How Doctors Solve Problems - Bradford VTS



How Doctors Solve ProblemsDIAGNOSIS - definition - "Achieving knowledge through symptoms" (Greek)The Inductive MethodIn the hospital / classical method, a diagnosis is sought out 'at all costs' and no stone left unturned until the truth is established. To achieve a diagnosis in the hospital context we use the Inductive Method to guide our consultations. The Inductive Model is systematic, indiscriminative and expensive in time and resources – total information precedes firm diagnosisComprehensive history of the presenting complaintFull symptomatic enquiryPast history, drug historyFamily history, social historyComplete physical examinationLaboratory investigationThe HypotheticoDeductive MethodIn General Practice, we think differently during a consultation. There is now considerable evidence to suggest that doctors begin to formulate diagnostic possibilities (or hypotheses) very early on in the consultation, often within the first few seconds. These hypotheses are based on cues, verbal and non-verbal, obtained from the patient and from reading their medical record. As the consultation develops these hypotheses are ranked and further information is gathered by history-taking and physical examination in order to confirm or refute individual hypotheses. Normally the doctor generates no more than five to seven hypotheses at the beginning of a consultation, and then refines these. New ideas may develop as the consultation proceeds and hypotheses may be revised if testing (by history taking and examination) reveals no support - narrowing the list down perhaps to one diagnosisFour factors seem to influence the ranking of diagnostic possibilitiesProbabilitySeriousnessTreatabilityNoveltyNovelty implies that the doctor may have recently made a rare diagnosis and think of it frequently when drawing up the list of diagnostic possibilities.Stimulated RecallOne way of examining the effectiveness of a doctor’s problem solving skills is to use a technique known as stimulated recall. This focuses on a doctor’s behaviour during the consultation and in particular, on his application of the hypothetico-deductive method. Ideally this should be carried out as soon as possible after the consultation using a video – when recall of events is fresh. The tape should be stopped frequently and the following types of questions asked:What was in your mind at this point?Why are you thinking that now?What diagnostic possibilities are you considering?In what order would you rank them?Why did you ask that particular question?Why did you perform that particular part of a physical examination?Why did you order that particular investigation?Through this method, it is possible to critically examine the doctor’s information gathering and analysing information. Such an exercise, if carried out honestly and openly, can help the doctor to learn much about their way of thinking and to develop a critical approach to their communication and problem-solving skills. 354838027305Existing Cues(prior knowledge of the patient)00Existing Cues(prior knowledge of the patient)15430566040Presenting Cues00Presenting Cues11372851322705002661285284670500174688556070500704851170305Hypothesis revision00Hypothesis revision32384996159500204787599060ProvisionalDiagnosis00ProvisionalDiagnosis460438520320HYPOTHESIS FORMATION00HYPOTHESIS FORMATION5270508382000263652042545002127884116840Appropriate history / exam(Further cues supplied or sought)00Appropriate history / exam(Further cues supplied or sought)72072520320Does not support ?00Does not support ?52641510414000189928510414000460438510160HYPOTHESIS TESTING00HYPOTHESIS TESTING212788510160Supports ?00Supports ?26841457366000228028597155DiagnosisorProblem definition00DiagnosisorProblem definition500443517075150041846501561465Resolution of Symptoms00Resolution of Symptoms3320415180721000-825501488440Does not support ?00Does not support ?1174750181165500271272012617450023241001573530Outcome00Outcome1823085687705Management DecisionsIncluding investigations(further cues supplied / sought)00Management DecisionsIncluding investigations(further cues supplied / sought)269367019240500 ................
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