Paulo Freire, Vygotsky and the
Revolution in EBCP Education
Peter Wyer MD
Associate Clinical Professor of Medicine
Columbia University College of Physicians & Surgeons
"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
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
A lesson in distributed cognition
GAME DESCRIPTION
A 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
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.”
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
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
ASE (Revised Narrative)
Group 5: Seen by retired physicin doing frist shift
Group 2:
Group 3:
Group 4:
24h Hospital
24h Hospital
Primary Care
Primary Care
Primary Care
4:00am
24h Hospital
24h Hospital
Primary Care
Primary Care
Primary Care
4:00am
WHAT HAVE WE DONE?
We have rehydrated a dessicated
case presentation
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”
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…”
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 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
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
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
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
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”
?!
Interpretations
• Time constraints
• Attentional deficit-’worst first’
• Escape from complexity
Categories of Criteria
The Patient
TRUST
Clinical Criteria
MYSELF vs environment
CRITERION BASED PRACTICE
CRITERIA FOR
INTERPRETATION/ACTION
CLINICAL EVIDENCE
NARRATIVE EVIDENCE
"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
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”