research information and assessment of directness • If the problem is wrong, the question is wrong; if the question is wrong, evidence based methods and resources are misguided