Lineamiento para evaluar la propuesta

As with all qualitative research, the results and analysis presented needs to be reviewed within the context of the researcher’s background, bias and worldview. Emergency medicine as a specialty attracts a certain type of physician: being pragmatic, focused and non-

judgmental are commonly cited prerequisites for a successful career in this demanding speciality (Koyfman and Long, 2017). In Section 5.2, I described how a pragmatic approach shaped participant selection and data collection for this qualitative phase of the research. When taking a patient’s history in the emergency department, in order to come to a diagnosis or to generate a management plan, an important process is to separate signal from noise, to focus on the key features which will lead to correct conclusions, while avoiding distractions from irrelevant information (Xu et al., 2012). In order to achieve this focus, we constantly make decisions on how much weight to attribute to individual pieces of information and how to structure it. Pitfalls to avoid are entering the consultation with preconceived ideas or being overwhelmed by the breadth of information provided.

When I analysed the transcripts of the interviews and discussions, I found myself following the routine I have practiced over and over again in the emergency department. I deliberately did not research any concepts, such as the Rule of Rescue or vertical vs. horizontal equity, prior to completing the analysis. During the coding and mapping process, I continuously narrowed down the focus of inquiry and structured the few key points into the themes described above. As a result, workable themes and structures are presented, at the cost of compression of the richness of the source data.

Finally, emergency physicians constantly witness humanity’s dark side, with aggression, self- destruction, addiction and abuse encountered daily (Korcha et al., 2014). One way to avoid arrogance and cynicism towards these often difficult patients is to adopt a deterministic worldview (Bear and Knobe, 2016). Most people probably would not actively choose a life of crime, intravenous drug use and recurrent emergency department presentations. More likely, the only differences between them and me are loving parents, lack of childhood trauma, a teacher saying the right thing at the right time, or simply fortunate circumstances. This deterministic world view, shaped and anchored by hours of providing emergency care, has significantly influenced analysis of this qualitative research. The reason I have not considered one stakeholder group’s view to be more valid than another is the underlying assumption that the views are largely determined by the context and personal and professional experience of the stakeholder, rather than freely and independently formed through intellectual deliberation.

5.6 Conclusions

In this chapter, I explored the views of five relevant stakeholder groups (patient and public; charities; commissioners; researchers; prehospital providers) on research and funding of prehospital critical care for OHCA. I described how, despite the common appreciation of the concepts of scientific enquiry, fairness and beneficence, the groups displayed significantly divergent views, particularly in regards to randomisation and funding strategies. The reasons for this divergence can largely be explained through the different personal experiences and situational contexts of each stakeholder group. Many aspects of the strategies suggested by the stakeholder groups only partially align with the principles of traditional evidence-based medicine, but are held with strong convictions. While the subject of prehospital critical care and OHCA is quite specific, the concepts and themes described will also apply to other areas of medicine, particularly in prehospital or emergency care.

5.7 What next?

Following the completion of the systematic review, the qualitative research was the next phase of the PhD project to be completed. Still outstanding at this point are the observational research analysing the impact of prehospital critical care on survival following OHCA as well as the impact of discrete critical care interventions, and the accompanying cost analysis. The results presented in this chapter therefore provide context, challenges and opportunities for the following quantitative work.

The context in which this research is undertaken is far from the current ideal approach to the evidence-based introduction of healthcare interventions. In the ideal model, a new intervention shows promise in early studies and is rigorously tested in randomised-controlled trials, whilst cost-effectiveness is assessed in accompanying economic analyses. Finally, funding decisions are made based on the information provided from this research. In contrast, prehospital critical care is already well established in some but not all parts of the country. It is a complex intervention and in the absence of clear evidence, numerous stakeholders have developed strong and often emotional views about its merits.

One question I asked at every discussion was what stakeholders would do with the results of my observational research, which will show that critical care either improves or doesn’t improve survival following OHCA? The replies from many of the stakeholders made it clear

that their views were not going to shift significantly with opposing research findings. The challenge which this phase of the PhD poses for the rest of the project is therefore: what good is the research if it does not change opinions? I struggled with the answer to this question initially, but finally found an answer in the concept of the Justified True Belief discussed in Chapter 3. With the true effect of prehospital critical care for OHCA impossible to ascertain, and the current lack of supporting evidence, stakeholders’ only choice in this matter is to have opinions. My research, limited in its validity by the observational design, will not provide a definite answer to the research question or completely shift any of the stakeholders’ views. It will, however, act to shift the focus of discussion in this area away from beliefs and towards justification, thus taking us one step closer to this particular definition of knowledge.

On the other hand, despite the often overriding interests of specific stakeholders, each group unequivocally endorsed my research project and prehospital research in general, as evidenced by their participation in this work and their expressions of support during the discussions. I was also able to review the plans for the quantitative and economic analysis in the light of the stakeholders’ views. Similarly to the findings from the systematic review (Chapter 4), the stakeholder discussions presented in this chapter again emphasised the need to better understand what prehospital critical care for OHCA actually entails. This is reflected in Chapter 2, Objective 3 “to understand what interventions are being delivered by

prehospital critical care practitioners during the care for out-of-hospital cardiac arrest.” In

regards to the economic analysis, considerations of equity in prehospital care for OHCA raised the question of how much is spent on current (ALS paramedic) care and whether it is enough, too little or too much. While the initial focus of the economic analysis was mainly the incremental cost incurred by prehospital critical care for OHCA, the stakeholder discussions made me broaden this focus to investigate the current costs of ALS care for OHCA in more detail, and this is considered further in Chapter 6.

Having described the context, stakeholders’ views and the underlying moral and ethical principles in this chapter, I will now focus on the quantitative and economic analysis of prehospital critical care for OHCA. These subject areas both contain their own challenges and opportunities, as the conversation between a participant and myself at the end of an interviews suggests.

“Mm. That’s the thing about what you're doing [research], it isn’t always going to give you a very clear outcome. But I don’t think that should stop you asking the question.”

“ Yeah. I'm going to turn it [the recorder] off.” [RECORDING ENDS]