Paulo Freire, Vygotsky and the Revolution in EBCP Education

1. Paulo Freire, Vygotsky and the Revolution in EBCP Education Peter Wyer MD Associate Clinical Professor of Medicine Columbia University College of Physicians & Surgeons

2. "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

5. Relevance to Health Managers • Health policy may be highly validated via clinical research • Health technology may be judiciously appropriate for a population--BUT • Decisions are social acts • Patients may not comply • External constraints may interfere

6. A lesson in distributed cognition

7. GAME DESCRIPTIONA Different Kind of Quiz Show • Start with an “answer” • Invent a “question” fulfilled by the “answer” • Invent the logic connecting “Q’s” to “A’s” • Identify sources of defense of the logic

8. Case Summary Case Heard At Signout “A 56 yo female with past history of diabetes presented to our (public health care) facility in Rio with right sided weakness and dysarthia. She is being admitted for control of hypertension.”

9. TASK 1. Study the case summary 2. Add details in such a way that the summary makes sense 3. Revise the summary in narrative form

10. CASE (Details) Group 1: A 56 yo female with past hystory of diabetes presented to our (public health care) facility in Rio de Janeiro with right sided weakness and dysarthria that started 30 min. ago. Head CT has shown no intracranial bleeding. She would have received thrombolytic therapy but presented with high blood pressure. She is being admitted for control of hypertension. Group 2: SAMU rescue a 56 yo female with past hystory of diabetes presented to our (public health care) facility in Rio de Janeiro with right sided weakness and dysarthria with interval of 20’. H. Souza Aguiar had head CT scan showing no intracranial bleeding; neurologist scores NIH = 8. Since PA was 190 x 118 mmHg, she was admitted at UTI for control of hypertension. Group 3: Presented to small Ed with limited equipment and no scan available BP very high Group 4: Poor no education, no address to no folowup in home facility. Admitted to that facility with dx of stroke stayded in ED waiting CT + taken ainti hptp

11. ASE (Revised Narrative) Group 5: Seen by retired physicin doing frist shift Group 2: Group 3: Group 4:

12. 24h Hospital 24h Hospital Primary Care Primary Care Primary Care 4:00am

13. 24h Hospital 24h Hospital Primary Care Primary Care Primary Care 4:00am

14. WHAT HAVE WE DONE? We have rehydrated a dessicated case presentation

15. Cases Heard at Signout Case 1 (New York) “75 yo male came in for abdominal pain, CT scan pending. If the CT does not show diverticulitis, admit for Acute Coronary Syndrome Level III” Case 2 (Rio) “This is a 50 year old male with a history of IDDM and bilateral above knee amputation. He presented last night with dyspnea. LE dopplers are pending”

16. Cases Heard at Signout (cont’d) Case 3 (New York) “55 yo male with vomiting and diarrhea for 3 days syncopized on the toilet today. He was hypotensive on arrival but has responded to fluids. He is admitted to cards on tele.” Case 4 (Rio) “ This is a 57 year old male who presented with syncope. He said he had sudden onset of severe chest pain beforehand. He is getting a head CT now…”

17. Cases Heard at Signout Case 1 (New York) “75 yo male came in for abdominal pain, CT scan pending. If the CT does not show diverticulitis, admit for Acute Coronary Syndrome Level III”

18. CASE 1 Group 1: -vague epigastric pain -Prior h/o MI -DM Group 2: -75 yrs old (age) -DM -EKG changes -LLQ pain -fever -WBC Group 3: -CAD -llq pain as angina -llq tenderness -low grade fever

19. CASE 1 Group 1: 75 yo M with vague epigastric pain/nausea, h/o diverticulitis, CAD s/p MI 2 wks ago, DM with nl EKG, WBC=11, LLQ tenderness on exam Group 2: 75 yo with DM, epigastric pain radiating to left 3with new lateral TWI, WBC = 12 and LLQ tenderness on exam Group 3: 75 yo with htn, DM, MI, CABG x 4, EKG with ST depressions in all leads, daily angina who presents with similar pain after popcorn and low grade fever

20. Case 1 Follow-Up-Review of Facts 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

21. 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

22. 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” • ?!

23. Interpretations • Time constraints • Attentional deficit-’worst first’ • Escape from complexity

24. Categories of Criteria The Patient TRUST Clinical Criteria MYSELF vs environment

25. CRITERION BASED PRACTICE CRITERIA FOR INTERPRETATION/ACTION CLINICAL EVIDENCE NARRATIVE EVIDENCE

26. "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

27. SUMMARY • Evidence based care requires continuity between policy and practice • Criterion based care subsumes EBM • Criterion based care requires “problematization” across all parties • This means “education for critical consciousness”