Medical Education Blog

This is the first in a series of postings about teaching medical problem solving.

The following five steps in problem solving can each create unique stumbling points for students and novice doctors:

1. Researching the problem


2. Differential diagnosis


3. Selecting criteria for possible treatment options


4. Therapeutic diagnosis


5. Evaluating the solution

Researching the problem

Medical history taking, examination and reviewing test results are the standard first steps in patient problem solving. Two common mistakes can be made at this point:

1. not asking the right questions - Novice physicians are particularly prone to not asking the right questions because they do not have the vast storehouse of experience to make connections in new or unique situations. They may also not have a clear understanding of affective or cultural influences in the patient’s life.
2. listening in order to record rather than with a problem-solving ear.

Differential diagnosis

The differential diagnosis process based on medical evidence for standard medical problems works well. Every supervising clinician should be aware of the following issues that can lead to medical errors:

1. attribution errors - an unjustified tendency to assume that a person's actions depend on what "kind" of person that person is rather than on the social and environmental forces that influence the person. An example from the book How Doctors Think - a woman comes in severely underweight; the physician thinks woman + underweight = anorexia and proceeds under that assumption without identifying the celiac disease that was the problem. Another example would be the drug abuser who tells an untrue story about what brought them to the emergency room; the physician thinks drug addict + lie = manipulating for more drugs and the physician misses seeing a brain injury.
2. assuming that scientific evidence is applicable beyond the parameters of the study. For example, studies done on men are assumed to be applicable to women or studies done on one race are assumed applicable to all races.

Selecting criteria for possible treatment options for this individual

There are factors that influence compliance with treatment that physicians need to consider that novice doctors may not be aware of such as the following:

1. affordability
2. resources in the home community or neighborhood
3. cultural or religious practices
4. age
5. support systems
6. other medical issues

(It is important to avoid attribution errors by not assuming a person is a stereotype.)

Therapeutic diagnosis

Novice doctors may run into difficulty in the following situations:

1. a previous diagnosis is assumed to be correct, therefore previous treatment is continued
2. the patient has complex problems combined with multiple therapies by multiple practitioners
3. the patient follows homeopathic or other health practices which may not be disclose under questioning such as “what drugs are you taking?”

Evaluating the solution

Ongoing reflection is an important skill for physicians, but students may not have an opportunity to receive information on what happened to patients after their brief encounter. This is particularly problematic when sub-optimal care results in short term solutions that create long-term issues that the student is not aware of.

Another issue that arises occasionally for students is the lack of resources available to deal with medical error in a constructive solution oriented way rather than punishment oriented (self or authority).