CLINICAL

PROBLEM
SOLVING
6.53

Che Bruce – Advanced Clinical

Practitioner / NMP / Paramedic
PROBLEM SOLVING –OVERVIEW
Two main thinking processes
Information-processing system theory (Newell & Simon 1972)
Stages model theory
• Information-processing system has two processes
• Understanding – based upon experience with similar situations and
immediate thought processes
• Solving- a search for a solution
• Most often associated with well-defined problems; frequently the
problems faced by advanced practitioners are complex and ill defined
The stages model is a
stepwise process involving
different stages and
different number of steps.
It has been suggested that
the stages represent a
rigid process of discrete
steps and so does not
adequately reflect what
happens in practice.
 Barrows and Pickell (1991) developed a clinical
decision-making model based on the stages
model theory.
Two components of clinical problem-solving
which are linked:
• Content – the knowledge base of the
practitioner
• Process – the method the practitioner uses to
apply that knowledge to the patient’s problem
NOVICE,
COMPETENT, EXPERT

The novice practitioner is characterised by:

Rigid adherence to taught rules or plans
Little situational perception
No discretionary judgment
THE COMPETENT PRACTITIONER:

Is able to cope with ‘crowdedness’ and pressure

Sees actions partly in terms of long-term goals or a

wider conceptual framework

Follows standardised and routinised procedures

 THE EXPERT PRACTITIONER:

No longer relies explicitly on rules, guidelines and

maxims
Has an intuitive grasp of situations based on deep,
tacit understanding
Uses analytic approaches only in novel situations or when
problems occur
Clinical Decision Making Model
• Forming the initial concept
• Generating Hypotheses
• Formulating an enquiry strategy
• Applying appropriate clinical skills
• Developing the problem synthesis
• Laboratory and diagnostic findings
• Diagnostic decision-making
• Therapeutic decision-making
• Reflection in and on practice
Forming the initial concept

Gather as much information as you can from the

patient’s appearance:
• Body language
• Facial expression
• Age
• Sex
• Speech
• Movement
• Smell
• People accompanying the patient
• Be careful not to make assumptions
• Stick to facts
• Be certain you are not stereotyping the patient
• Avoid translation errors – stick to the patient’s
words until you have clarified exactly what the
patient means
• Look at your patient carefully
• Listen carefully
• Be objective about what you see and hear
• Pull all this information together – form your
initial concept and your hypotheses will follow
Generating Multiple Hypotheses

Hypothesis – a provisional explanation

for the occurrence of the patient’s
problem.
It provides a label for the information,
which has been collected and allows the
practitioner to focus a line of enquiry
From the initial concept several different
hypotheses may spring to mind
• The hypothesis generated will depend on the initial
concept. If just one element were to change in the
initial concept the hypothesis could change
significantly.
• The initial concept seems to cause hypotheses to be
generated almost at once.
• These are kept very broad.
Narrowing down hypotheses
• Vague complaints such as ‘tired all the time’
generate many potential hypotheses, which
need to be narrowed down to focus the
consultation.
• You need more information to determine what
the patient means by ‘tired’
• Use of a symptom analysis tool will assist in your
development of hypotheses. e.g.
PQRST/OLDCARTS
Exercise

• Mr Hawkins is a 54-year-old man with chest pain.

His vital signs are normal. As you enter the room
you see that Mr Hawkins appears to be about his
stated age of 54. He is mildly obese, casually
dressed and appears to be sweating although
the room and outside temperatures are cool. He
is not otherwise in obvious distress. He is sitting
on the examining table, bent forward and
bearing his weight on his hands, which are
grasping the edge of the table. His speech is
clear and slightly hurried, with an anxious tone.
He is accompanied by his wife who appears
anxious.
• After you introduce yourself, Mr Hawkins says “I have
this persistent pain in my chest that won’t go away. It
feels like indigestion.”
• You note brown stains on Mr Hawkin’s right second
and third fingers and an odour characteristic of
distilled spirits.
• What is your initial concept of this patient?
Formulating an enquiry strategy

• What does it take to rule out the

incorrect hypotheses and establish
the correct one?
• Choosing the correct hypothesis is
the vehicle for selecting the
appropriate treatment for the patient.
FOUR SEPARATE COMPONENTS:
• Deduction – process to substantiate, reject or
generate new hypotheses
• Efficiency – economise on time, cost and energy
• Search and scan – focus on the presenting problem,
scan the horizon for further clues.
• Hypothesis generation – does your enquiry strategy
add information to refine your hypothesis?
For example if you ask Mr Hawkins
• “do you feel the pain anywhere else?” and he
answers “yes I have a heavy, achy feeling in my
left arm and in my lower jaw”
• You have enough information to make ischaemic
heart disease the working diagnosis.
• Do not rule out other hypotheses but have them
in the back of your mind.
• Because of the diagnosis you are directed
towards the safety of the patient, definitive
evaluation and treatment.
 The list of hypotheses remain the same except
ischaemic heart disease is now divided into:
• Recurring angina
• Unstable angina
• Coronary insufficiency
• Myocardial infarction uncomplicated
• Myocardial infarction complicated
 This leads to the next set of questions to rule out
other possibilities
• “do you have any heartburn or burning in your
chest?”
• “No”
• “Do you have any difficulty breathing?”
• “ Just a sort of heavy feeling in my chest like it’s
difficult to get a good breath in”
• This response adds some weight to myocardial
ischaemia and makes GI pain less likely. But it
could also be a PE.
Applying Appropriate clinical skills

• The scientist reads then experiments

• The detective questions then uses laboratory
results
• The clinician takes a history and then examines
• The physical examination is guided by the
generated hypotheses. It is simply to confirm
the diagnosis.
• Physical examination can be carried out after the
history taking or at the same time.
Developing the problem synthesis

• Adding new data – Are new findings on history

and physical accurate?
• Evaluating the new data – Are new findings
significant in terms of the hypotheses
entertained? Do they support or weaken any of
the guiding hypotheses?
 Divide the findings into positive and
negative

• Positive – signs and symptoms that

you would expect to find if a
particular hypothesis were true – i.e.
supporting the hypothesis
• Negative – expected facts that are not
present, i.e. facts that would be
expected if the hypothesis were true –
therefore weaken the hypothesis
• These facts are then added to the initial concept; this
continual and cumulative assembly of significant data
is the problem synthesis
• It is essential throughout the problem solving process
to check the accuracy of the findings with the patient’s
perception of the problem.
Laboratory and diagnostic findings
These can be used to support or reject the
generated hypotheses
When deciding which tests to utilise consider:
• Inconvenience to patient
• The harm caused to him/her
• The cost of the test
• What information is the test going to provide?
• How long will it take to get the results?
• What will you do with the information?
• Will the results make any difference to your
management plan?
• Sensitivity – How well does the test detect the
presence of the suspected disease process?
• Specificity – How specific is the test for the
disease process suspected?
• Relevance – Will the test really make a difference
in the diagnosis and management of the
patient?
Diagnostic decision making
• The diagnosis or working hypothesis is needed
by the end of the patient encounter.
• It may not be possible to make an immediate
decision about a patient’s problem
• If the diagnosis is uncertain the clinician has to
decide how to progress.
• It might be necessary to implement a treatment
monitor the results and then make a diagnostic
decision based upon the results of the therapy.
• Once a decision is made the practitioner then
has a further process of decision-making – how
to treat the patient.
Therapeutic decision-making

Consider:
• What is your treatment objective?
• Is it to cure the patient, correct the underlying
pathophysiological disorder, relieve symptoms,
prevent complications or what?
• How effective is the treatment for the purpose
for which you are employing it?
• How effective is it in correcting the
pathophysiological mechanism of the disease
process?
• How effective is it in preventing complications,
relieving symptoms and so on?
• What experience do you have in this form of
treatment?
• How do you know it works?
• Are you basing your therapy on evidence or
what?
Barrows,H.S. Pickell, G.C. (1991). Developing
Clinical Problem Solving Skills: A Guide to More
Effective Diagnosis and Treatment. New York:
Norton Medical Books.
Elstein,A,S & Schwarz, A.(2002). Clinical
problem solving and diagnostic decision
making: selective review of the cognitive
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Newell, A. Simon, H.A. (1972). Human Problem
Solving. New Jersey: Prentice- Hall.
Walsh, M. Crumbie, A. Reveley, S. (2001). Nurse
Practitioners: Clinical Skills and professional
Issues. Oxford: Butterworth- Heinemann