Teaching Evidence Assimilation for Collaborative Health Care

Building Capacity for Scientifically Informed Healthcare

Peter Wyer MDCo-Chair, Section on Evidence Based Health Care

New York Academy of MedicineDepartment of Medicine, Columbia University Medical Center

ACKNOWLEDGEMENTS

SEBHCSEBHC TEACH TeamTEACH Team AdvisorsAdvisors NYAM StaffNYAM Staff

Arlene SmaldonePeter WyerCo-Chairs

Barney EskinSecretary

Michael CantorTreasurer

Barney Eskin Louise FalzonPat GallagherJudy HonigTJ JirasevijindaEddy LangPattie Mongelia Patricia QuinlanKaren SchoellesSuzana Alves SilvaArlene SmaldoneAlexandr TichterCraig Umscheid Dorice Vieira

Ian Graham Deborah KorensteinEddy LangSharon Straus

Claudette Dykes-Brown Donna FingerhutMargarita GuevaraSejal GhandiRichard ShihTawana Wright

External Support

Generous Donation of Electronic Resources: Annals of Internal Medicine (ACP Journal Club)

BMJ Group (Clinical Evidence, Best Practice, EB Journals)Cochrane Collaboration (Cochrane Library) EBSCO (Dynamed, CINAHL)

Elsevier (Clinical Key)McGraw-Hill-JAMA (JAMAEvidence)

Wolters-Kluwer (Joanna Briggs)

TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE

SPEAKERS, COURSE DIRECTORS AND PLANNING COMMITTEE MEMBERS REPORTING NO RELEVANT FINANCIAL

RELATIONSHIPS WITH COMMERCIAL INTERESTS TO DISCLOSE:

Suzana Alves da Silva MD, PhD Andy Oxman MD

Sharron Close MS, PhD Patricia Quinlan RN DNSc MPA

Barnet Eskin MD PhD Karen Schoelles MD SM FACP

Rishi Goyal MD PhD Arlene Smaldone DNSc CPNP CDE

Ian Graham PhD Dawn Stacey PhD MScN

Judy Honig DNP EdD Edward Suh MD

Thanakorn Jirasevijinda MD Shahnaz Sultan MD MHSc

Vepuka Kauari RN Alexsandr Tichter MD

Deborah Korenstein MD FACP Marita Titler PhD RN FAAN

Eddy Lang MD Craig Umscheid MD MSCE

Reem Mustafa MD Peter Wyer MD

DISCLOSURE OF FINANCIAL RELATIONSHIPS

UAMS DISCLOSURE POLICY It is the policy of the University of Arkansas for Medical Sciences (UAMS) College of Medicine to ensure balance, independence, objectivity, and scientific rigor in all sponsored or jointly sponsored educational activities. All individuals who are in a position to control the content of the educational activity (course/activity directors, planning committee members, staff, teachers, or authors of CME) must disclose all relevant financial relationships they have with any commercial interest(s) as well as the nature of the relationship. Financial relationships of the individual’s spouse or partner must also be disclosed, if the nature of the relationship could influence the objectivity of the individual in a position to control the content of the CME. The ACCME describes relevant financial relationships as those in any amount occurring within the past 12 months that create a conflict of interest. Individuals who refuse to disclose will be disqualified from participation in the development, management, presentation, or evaluation of the CME activity

The TEACH Design

• Basic foundational skills

• Developing clinical recommendations within specific healthcare settings

• Knowledge creation and implementation

Common Skills Across Dimensions

• Problem delineation• Formulating information needs• Finding the most relevant evidence• Appraising evidence quality and importance• Integration with practice-based evidence• Assimilation of resulting knowledge into clinical and

systems actions

TEACH

• Evidence Assimilation

• Collaborative Health Care

“Knowledge does notextend from thosewho consider theyknow to those whoconsider they do notknow. Knowledge isbuilt in therelationship betweenhuman beings andperfects itself in thecriticalproblematization ofthese relations.”Paulo Freire

Silva, Charon Wyer J Eval Clin Pract 2011

Narrative Evidence Based Medicine• NM: ‘Story telling and receiving as a clinical discipline’• EBM: Information literacy within clinical medicine• NEBM: Clinical information literacy nested within NM

– Attention/Representation/Affiliation

Patient Preferences

Patient Preferences

Research Evidence

Research Evidence

Clinical Expertise

Clinical Expertise

Patient Preferences and Actions

Patient Preferences and Actions

Research EvidenceResearch Evidence

Clinical State and

Circumstances

Clinical State and

Circumstances

Haynes et al. ACP J Club, 2002: 136:A-11-14

Haynes et al. ACP J Club, 1996:125:A-14-16

Who Decides? Early Models of Evidence-Based Medicine

Wyer Silva J Eval Clin Pract 2009

Relationship Centered Care• 1993-94: Pew Commission/Fetzer Institute• Tasked to integrate psychosocial and biomedical

issues in health care• Epistemologically defined construct

– Polanyi: tacit dimension– Merleau-Ponty: predecessor of complexity theory

• Explicitly aligned with established tendencies– Schon: Reflective action – Engel: Biopsychosocial model

Relationship Centered Care• Extended applications of RCC-Pew/Fetzer

– Complexity theory in health care organizations

– Critique of methodology of research into health care communications and interactions

– Integration of relationship-based and evidence-based care

• Additional elaborations– Connection to organizational knowledge creation (Nonaka)

– Affinity with social constructivism (Freire)

Wyer, Silva Post Quinlan J Eval Clin Pract 2014

Punch Lines

• Evidence serves, it is not served

• “In the struggle between yourself and the world-back the world” (Franz Kafka)

• “The way out is through the door” (Confucious)

Reflections of Rationalism

• Guidelines are not used• Patients do not get evidence-based care• Regulatory indicators fail to correlate with

tangible improvements in the value of health services

• QI projects lead to paper trails and work-around• Shared decision making seen as a tool for

evidence transfer• Relational skills = a sub-specialty of practice

Remedies

• Starting knowledge creation at the point of knowledge use

• Starting implementation by engaging end-user needs

• Including patient perspectives in research design (PCOR)

• Including relational principles in the “EBM” curriculum