1. Clinical Problem-Solving in FP “Diagnostic process” Problem-Solving in FPDr Lubna Al-Ansary

2. “ I had not long been in the practice when I discovered how defective was my knowledge. I left college under the impression that every patient’s condition could be diagnosed. For a long time, I strove to make a diagnosis and assiduously studied my lectures and textbooks, without avail. Reflections… Sir McKenzie - 1973 Problem-Solving in FPDr Lubna Al-Ansary

3. did not exist….” For some years, I thought that this inability to diagnose my patients’ complaints was due to personal defects, but gradually, through consultations and other ways, I came to recognize that the kind of information I wanted did not exist….” Mackenzie (Mair 1973) Reflections… Problem-Solving in FPDr Lubna Al-Ansary

4. Why? Pattern of illness: Community vs hospital Undifferentiated & unorganized illness No prior assumptions Information on which to base a precise diagnosis is lacking- early presentation Direct availability of physicians & unpredictable workload Doctor-patient relationship- Use of time Problem-Solving in FPDr Lubna Al-Ansary

5. Contrasting Causes of Chest Pain General PracticeHospital Problem-Solving in FPDr Lubna Al-Ansary

6. Problem-Solving Styles Cookbook Problem-Solving in FPDr Lubna Al-Ansary

7. Problem-Solving Styles Problem-Solving in FPDr Lubna Al-Ansary

8. Problem-Solving Styles Biomedical Scientist Problem-Solving in FPDr Lubna Al-Ansary

9. Problem-Solving Styles Basket Problem-Solving in FPDr Lubna Al-Ansary

10. Inductive Method of Problem-Solving Full history: Presenting complaint/ Systematic enquiry Previous medical history/ Drugs/ Social/ family PLUS Complete physical Examination PLUS Investigations Diagnosis Problem-Solving in FPDr Lubna Al-Ansary

11. Hypothesis Matrix “Chest Pain” Pathophysiologic process Organ System Cardio- vascular PulmonaryGastro- intestinal Mechanical Inflammatory Infectious MI Dissecting aneurysm Pericarditis Endocarditis Myocarditis EmbolismAchalasia Pleuritis Pneumonia Ulcer GE Problem-Solving in FPDr Lubna Al-Ansary

12. 1. Identify the problem clearly. 2. Generate as many solutions as possible : - do not reject a solution at this stage, however preposterous it sounds. 3. Take STEPs toward solving the problem : a) S a) Select a solution. b) T b) Try it out. c) E c) Evaluate what happens. d) P d) Persist until you feel better. 3 Stages of Problem Solving Problem-Solving in FPDr Lubna Al-Ansary

13. Hypothetico-Deductive Model CUES (Clinical, behavioural, contextual) FOLLOW UP UNEXPECTED CUES REVISE HYPOTHESIS(ES) (Based on probability, payoff and personal knowledge) SEARCH (History, examination, investigation) MANAGEMENT DECISION Problem-Solving in FPDr Lubna Al-Ansary

14. A 61-year-old widow presents with a history of ‘wetting herself’ for the previous 5 days because she ‘can’t get to the toilet on time’. She had felt ‘perfectly well’ prior to the onset of her present symptomatology. Her medical records reveal she has no history of significant illness and that she is an infrequent attender. Case 1 Problem-Solving in FPDr Lubna Al-Ansary

15. A 32-year-old divorcee with 2 children who has been ‘well’ until 2 months previously. She presented with: Presentation 1 Tiredness Irritability Weight loss Dislike of hot weather Increased sweating Palpitations Trembling of hands Increased appetite Case 2: Presentation 2 Tiredness Irritability Increased sweating Weight loss Palpitations Diminished appetite Presentation 3 Tiredness ? Weight loss Normal appetite Problem-Solving in FPDr Lubna Al-Ansary

16. Identification of Errors CUES (Clinical, behavioural, contextual) FOLLOW UP UNEXPECTED CUES REVISE HYPOTHESIS(ES) (Based on probability, payoff and personal knowledge) SEARCH (History, examination, investigation) MANAGEMENT DECISION Problem-Solving in FPDr Lubna Al-Ansary

17. Quiz Problem-Solving in FPDr Lubna Al-Ansary

18. Key Messages WHD 2007 Threats to health know no borders “Invest in health, build a safer future” Health leads to security; insecurity leads to poor health Preparedness and quick response improve international health security The World Health Organization is making the world more secure Problem-Solving in FPDr Lubna Al-Ansary

19. Hypothetico-Deductive Model CUES (Clinical, behavioural, contextual) FOLLOW UP UNEXPECTED CUES REVISE HYPOTHESIS(ES) (Based on probability, payoff and personal knowledge) SEARCH (History, examination, investigation) MANAGEMENT DECISION Problem-Solving in FPDr Lubna Al-Ansary

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21. The 2 x 2 Table Problem-Solving in FPDr Lubna Al-Ansary

22. SpPin and SnNout Problem-Solving in FPDr Lubna Al-Ansary

23. SpPin and SnNout s SnNout: A highly sensitive test, if negative, helps to rule the disease out. SnNout Problem-Solving in FPDr Lubna Al-Ansary

24. SpPin and SnNout s SpPin: A highly specific test, if positive, helps to rule the disease in. SpPin Problem-Solving in FPDr Lubna Al-Ansary

25. Chest Pain and ECG How helpful is the ECG in diagnosing MI among patients presenting with acute chest pain? Sensitivity: 60% Specificity: 91% Likelihood ratio: +ve: 6.7 -ve: 0.4 Problem-Solving in FPDr Lubna Al-Ansary

26. Chest Pain and ECG- Scenario 1 Middle aged man Typical history of angina Tight substernal pain by exercise by rest- within 5 min Probability of IHD: 90% Stress ECG? Post-test probability of IHD: 98% +ve = 98% 70% -ve = 70% Problem-Solving in FPDr Lubna Al-Ansary

27. Chest Pain and ECG- Scenario 2 40-year-old Vague (L) Sided chest pain Unrelated to exercise by moving the chest wall Probability of IHD: 5% Stress ECG? Post-test probability of IHD: 28% +ve = 28% 2% -ve = < 2% Problem-Solving in FPDr Lubna Al-Ansary

28. Chest Pain and ECG- Scenario 3 Middle aged man Attacks substernal pain several months Occurs at rest few min – ½ hr Worsened since onset By exertion X relieved by rest Probability of IHD: 50% Stress ECG? Post-test probability of IHD: 87% +ve = 87% 25% -ve = 25% Problem-Solving in FPDr Lubna Al-Ansary

29. Likelihood Ratios We take our initial assessment of the likelihood of disease (“pre-test probability”), do a test to help us shift our suspicion one way or the other, and then determine a final assessment of the likelihood of disease (“post-test probability”). Likelihood ratios (LRs) tell us how much we should shift our suspicion for a particular test result. The “positive likelihood ratio” (LR+) tells us how much to increase the probability of disease if the test is positive, while the “negative likelihood ratio” (LR-) tells us how much to decrease it if the test is negative. Problem-Solving in FPDr Lubna Al-Ansary

30. Likelihood Ratios LR+=----------------------------------------------------------------- LR- =----------------------------------------------------------------- Probability of an individual with the condition having a positive test Probability of an individual without the condition having a positive test Probability of an individual with the condition having a negative test Probability of an individual without the condition having a negative test Problem-Solving in FPDr Lubna Al-Ansary

31. Likelihood Ratios LR+=-------------------- - LR - =----------------- Sensitivity 1-specificity 1-sensitivity Specificity Problem-Solving in FPDr Lubna Al-Ansary

32. Scenario 1 +ve -ve Problem-Solving in FPDr Lubna Al-Ansary

33. Scenario 2 +ve -ve Problem-Solving in FPDr Lubna Al-Ansary

34. LR Interpretation Large & often conclusive increase in the likelihood of disease >10 Moderate increase in the likelihood of disease5-10 Small increase in the likelihood of disease2-5 Minimal increase in the likelihood of disease1-2 No change in the likelihood of disease1 Minimal decrease in the likelihood of disease0.5-1.0 Small decrease in the likelihood of disease0.2-0.5 Moderate decrease in the likelihood of disease0.1-0.2 Large & often conclusive decrease in likelihood of disease <0.1 Problem-Solving in FPDr Lubna Al-Ansary

35. Clinical Symptoms & Diagnosis of UTI P 1. Patient population. I 2. Intervention. C 3. Comparison intervention. O 4. Outcomes. Women in child bearing age Symptoms Probability of UTI “ In women in child bearing age suspected to have UTI, to what extent, would the presence or absence of certain symptoms relate to the probability of UTI? “ In women in child bearing age suspected to have UTI, to what extent, would the presence or absence of certain symptoms relate to the probability of UTI? Problem-Solving in FPDr Lubna Al-Ansary

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49. Remember… Problem-Solving in FPDr Lubna Al-Ansary

50. “It is the quality of thinking and NOT the quantity of facts that is likely to lead to the resolution of clinical problems”. Marinker, 1976 Remember… Problem-Solving in FPDr Lubna Al-Ansary