Explaining variability clinical decision making as problem solving

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In addition, if doctors’ behaviour were objective then their behaviour would be consistent. However, considerable variability among doctors in terms of different aspects of
their practice has been found. For example, Anderson et al. (1983) reported that doctors
differ in their diagnosis of asthma. Mapes (1980) suggested that they vary in terms of
their prescribing behaviour, with a variation of 15–90 per cent of patients receiving
drugs. Bucknall et al. (1986) reported variation in the methods used by doctors to
measure blood pressure and Marteau and Baum (1984) also reported that doctors vary
in their treatment of diabetes.
According to a traditional educational model of doctor–patient communication, this
variability could be understood in terms of differing levels of knowledge and expertise.
However, this variability can also be understood by examining the other factors involved
in the clinical decision-making process.
Explaining variability – clinical decision making as
problem solving
A model of problem solving
Clinical decision-making processes are a specialized form of problem solving and have
been studied within the context of problem solving and theories of information processing. It is often assumed that clinical decisions are made by the process of inductive
reasoning, which involves collecting evidence and data and using this data to develop a
conclusion and a hypothesis. For example, within this framework, a general practitioner
would start a consultation with a patient without any prior model of their problem.
The GP would then ask the appropriate questions regarding the patient’s history
and symptoms and develop a hypothesis about the presenting problem. However,
doctors’ decision-making processes are generally considered within the framework of
the hypothetico-deductive model of decision making. This perspective emphasizes the
development of hypotheses early on in the consultation and is illustrated by Newell and
Simon’s (1972) model of problem solving, which emphasizes hypothesis testing. Newell
and Simon suggested that problem solving involves a number of stages that result
in a solution to any given problem. This model has been applied to many different
forms of problem solving and is a useful framework for examining clinical decisions (see
Figure 4.2).
The stages involved are as follows:
1 Understand the nature of the problem and develop an internal representation.
At this stage, the individual needs to formulate an internal representation of the
problem. This process involves understanding the goal of the problem, evaluating any
given conditions and assessing the nature of the available data.
2 Develop a plan of action for solving the problem. Newell and Simon differentiated
between two types of plans: heuristics and algorithms. An algorithm is a set of rules
that will provide a correct solution if applied correctly (e.g. addition, multiplication,
etc. involve algorithms). However, most human problem solving involves heuristics,
which are rules of thumb. Heuristics are less definite and specific but provide
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Fig. 4-2 A simplified model of problem solving
guidance and direction for the problem his solver. Heuristics may involve developing
parallels between the present problem and previous similar ones.
3 Apply heuristics. Once developed, the plans are then applied to the given situation.
4 Determine whether heuristics have been fruitful. The individual then decides
whether the heuristics have been successful in the attempt to solve the given problem.
If they are considered unsuccessful, the individual may need to develop a new
approach to the problem.
5 Determine whether an acceptable solution has been obtained.
6 Finish and verify the solution. The end-point of the problem-solving process
involves the individual deciding that an acceptable solution to the problem has been
reached and that this solution provides a suitable outcome.
According to Newell and Simon’s model of problem solving, hypotheses about the causes
and solutions to the problem are developed very early on in the process. They regarded
this process as dynamic and ever-changing and suggested that at each stage of the
process the individual applies a ‘means end analysis’, whereby they assess the value of
the hypothesis, which is either accepted or rejected according to the evidence. This type
of model involves information processing whereby the individual develops hypotheses
to convert an open problem, which may be unmanageable with no obvious end-point, to
one which can be closed and tested by a series of hypotheses.
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Clinical decisions as problem solving
Clinical decisions can be conceptualized as a form of problem solving and involve the
development of hypotheses early on in the consultation process. These hypotheses are
subsequently tested by the doctor’s selection of questions. Models of problem solving
have been applied to clinical decision making by several authors (e.g. MacWhinney
1973; Weinman 1987), who have argued that the process of formulating a clinical
decision involves the following stages (see Figure 4.3):
1 Accessing information about the patient’s symptoms. The initial questions
in any consultation from health professional to the patient will enable the health
professional to understand the nature of the problem and to form an internal representation of the type of problem.
2 Developing hypotheses. Early on in the problem-solving process, the health
professional develops hypotheses about the possible causes and solutions to the
problem.
3 Search for attributes. The health professional then proceeds to test the hypotheses
by searching for factors either to confirm or to refute their hypotheses. Research
into the hypothesis testing process has indicated that although doctors aim to
either confirm or refute their hypothesis by asking balanced questions, most of their
questioning is biased towards confirmation of their original hypothesis. Therefore, an
initial hypothesis that a patient has a psychological problem may cause the doctor
to focus on the patient’s psychological state and ignore the patient’s attempt to talk
about their physical symptoms. Studies have shown that doctors’ clinical information
Fig. 4-3 Diagnosis as a form of problem solving
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