Medical Education Blog

First year Family Medicine residents were able to arrive at the correct diagnosis for only 25% of the presented (complex) problems – Norman, 1994

Clinicians approach problems flexibly; the method they select depends upon the perceived characteristics of the problem. Complex problems need a combination of three strategies:

1. Pattern recognition (illness scripts, schema) is the result of years of clinical experience; this recognition is associated with higher rates of successful diagnosis (Coderre, 2003.)


2. Forward-based reasoning works well for routine and well-researched medical problems. Standard clinical teaching follows a pattern whereby several diagnostic hypotheses are generated from the patient’s signs and symptoms, then additional information is sought to confirm or refute individual hypotheses.


3. Backward reasoning means guessing at an explanation and working backward to find data that supports the explanation. Novice doctors have a tendency to use backward reasoning and should be encouraged to use this strategy for non-routine, complex cases but not those that are routine and/or well-researched.

These three thinking strategies are the most commonly used clinical problem solving strategies because they create a constant regenerating of new hypotheses to test.

Steps for Teaching Problem Solving

Step 1: Identify the problem solving objectives for your student
The information on the following website might be useful for identifying learning objectives http://www.hsc.stonybrook.edu/som/solving.cfm

Step 2: Reinforce problem-solving steps in clinical settings

Researching the problem
Consistently use a Subjective (what is the patient saying, what is the family saying), followed by Objective (what does the examination and tests tell you) process for patient presentation, so the student becomes used to thoroughly investigating the problem, both scientifically and affectively/culturally. Having the student draw a decision tree http://dms.irb.hr/tutorial/tut_dtrees.php may also be useful in helping them identify gaps in their investigation.
Teach students to use close-ended questions (What medication are you taking?) for diagnosing standard problems and open-ended questions (What issues is the abdominal pain causing in your day-to-day life?) for more complex problems.
Question the student to help them pinpoint gaps in their approach: “Are their other systems involved? Is there something you missed or are unclear about in the initial examination? What other information do you need that isn’t readily available? What was difficult about this patient? What assumptions are you making (possible attribution errors) about this patient?”
Differential diagnosis
You can assist students to begin to recognize patterns as well as recall previously learned information by involving them in a large number of cases, thinking out loud so the student sees your pattern making and asking questions like “What were the major findings that led you to this conclusion? What else could it be? Have you seen anything similar before? Is there something different about this case from other cases you have seen or read? What is the pattern here? How would you categorize this problem? If xxx changed, how would you approach the problem?”
Selecting criteria for possible treatment options
Ask the student “Given what you know about the patient subjectively and objectively what should be considered before suggesting a treatment plan?” There are factors that influence compliance with treatment that physicians need to consider before deciding on a therapeutic diagnosis that novice doctors may not be aware of such as the following:

• affordability


• resources in the home community or neighborhood


• cultural or religious practices


• age


• support systems


• other medical issues

Help the student to check the validity of any biases that might result in attribution errors (an unjustified tendency to assume that a person's actions depend on what "kind" of person that individual is rather than on the social and environmental forces that influence the person).
Therapeutic diagnosis
Use One Minute Preceptor technique to clarify the student’s decision-making process. http://www.oucom.ohiou.edu/FD/monographs/microskills.htm
Evaluating the solution
Metacognition or the process of thinking about how one problem solves is an important step in improving student skills. Metacognition is the result of two components in the learning environment: written reflection and probing questions from peers and instructors. Questions such as the following can be useful in creating a more reflective mind set: “What did you learn from this patient? How could you have involved other people (family, community groups, nurses) in the care of this patient?”

Step 3: Place students in situations were the routine approach will fail (without endangering the patient or the student)

Students need opportunities to be challenged by cases that are more complex or difficult to define. They also need opportunities to correct mistakes safely because it is through practicing non-routine decision-making that critical thinking skills are honed. On the other hand, student and patient physical and emotional safety must be ensured if you want the student to continue to increase their skills.

References
Coderre, S. et all, Diagnostic reasoning and diagnostic success Volume 37, Number 8, August 2003, pp. 695-703.
Norman, G.R. et all, Cognitive Differences in Clinical Reasoning, Teaching and Learning in Medicine, Number 6, 1994 , pp.114–20.

Web Resources
Teaching students to think like physicians http://www.uab.edu/uasomume/cdm/issue6.htm
Teaching problem solving and decision-making https://www.cu.edu/academicaffairs/assessment/assessment_toolbox/documents/TchngPrbSlvMedEd_000.pdf
Internal Medicine Clinical Teaching Unit: Is it an Inappropriate Site for Student Learning?
http://www.leaonline.com/doi/abs/10.1207/S15328015TLM110402?journalCode=tlm
View box exercises for teaching problem solving http://www.ajronline.org/cgi/reprint/128/2/271.pdf