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Encouraging a problem-based approach to diagnosis
  1. Jill Maddison

Abstract

Jill Maddison is director of professional development and head of the CPD unit at the Royal Veterinary College (RVC). She also chairs the WSAVA's continuing education committee (see box on pii) and is encouraging clinicians in other parts of the world to take a problem-based approach to cases

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In the past few years, I have been privileged to be involved in continuing education (CE) in South East Asia (Myanmar, the Philippines, Sri Lanka, India and Thailand) to familiarise veterinarians with the problem-orientated approach to clinical reasoning (POA). POA (also known as logical clinical problem solving or deductive clinical reasoning) is a structured form of clinical reasoning that can enhance a veterinarian's ability to solve clinical cases and gain the best value from their most important clinical resource – their brain! I was taught this way by my mentors in small animal medicine, Brian Farrow and David Watson, several decades ago during my undergraduate education at the University of Sydney. In the years since then I have developed and refined the approach, taking it from a purely academic teaching environment and enhancing its value and relevance to practising veterinarians.

POA forms part of the current curriculum at the RVC and we run online (and occasionally face-to-face) CE courses for veterinarians in the UK and beyond. The approach also forms the basis of a distance education programme I have been running for the Centre for Veterinary Education at the University of Sydney for the past 20 or so years.

At the RVC we also encourage our certificate of advanced veterinary practice candidates to develop their skills in applying a problem-based approach to their medical case reports in the B module, and this is often cited by candidates as one of the most rewarding aspects of their learning journey through this module.

Participants in a WSAVA CE course on taking a problem-oriented approach to neurological examination, held in Sri Lanka in 2013

Why does POA need to be taught explicitly?

As we progress from student to experienced clinician, we learn knowledge and skills in a conscious and structured way. Veterinary undergraduate education in most universities is based on systems teaching, species teaching or a mixture. These are excellent approaches to help develop a thorough knowledge base and understanding of disease processes and treatments. However, when an animal becomes unwell, the clinical signs it exhibits can be an indication of a number of disorders of a number of different body systems. The differential diagnoses list can seem endless, so to fully access the knowledge we have accumulated, we need a robust method of clinical reasoning to enable us to consolidate and relate our knowledge to a clinical case and progress to a rational assessment of the likely differential diagnoses.

Clinicians around the world use several methods to solve clinical cases. Pattern recognition (or development of an ‘illness script’) is the most common – ‘what diseases do I know that would cause the clinical signs I am seeing in this patient?’. This does not need to be explicitly taught – we do it naturally – and works best:

▪ For common disorders with typical presentations.

▪ If a disorder has a unique pattern of clinical signs.

▪ When all clinical signs have been recognised and considered and the differential list is not just based on one cardinal clinical sign and the signalment of the patient presented.

▪ If there are only a few diagnostic possibilities which are easily remembered or can easily be ruled in or out by routine tests.

▪ If the vet has benefited from a good education in companion animal practice at university, has extensive experience, is well read and up to date, reviews all of the diagnoses made regularly and critically, and has an excellent memory.

Pattern recognition also has the advantage of being quick and cost effective – so long as the diagnosis is correct. We can impress the client because we have acted decisively and confidently – again, so long as the diagnosis is correct. However, pattern recognition can be flawed and unsatisfactory:

▪ When the clinician's knowledge base is poor.

▪ If they are inexperienced and therefore have seen very few patterns (eg, new graduates, veterinarians changing their area of practice).

▪ If they only consider or recognise a small number of factors and ignore others.

▪ If they are unaware that pattern recognition is mainly driven by unconscious processes, which might need to be reflected upon if they fail.

Even for an experienced clinician, pattern recognition can be flawed for uncommon diseases or common diseases presenting atypically, when the patient is exhibiting multiple clinical signs that are not immediately recognisable as a specific disease, or if the pattern of clinical signs is suggestive of certain disorders but not specific for them.

Role of the WSAVA's CE committee

The WSAVA's continuing education (CE) committee is a very active and busy group, and the job of chairing it, which I have done for just over two years, has considerably increased the e-mail traffic to my inbox!

The purpose of the WSAVA's CE scheme is to encourage learning and professional development for companion animal practitioners, and to assist member associations develop self-sufficiency in CE programmes. By funding CE meetings in emerging companion animal markets the WSAVA aims to ‘prime the pump’ of CE programmes for the recipient country. The support varies from full financial support for countries that are currently not in a position to support CE meetings featuring international speakers, to partial financial support for countries whose CE programmes are established but yet not yet fully self-sufficient. The goal is to provide practical, relevant and inspiring CE that assists general practitioners solve clinical problems regardless of the size and sophistication of their practice. We oversee over 30 meetings every year in Asia, Eastern Europe, South America and Africa.

My role as WSAVA CE chair has provided me with a wealth of opportunities to learn about and contribute to CE around the world and to meet wonderful and inspiring colleagues who are striving to improve companion animal practice in their countries. I am a strong believer that CE should be meaningful for the delegates. Whatever the country or level of practice, it should provide practical benefits that the veterinarian can bring to her/his practice immediately, as well as inspire them to aim for a higher level of practice. There are different cultural expectations which have to be respected but, wherever possible, our lecturers deliver education that is directly relevant to the audience in their day-to-day practice, not just ‘what a specialist can do’.

The problem-based approach we teach at the RVC and through the WSAVA CE courses focuses around key steps, including defining and refining the problem, system, location and lesion. It does not replace pattern recognition, but complements it by providing an alternative form of clinical reasoning when required that has a sound pathophysiological basis, allowing the clinician to:

▪ Make maximum use of information gained from the history and clinical examination.

▪ Plan more focused and cost-effective diagnostic procedures including treatment trials.

▪ Communicate more clearly with the client.

Some believe that CE only involves experts imparting factual complex knowledge, preferably to a large audience. But, unless the recipients are able to truly understand and incorporate that knowledge into a rational method of clinical reasoning relevant to their own patients, the acquired knowledge may be lost or wasted. Teaching a structured problem-based approach seeks not just to provide a robust form of clinical reasoning that will never go out of date, but also to enhance understanding of the principles of clinical medicine and pathophysiology. It develops skills in problem solving and reflection that are essential for successful case assessment and management. And using this approach as the cornerstone of a CE course provides a scaffold to build courses that also enhance medical knowledge, clinical pathology interpretation and therapeutics as a logical progression from the initial clinical assessment of common presenting signs.

We are confident that the approach works and enhances clinical practice; as one of our course participants said: ‘What I liked most about the course was being taught a thoroughly practical approach to cases with emphasis on asking the right questions rather than reliance on memorising facts.’

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