1. Extended Prescribing Consultation Skills Module Clinical Problem Solving Dr Adrian Hastings, Senior Clinical Educator

2. Problem solving Accesses relevant information from patients/clients’ records Identifies patients/clients’ reason(s) for attendance and associated concerns and expectations Elicits relevant information from patients/clients Seeks relevant clinical signs and makes appropriate use of ‘near patient testing’

3. Problem solving Correctly interprets information gathered Applies clinical knowledge appropriately in the identification and management of the patients/clients’ problem Uses protocols as appropriate Recognises limits of personal competence and acts accordingly

4. Problems most likely to result in harm to patients Incorrect diagnosis (knowledge/interpretation14 Insufficient or wrong information from patient8 Inability to gain agreement, understanding or compliance7 Failure to recognise the severity of the problem4 Referral difficulties (including lack of availability)3 Follow up (incorrect, or problematic due to service)3 Recognition of limits of competence1 Poor communication with colleagues1

5. Why did I make the wrong diagnosis? It never crossed my mind I paid too much attention to one finding I didn’t listen enough to the patient’s story I was too much in a hurry I didn’t know enough about the disease I let someone else convince me I didn’t reassess the situation The patient had too many problems at once I was influenced by a similar case I failed to convince the patient to come back I was in denial of an upsetting diagnosis Bordage 1999 Academic Medicine Vol 74. No 10

6. Understanding how we diagnose Pattern recognition Fast Accurate (with experience) Depends on relating the event to similar events stored in memory Prone to error as unusual events tend to be remembered more easily

7. Pattern Recognition – an example Sandra is 23: “It’s cystitis again. I’m peeing all the time and I can’t hold it long. Can you do me a prescription for antibiotics, they worked for me last time?” What is the diagnosis Are there other possibilities What is the next step If urine dip test is: Protein +, WBC +, RBC -, Nitrite -, What next?

8. Understanding how we diagnose Analytical thinking Features are identified Different diagnoses are considered Interpretation is made

9. Analytical thinking – an example Maureen is 42: “I have got pains in my legs, I am short of breath and I feel distant”. What is the diagnosis Are there other possibilities What is the next step

10. Understanding how we diagnose Problem representation Translate findings into abstract terms Use mental pictures Creating a summary Accessing concepts and instances

11. Problem representation – an example Margaret is 60: “I feel as though my food has not been going down properly. The gaviscon I have always taken for heartburn isn’t helping anymore, and I don’t fancy my food like I used to” What abstract terms can we use to translate the findings? What further enquiry should we make? What is the likely diagnosis? Should other diagnoses be considered?

12. Making a diagnosis – Key concepts Clarifying the presenting problem Preliminary interpretation Identifying key features Reinterpretation of information Active elimination Seeking specific features

13. Clarifying the presenting problem Pain Site and radiation Quality Intensity Timing Aggravating/relieving factors Symptoms associated Diarrhoea Nature/appearance Frequency Timing Aggravating/relieving factors Symptoms associated

14. Diarrhoea: an example Quality: Colour and consistency of faeces Intensity: Volume and frequency of opening bowels Timing: When did it begin and is it getting worse Aggravating factors: Eating meals or particular foods Relieving factors: Use of o.t.c. remedies Secondary symptoms: Vomiting, abdominal pain, blood in faeces

15. Making a diagnosis – an example Parveen is 56: “I have had a cough for two months, and it has been getting worse. My brother says it might be asthma as he has it.” What clarifying enquiry needs to be made of his presenting problem What is the preliminary interpretation What are the key features for this diagnosis How do we reinterpret this information What features would help us to eliminate a diagnosis What specific features need to be sought

16. Commentary on Group Work Be clear about what is a diagnosis Rank competing diagnoses – Most likely, less likely but important to consider Elimination often easier than confirmation Aim for optimum diagnostic precision Competing diagnoses may have several key features in common Additional symptoms may not increase the probability of the eventual diagnosis

17. Commentary on Group Work – continued Clarification of the timing of a symptom is often the key to eliminating a diagnosis Some features, often enquired about, can mislead by being over-interpreted SpPin and SnNout Diagnostic probabilities are strongly influenced by the setting in which you work Many nurses work in situations where the primary diagnosis is known, but they are challenged to make secondary diagnoses

18. Organisation of the consultation Interpret prior knowledge about the patient Set goals for the consultation Discover the patient’s ideas, concerns and expectations about the problem(s) Gather sufficient information to make a provisional, triple diagnosis Carry out appropriate physical examination and near patient tests to confirm or refute the diagnosis

19. Organisation of the consultation Reconsider your assessment of the problem Reach a shared understanding of the problem with the patient Give the patient advice about what they need to do to tackle the problem Explain the actions you will be taking Summarise and close

20. Care planning – Key concepts

21. Reach a shared understanding Acknowledge patients views and show respect for them Provide sufficient explanation to make informed decisions Tailor explanation to reason for consultation Do not assume understanding of concepts Do not concede to a course of action you believe to be incorrect Repeat key messages Break down information into smaller chunks

22. Providing advice about self care Life style advice Spiral of change General or specific Self medication

23. Actions decided by health professsionals Primum non nocere Prescribing Evidence based treatment Investigation – Confirmation – Refutation – Pre and post test probabilities – Sensitivity and specificity – Patient Safety – Reassurance Referral

24. Summary and closure Checking understanding Reinforcing key messages Ask patient to relate back elements of plan Use written information Negotiate follow up Hand back responsibility