Intro to PA Week 2 Lecture 1 PDF

Problem Solving and Medical Decision Making Gave examples of what to do policy briefs first 3 min of recording - 1 page double spaced Amanda Stevenson-Cali, PA-C...

Problem Solving and Medical Decision Making Gave examples of what to do policy briefs first 3 min of recording - 1 page double spaced Amanda Stevenson-Cali, PA-C Intro to Profession Block 1 PRESBYTERIAN COLLEGE CONFIDENTIAL  Agenda Lecture Objectives – Identify problem-solving analysis theories and the steps in problem-solving frameworks – Examine medical decision-making – Dissect the differential diagnosis – Apply medical decision making theory to a patient case Theory of Problem Solving Why are we talking about this?? – YOU Students have to solve instructional problems in order to succeed Can’t happen unless you have the willingness to work – PAs Have to solve problems their patients face Can’t happen unless PAs have the willingness to work – Patients Have to solve problems about their health Can’t happen unless they, too, have the willingness to work The Theory of Problem Solving Cognition Behavior “Thinking” “Doing” A Problem = Dealing with A Problem = Action to contradictions remove problem Analyzing problem Performing problem tasks situations Theory of Problem Solving Solving Problems – No one solves a problem before a problem exists – Problem solving begins when a person recognizes there is problem AND said problem REQUIRES a solution Theory of Problem Solving Solving Problems – Once it’s been decided that a problem NEEDS a solution, a willingness to solve the problem must exist – Willingness cannot be assumed Theory of Problem Solving Solving Problems – Action Action against a problem can be either cognitive (internal) or behavioral (external) Action requires planning Planning requires knowledge – Knowledge of the parameters of the problem – Knowledge of the parameters of the solution Theory of Problem Solving To begin solving a problem – 1. Recognize a problem exists – 2. Recognize that a problem needs a solution – 3. Be willing to act – 4. Act Understand what causes a problem What stops (or suspends, or precludes, or slows down) the problem – 5. Maintain Once a problem is solved, do steps need to be taken to prevent the problem from returning or worsening? Theory of Problem Solving YOU – Will learn the skills and information to be able to confidently and competently solve medical problems PAs – Will refine their knowledge and skills over their practice careers Patients – Need your help to solve problems Medical Decision Making www.Smdm.org Society for Medical Decision making Chapter 3 Harrison’s Internal Medicine (19th Edition) Medical Decision-making Definition – How healthcare providers and patients make routine decisions/solve problems MDM Theory – People are assumed to make decisions in a “normative” way Meaning: thinking clearly and rationally – In reality, no one thinks clearly and rationally BIASES (unconscious or obvious) – In medicine, PAs must be able to make medical decisions about patient care that: 1. Emphasizes patient health 2. Includes patient input MDM Developing the MDM – Begins with patient evaluation Medical History Physical Exam Laboratory or diagnostic data – Formulating a diagnosis – Proposing a treatment Patient’s Goals (cost effective, safe, patient compliance, true benefit) - MDM Two types of Medical Decision – 1. Diagnostic What needs to be done to make the diagnosis? – 2. Therapeutic What needs to be done to maximize the treatment? – Either way, both must involve the “best evidence available” and both must involve the patient’s input/preferences Shared decision-making MDM Making the Decisions (Dual process theory) – Intuition (gut feeling) Rapid, effortless judgement (cannot be traced) don’t go down rabbit hole Uses pattern recognition and heuristics (“rules of thumb”) – Analysis (charting) Slow, deliberate thinking Requires research, methodology, and can be be traced Note: BOTH CAN BE INFLUENCED BY BIASES MDM Biases Bias Description Availability Think about easy-to-remember or most recent diagnoses regardless of prevalence Base Rate Neglect Pursuing “zebras” – rare diagnoses Representativeness Ignoring atypical features that are inconsistent with the favored diagnosis Confirmation Bias Seeking data to confirm vs refute the initial hypothesis Premature Closure Stopping the diagnostic process too soon MDM Other Influences on decision making – Practice Style The clinical behaviors of the individual provider Personal experience (“expertise”); Specialization; how one interprets the medical evidence – Practice Setting Resources available to the practice, provider, or community – Economic Incentives Following the money can lead to both GOOD and BAD influences on patient care MDM Clinical Support Tools – Information technology Computers/systems can formulate probabilities that influence decisions (Framingham Scores, i.e.) – Evidence-based Algorithms – Evidence-based Medicine (EBM) (gold-standard) Can follow the suggested guidelines Beware following blindly!! (need to use intuition, expertise, trial/error, avoid biases, and recognize your outside influences) MDM McMasters University – Dr Saeed: https://hslmcmaster.libguides.com/c.php?g=570518&p=3932127 MDM https://emuniversity.com/MedicalDecision-Making.html MDM Examples – A patient presents with a cough What can you think of that would make this presentation more serious? Less serious? If it is more serious, are you going to order more tests or less tests? MDM Influences in MDM: Acuity of action – Is the issue acute, subacute, chronic, or emergent? Type of evaluation (Hx and PE) – Is the issue complex or simple? Developing the Differential – What is most likely? Most dangerous? Treatment – What are the patient preferences and/or resources? Social determinants of health – What does the evidence say is best? – is it the gold standard Differential Diagnosis - DDx Introduction What is a Differential Diagnosis? (Abbreviated “DDx”) – A prioritized LIST of all possibilities based on the unique clinical findings of a patient – A process to evaluate information or results to narrow decisions to a working, accurate diagnosis In the beginning... – You will have huge differentials and try to follow a process to eventually get a diagnosis – Over time, you will make better use of Expertise, Pattern Recognition, and Risk to make faster, more accurate decisions Differential Diagnosis Formulating the DDx 1. Start with basic patient information – Symptoms (hx) – Signs (phys exam) 2. Rank Order Most Likely → Most Common → Most Dangerous → Least Likely 3. Investigate – Treatment and response? – Order lab or image? 4. Did it work? Is what you thought still what you think? Differential Diagnosis Practice References Harrison’s Principles of Internal Medicine. Kasper, Fauch, et al. McGraw-Hill; 2014 (Available on AccessMedicine)