The everyday skills that we use to reach decisions are far from simple and still poorly understood. Imagine that you are a patient, that you like your doctor, who is very popular and talks to you with great sensitivity and concern, but is in fact clinically incompetent – how are you to know this?
Many might suggest that their doctor’s medical degrees will help, but think of your own experience in medical examinations and ask yourself how well your own problem solving skills have been tested? I suggest the most honest answer is very superficially.
Let us try to explore the essential ingredients of effective clinical decision making in the primary care setting. This is a difficult stew to prepare. The cook books start with the hypothesis testing deduction methodology beloved of Sherlock Holmes fans; mix this with a bit of Bayesian probability and a good dollop of evidence-based theory and behold everyone can be a diagnostic Sherlock.
If only it were that easy. We have to throw heuristics into the mix, the simplest being rule of thumb, common sense, whatever that is in the medical setting, and trial and error, which might just unnerve our patient. Then we must add cognitive biases; this means things like attitudes, how you frame certain problems, how certain presentations trigger a given response, feelings, and so on.
So what actually happens in your own surgery? You can work on this by recording some consultations and giving yourself a running commentary on your thought processes when you watch them. This will probably surprise you.
The patient enters and if you already know them several attitudes, preconceptions and probabilities instantaneously come into play before they have even sat down. Now (hopefully) you are watching out for cues, but even if you are not you are going to get several cues – age, sex, communicative ability, social class – still almost instant.
Within a few more moments, almost simultaneously with the perception of initial cues, ideas will form; you might have a hunch, possibly the odd guess. This collection of rapidly formed hypotheses serves as an almost unconscious guide for the rest of the communication: doctors are often unaware of the existence of these almost hidden hypotheses in their thinking and will say they had no initial idea about the patient’s problems.
After a few exchanges these early hypotheses coalesce to form some more conscious thoughts that then get tested. It is these thoughts and how you deal with them that form the basis of good or bad clinical problem-solving.
Here are five strategies you can use in difficult cases, as suggested by Jerome Groopman in his book How Doctors Think:
The magic ingredient
No one has yet clearly identified the magic ingredient that separates the novice from the expert in medicine. Observing many doctors consulting both well and badly suggests that a good knowledge base, a willingness to listen and act on what the patient tells you is a good start but not sufficient.
Experience can work both ways: if it shuts down the search too quickly it is unhelpful; if it allows exploration of paths not easily seen then it is useful. A simple guide to effective or less effective primary care problem-solving is the time to the examination in a new problem.
In most cases the examination signals the end of the problem-solving phase, the examination is usually confirmatory, very seldom revelatory and the explanation that follows is already etched in stone; so a very simple heuristic – the quicker the examination, the more fragile the problem-solving.
With complex problems it is of course even more difficult. The most helpful skill in these cases is the ability to remain open to new ideas and information. The effective synthesis of all this information is what separates the diffident novice from the true expert, and the fact that some are better than others at this suggests that it is a subtle mix of the ‘science’ of clinical reasoning and the ‘art’ of good medical practice.
Most GPs add to their factual knowledge cumulatively and as they practice applying that knowledge, a deeper understanding develops. As their knowledge and problem-solving skill improve within a domain, problem-solving behaviours become more expert-like.
We do really have to emphasise the positive. Yes we make mistakes, but expert clinical reasoning is very likely to be right in the majority of cases.
- Dr Tate is a retired GP in Dorset, and author of The Doctor's Communication Handbook and the Effective Consulting DVD. The Effective Consulting Video Learning Package is available to buy on MIMS Learning
These action points will provide further learning opportunities in this area: