From problem solving to problem definition: scrutinizing the complex nature of clinical practice

Statistical Inference for Stochastic Processes, Dec 2016

In medical education, we have tended to present problems as being singular, stable, and solvable. Problem solving has, therefore, drawn much of medical education researchers’ attention. This focus has been important but it is limited in terms of preparing clinicians to deal with the complexity of the 21st century healthcare system in which they will provide team-based care for patients with complex medical illness. In this paper, we use the Soft Systems Engineering principles to introduce the idea that in complex, team-based situations, problems usually involve divergent views and evolve with multiple solution iterations. As such we need to shift the conversation from (1) problem solving to problem definition, and (2) from a problem definition derived exclusively at the level of the individual to a definition derived at the level of the situation in which the problem is manifested. Embracing such a focus on problem definition will enable us to advocate for novel educational practices that will equip trainees to effectively manage the problems they will encounter in complex, team-based healthcare.

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From problem solving to problem definition: scrutinizing the complex nature of clinical practice

Perspectives on Medical Education February 2017, Volume 6, Issue 1, pp 54–57 | Cite as From problem solving to problem definition: scrutinizing the complex nature of clinical practice AuthorsAuthors and affiliations Sayra CristanchoLorelei LingardGlenn Regehr Open Access Eye-Opener First Online: 05 December 2016 12 Shares 1.6k Downloads 3 Citations Abstract In medical education, we have tended to present problems as being singular, stable, and solvable. Problem solving has, therefore, drawn much of medical education researchers’ attention. This focus has been important but it is limited in terms of preparing clinicians to deal with the complexity of the 21st century healthcare system in which they will provide team-based care for patients with complex medical illness. In this paper, we use the Soft Systems Engineering principles to introduce the idea that in complex, team-based situations, problems usually involve divergent views and evolve with multiple solution iterations. As such we need to shift the conversation from (1) problem solving to problem definition, and (2) from a problem definition derived exclusively at the level of the individual to a definition derived at the level of the situation in which the problem is manifested. Embracing such a focus on problem definition will enable us to advocate for novel educational practices that will equip trainees to effectively manage the problems they will encounter in complex, team-based healthcare. KeywordsPerspectives Interactions Systems Engineering  “Nothing ever exists entirely alone; everything is in relation to everything else.” (Buddha) Problem solving has been one of the central areas of exploration for researchers studying medical expertise. This work has revealed some important insights into how medical experts grapple with addressing relatively stable, well-defined problems. However, in focusing on problems that are singular, stable, and solvable, these insights might have limited value in preparing clinicians to deal with the complexity of the 21st century healthcare system in which they will provide team-based care for patients with complex medical illness [1]. In the medical education literature, this concern is gaining recent attention as researchers begin to challenge taken-for-granted assumptions about clinical reasoning activities, such as diagnosis [2]. When activities such as diagnosis or treatment planning are framed as ongoing processes of meaning making, problem solving can no longer be thought of merely as converging on the correct solution. Consider the following example, derived from a research interview with a senior general surgeon: Dr. Smith was scheduled to operate on a gentleman with a pelvic exoneration that required removing all the organs within the pelvis. Chemotherapy prior to surgery would likely increase the success of surgery. The patient was assessed by the oncologist who decided not to provide chemotherapy before the operation because the oncologist thought the patient was ‘not reliable’. To determine what to do, Dr. Smith engaged in a series of conversations with the nurse, the social worker, the oncologist and a more senior colleague. Dr. Smith felt very strongly that ‘treating someone with less than the standard of care’ was inappropriate. Yet, the oncologist continued to resist. As the day of the surgery approached, Dr. Smith gathered support from the rest of the team members involved and essentially ‘tricked the oncologist’ by admitting the patient to the hospital in advance. With this decision, Dr. Smith presented a new situation to the oncologist saying ‘ok, well, now he’s in hospital, he’s very reliable; he’s not going anywhere … now you can treat him’. The oncologist reframed his concern, remarking back to the surgeon that ‘sometimes what is good for this patient may not necessarily be good for society’. Notwithstanding this stance, the oncologist acknowledged that since the patient was already in the hospital, he had to fulfil his professional responsibility of providing chemotherapy. As this treatment was taking place, Dr. Smith felt ‘somewhat morally conflicted because I get what the oncologist is worried about …’. He now reported viewing the situation as ‘teetering’ between doing the right thing for one patient and imposing a significant cost on the system. In describing the shifting context that defined his efforts to help this patient, he characterized the situation as being one of making judgments like a rock climber: ‘very, very slow, inching your way … that feels like a solid hand-hold, ok, I’ll take that … or that doesn’t seem like it’s gonna go, so maybe I’ll try a different strategy, and often what you do at a certain moment in time, opens up what you can see at another moment … I think it’s like being in a constant evolution of finding your place.’ What does this story reveal about the nature of problem solving in every day clinical practice? First, (...truncated)


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Sayra Cristancho, Lorelei Lingard, Glenn Regehr. From problem solving to problem definition: scrutinizing the complex nature of clinical practice, Statistical Inference for Stochastic Processes, 2016, pp. 54-57, Volume 6, Issue 1, DOI: 10.1007/s40037-016-0314-0