MCCCARS – History and 2002 Report
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
January 30, 2003
On May 16, 2002, I
established the MCCCARS, which stands for Multi-center Cooperative
Collaborative Action Research Study based on the following rationale and concept:
Situation:
Basic Concept:
Secretariat –
Department of Surgery of Ospital ng Maynila Medical Center under Dr. Reynaldo
O. Joson
Output
expected: Multi-center cooperative and collaborative action research papers
Impact
expected:
Who can join:
Anybody, at
any stage of training or experience, who is interested, can communicate through
email with the secretariat, and willing to follow rules and regulation of the
secretariat.
As of October, 2002,
17 surgeons subscribed to the e-group of the MCCCARS and these surgeons were
affiliated with 8 different centers distributed over Metro Manila, other parts
of Luzon, the Visayas, and Mindanao
(Ospital ng Maynila Medical Center; Philippine General Hospital; Manila
Doctors Hospital; Zamboanga City Medical Center; Davao Regional Hospital;
Visayas Community Medical Center, Batangas Regional Hospital; Region 1 Medical
Center).
An e-group (mcccars@yahoogroups.com) and a
website (http://mcccars.tripod.com)
were set-up to facilitate communication among members of MCCCARS.
For the year 2002, there
were two multi-center cooperative and collaborative action research studies
completed, namely:
1. Reducing the
discrepancy of clinical and pathological tumor and nodal evaluation in patients
with breast cancer
2. Is a recumbent
plain abdominal x-ray (without an upright film) sufficient in the evaluation of
patients with acute intestinal obstruction?
Table 1 shows the
number of centers that participated to contribute to at least one action
research objective, number of surgeons who actively participated in the focused
group discussion, and total number of surgeons who participated.
Table 1. Number of
centers and surgeons participating in MCCCARS.
|
Action research study |
Number of centers that contributed to
at least one action research objective |
Number of surgeons who participated
in the focused group discussions |
Total number of surgeons who
participated (principal investigators + focused group discussants) |
|
1. Reducing the
discrepancy of clinical and pathological tumor and nodal evaluation in patients
with breast cancer |
4 Ospital ng Maynila
Medical Center Philippine General
Hospital Manila Doctors
Hospital Visayas Community
Medical Center |
6 |
16 |
|
|
|
|
|
|
2. Is a recumbent
plain abdominal x-ray (without an upright film) sufficient in the evaluation
of patients with acute intestinal obstruction? |
6 Ospital ng Maynila
Medical Center Manila Doctors
Hospital Philippine General
Hospital Zamboanga City
Medical Center Davao Regional
Hospital Batangas Regional
Hospital |
6 |
20 |
These two papers were
presented in various research forums and contests. See Table 2.
Table 2. Research
forums and contests joined.
|
Action research study |
Research forums and contests |
Recognition |
|
1. Reducing the
discrepancy of clinical and pathological tumor and nodal evaluation in
patients with breast cancer |
August 12, 2002 –
Manila Doctors Hospital Research Paper Contest |
|
|
|
August 13, 2002 –
Ospital ng Maynila Medical Center Department of Surgery Research Paper
Contest |
3rd
prize |
|
|
September 27, 2002
– Philippine Society of General Surgeons’ Regional Research Contest |
Finalist – no prize |
|
|
September 28, 2002
– Philippine College of
Surgeons’ Regional Research
Paper Contest |
2nd
prize |
|
|
December 1, 2002 –
Philippine College of Surgeons’ Annual Research Paper Contest |
Finalist- no prize |
|
|
|
|
|
2. Is a recumbent
plain abdominal x-ray (without an upright film) sufficient in the evaluation of patients with
acute intestinal obstruction? |
August 12, 2002 –
Manila Doctors Hospital Research Paper Contest |
3rd
prize |
|
|
August13, 2002 –
Ospital ng Maynila Medical Center Department of Surgery Research Paper
Contest |
|
|
|
September 27, 2002
– Philippine Society of General Surgeons’ Regional Research Contest |
Finalist – no prize |
|
|
September 28, 2002
– Philippine College of
Surgeons’ Regional Research
Paper Contest |
3rd
prize |
|
|
December 1, 2002 –
Philippine College of Surgeons’
Annual Research Paper Contest |
2nd
prize |
The papers are
presently being prepared for publication.
Evaluation:
The multi-center cooperation and collaboration was able to solve
the logistic and technical problems encountered by some centers in data
gathering, patient accrual, and validity testing of proposed solutions.
Based on expected
impact, these were evidently achieved by the 2 multi-center cooperative and
collaborative action research studies.
Table 3 presents the evidences and justifications for claiming impact
achievement. Furthermore, from all the
centers and members of MCCCARS, the feedback was a unanimous affirmation of
impact achievement.
Table 3. Evidences
and justifications for claiming impact achievement.
|
|
Reducing the discrepancy of clinical
and pathological tumor and nodal evaluation in patients with breast cancer |
Is a recumbent plain abdominal x-ray
(without an upright film) sufficient in the evaluation of patients with acute intestinal
obstruction? |
|
Utility
(problem-solving and improvement in patient care) not only in one institution
but also in multiple institutions and simultaneous at that |
The MCCCARS contributed to
problem-solving and improvement in patient care not only in one institution
but also in multiple institutions and simultaneous at that. Despite the fact that these papers
have not yet been published, the utility is already seen in several centers
all over the country. |
|
|
|
Problem of
discrepancy of clinical and pathological tumor and nodal evaluation in
patients with breast cancer being reduced in at least 4 centers |
Cost-effective use
of radiological examination of the abdomen in patients with suspected acute
intestinal obstruction being promoted in at least 6 centers |
|
|
||
|
Learning of
research methodology by participants in the process of cooperating and
collaborating |
All the members of the MCCCARS
learned action research methodology in the process of cooperating and
collaborating. 17 in the egroup; 20 residents outside
the egroup. |
|
|
|
At least 3 surgical
residents from OMMC alternated in the presentation of the paper. |
At least 3 surgical
residents (2 from OMMC and 1 from ZCMC) alternated in the presentation of the
paper. |
|
|
||
|
Motivation
to do research in the process of cooperating and collaborating |
The MCCCARS got 8 centers and 17
surgeons interested and motivated to join in doing action research in 2002. There are inquiries on what action
research will be put up by the Secretariat in 2003. The MCCCARS have recruited new
members in December, 2002. |
|
Reflection:
1.On the action
research
Action research is a methodology that pursues action (change) and research (understanding) at the same time and which consists of four basic themes: empowerment of participants; collaboration of participants; acquisition of knowledge; and social change.
From the 2 action
research studies completed, evident were the empowerment and collaboration of
the participants in instituting change at the same time acquiring better
understanding of the problem being solved.
The action research
methodology used in these two projects followed the concept as defined by Cohen
and Manion (1), that is, "small scale intervention in the
functioning of the
real world and a close
examination of the effects of such intervention." It is situational in that it is concerned
with diagnosing a problem in a specific context and attempting to solve it in
that context. Usually collaborative
teams of researchers and practitioners work together on a project. It is
participatory in the sense that the team members themselves take part directly
or indirectly by implementing the research.
Lastly, it is self-evaluative in that modifications are continually
evaluated within the ongoing situation, the ultimate objective being to improve
practice in some way or another.
While
experimental research is concerned mainly with establishing relationships and
testing theories, action research has, as a focus, a specific problem in a
specific setting. It makes no attempt to identify one particular factor and
study it in isolation divorced from the context giving it meaning.
As Margules(2) points
out, "in combining action processes (planning, implementation, and
evaluation) with research processes (problem identification, hypothesis
formation, and testing), the result is a sequence of steps and activities that
identify the relevant events that must happen in the initiation and
implementation of change."
The essential steps
in action research are the following: analysis of the problems, research
designs on how to solve the problems, implementation of an action plan and
evaluation of results of implementation.
In the Philippines,
most of the medical researches done are not of the action research type. Thus, their utility just ends in being
published in journals. They are not
being used by the people in the institution of origin of the research
papers. More so, they are not being
used by people outside the institution of origin.
The other problems in
conducting research projects in the country are the number of clinical subjects
and lack of resources.
These action researches have shown how a real world problem was being solved systematically, cooperatively, and collaboratively. The multi-center cooperative and collaborative effort has illustrated the advantages of sharing of resources. The ultimate impact of this action research consists of solutions of problems and implementation of improvement measures in patient care being simultaneously undertaken in several centers in the country.
Unfinished tasks:
1.
Continuous search and
incorporation of new data to refine and strengthen the information on hand
2.
Institutionalization
of the validated clinical practice guidelines in participating centers
3.
Dissemination of the
results to promote changes in other centers in the country
2. On the email group
and website
The use of email and
a website definitely facilitated communication among the members of the MCCCARS
who were stationed in various parts of the country.
The use of email
group or egroup (mcccars@yahoogroups.com) facilitated surveys and focused group
discussion. An email sent by a member
of the group is seen simultaneously by all the members of the group. An answer to a question or any reaction
posted by a member is seen simultaneously by all the members of the group.
The website (http://mcccars.tripod.com) posted all the
synthesized discussions of the group.
The difficulties
encountered in the egroup were not with the email system but with the
members. The silence of the members
tended to bog down the schedule and progress of the action research study. Silence may be due to members not opening
their emails regularly and at least once a week as agreed upon or if they do,
they were shy to give feedback and would rather watch the interactions of the
other members. To keep the interactions and project continuously running and
progressing, the secretariat or moderator had to be patient and perseverent in
sending emails at least once a week to keep the flame burning, setting
deadlines for each activity, sending out reminders, and other strategies that
would make research relatively easy for the members. Fortunately, in the end, there were adequate number of centers
and members who participated for the action research studies to be
completed. In the future, more
effective and efficient strategies would have to be worked out to make the
tasks of the secretariat easier.
3. Appendix 1 and
Appendix 2 show the chronological events in the accomplishment of the two
action research papers respectively.
Reducing the
discrepancy of clinical and pathological tumor and nodal evaluation in patients
with breast cancer
Series of emails
(steps, activities, and actions taken):
Secretariat posed 3
questions for members to answer:
1. Do you consider
the discrepancy of the clinical and pathological tumor and node evaluation in
patients with breast cancer a significant health concern or problem in your
practice and in the training of surgical residents that an action research is
worth trying?
2. In the
Philippines, there are no published statistics on the discrepancy rate between
clinical and pathological TNM staging in patients with breast cancer.
3. Discrepancy between clinical and pathological TNM staging
in patients with breast cancer certainly has a negative impact in management,
particularly in the choice of primary treatment as well as in the advice of
patients on extent of cancer prior to treatment.
With majority of the
respondents answering yes, no, and yes respectively to the 3 questions posed,
the Secretariat decided there was a need to conduct an action research on the
discrepancy of cTN and pTN. It
presented a tentative title and a draft of the introduction and objectives for
comments.
With no strong
objections and suggestions for major revisions, the Secretariat presented a
draft of the methodology for objective
1 for comment.
Objective1: To
determine the extent of discrepancy of clinical-pathological TN staging in
patients with breast cancer in the focal institution.
With no strong
objections and suggestions for major revisions on the proposed methodology for
Objective 1, the Secretariat asked which centers were capable of conducting a
retrospective chart review for Objective 1.
Several centers answered negatively, others would try, and a few could.
In the end, OMMC, PGH, and VCMC contributed to the achievement of Objective
1. MDH tried but failed to come out
with adequate and reliable data.
While waiting for the
results from PGH, MDH and VCMC, the Secretariat presented the results of OMMC
on Objective 1 (done in 2001) and asked the MCCCARS members if the results were
reliable enough as a baseline and whether they represented the true state of
the problem, that a significant discrepancy really existed. The answers to both questions were
affirmative.
The next
question posed by the Secretariat was whether the
extent of discrepancies was acceptable? If YES, the action research would be
stopped at this point. IF NO, action research would continue to find ways on
how to reduce the extent of discrepancy.
The answer was NO, the discrepancy was not acceptable.
Focused group
discussion was done to determine what standards should be considered as
acceptable discrepancy rates between cTN and pTN. The consensus was 5% for cT and pT and 30% for cN and pN.
After
deciding that the prevalent discrepancy rate was not acceptable based on the
agreed standards, the Secretariat proceeded to Objective 2, which was to
determine the root causes of the discrepancy. The Secretariat asked the group what
methodology to use to accomplish Objective 2.
The answers were focused group
discussion among researchers and discussion with pathologists. These were accomplished.
OMMC presented its
analysis which consisted of viewpoints of the surgeons and the
pathologists. The other members gave
input to the possible causes.
After
determining and agreeing on the root causes, the members decided to formulate
strategies to reduce the discrepancy which was Objective 3. The consensus was reached on two strategies,
communication with pathologists ending with a memorandum of cooperation and
structured training for the surgeons, specifically the residents. The memorandum of cooperation and training
program were drafted by OMMC and presented to the group for approval. After approval, the strategies were
implemented. At the end of the study,
as of October, 2002, 4 centers were
able to implement the strategies.
A
preliminary paper was written by the Secretariat incorporating whatever results
on the residents’ report cards were available on the last week of July,
2002. The preliminary paper was
presented in the Manila Doctors Hospital Research Paper Contest on August 12,
2002 by Dr. Malou Bastan. Comments from
the judges were noted down and improvements were subsequently made. The paper was also presented in the
Department of Surgery of OMMC on August 13, 2002 by Dr. Nolim’t Jay
Raquel. Again, comments from the judges
were noted down and improvements were subsequently made. The paper was also presented in the PSGS
Regional Contest on September 27, 2002, in the PCS Regional Contest on
September 28, 2002, and in the PCS Annual Convention on December 1, 2002.
Is a recumbent plain abdominal
x-ray (without an upright film) sufficient in the evaluation of patients with
acute intestinal obstruction?
Series of emails
(steps, activities, and actions taken):
Secretariat posed 1
question for members to answer:
A recumbent and an upright plain abdominal x-ray are usually requested by clinicians in the evaluation of patients with possible acute intestinal obstruction. What is your present practice when you need an x-ray of the abdomen in such patients?
Getting differing
answers, the Secretariat decided there was a need to conduct an action research
on whether a supine x-ray would be sufficient. It presented a tentative title
and a draft of the introduction and objectives for comments.
With no strong
objections and suggestions for major revisions on the introduction and
objectives, the Secretariat presented a draft of the methodology for the
objectives for comment and a call for active participation.
Some centers
committed and actively participated.
Some stood by the side and just joined the focused group discussion and
gave feedback.
After the data
gathering, the Secretariat collated and analyzed the data and then wrote a
preliminary draft of the paper. The
paper was presented to the group for comment.
The
preliminary paper was presented in the Manila Doctors Hospital Research Paper
Contest on August 12, 2002 by Dr. Ricardo Naval. Comments from the judges were noted down and improvements were
subsequently made. The paper was also
presented in the Department of Surgery of OMMC on August 13, 2002 by Dr. Alfred
Troncales. Again, comments from the
judges were noted down and improvements were subsequently made. The paper was also presented in the PSGS
Regional Contest on September 27, 2002, in the PCS Regional Contest on
September 28, 2002, and in the PCS Annual Convention on December 1, 2002.
REFERENCES:
1. Cohen L, Manion L. Research Methods in
Education. London, Croom Helm, 1980.
2. Marguiles N. Managing change in health
care organization. Medical Care 1977;15:693-704.