Clinical Problem Solving: A Behavioral Analysis

Abstract

To extend the understanding of the clinical problem-solving process, we have analyzed the tape-recorded behavior of experienced clinicians engaged in "taking the history of the present illness" from a simultated patient. We showed that specific diagnostic hypotheses were generated often with little more information than presenting complaints, that testing of diagnostic hypotheses consisted of various case-building strategies for corroborating and discrediting hypotheses, and that the process of information gathering included techniques to evaluate the validity of data and assess the need for immediate action. Overall strategies were more difficult to discern but included a focused approach, a systemic exploration method, and a chronologic technique. The data have potential value in medical education and in developing computer programs to simulate the diagnostic process.

Methods and Outcomes for the Remediation of Clinical Reasoning

“…The remediation plan was intentionally created using our understanding of the clinical reasoning process and prior work on the development of expertise. [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29]34,35 The steps provide a concrete way of teaching discrete skills needed to problem solve in medicine.…”

“…[14][15][16] Approaches to remediating clinical reasoning would have to take into account these methods as well as the following relevant information: the mental processing that begins through observation early in the patient encounter; the initial list of possible diagnoses including the most common and the most lethal, and the gathered historical and physical exam information. [17][18][19] The process includes narrowing the list of diagnoses, considering the supporting and refuting evidence and invoking probabilities, which rely heavily on how knowledge is organized into memory. [20][21][22] The ability to create and recall illness scripts, or mental models of disease, and compare and contrast these scripts results in better clinical reasoning.…”

Does Choosing a Treatment Depend on Making a Diagnosis? U.S. and French Physicians' Decision Making about Acute Otitis Media

“…5(p220-1) Even Kassirer's team, however, did little investigation of the relation between a diagnostic judgment and a therapeutic choice. 5,17 Yet, it is important to ascertain the accuracy in clinical practice of the classical model because it is the paradigm taught to aspiring and practicing physicians.…”

Decision Support by Visual Incidence Anamneses for Increased Patient Safety

“…Instead of expressing that diagnoses are either true or false, the human agents might express the assessment of diagnoses in terms of "probable" or "highly likely" (Ibid). In medical decisions requires strategies and one is to employ an iterative process for data collection and interpretation referred to as the hypothetico deductive approach (Shortliffe 2006, Elstein et al 1978, Kassirer and Gorry 1978. The method comprises data collection and selection of a hypothesis of the most probable diagnosis, iteratively repeated (refinements of hypotheses by means of additional data) until there is a hypothesis that either is considered true or the uncertainty is reduced to lowest possible level (Shortliffe 2006).…”

“…CISIT1 could have Stroke as the true cause of the symptoms. However, the hypothesis of Migraine as the most probable cause of the symptoms was chosen and the iterative process of a hypothetico deductive approach (Shortliffe 2006, Elstein et al 1978, Kassirer and Gorry 1978 to the problem was decided to be stopped. No further tests were prescribed.…”