Problem Framing

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Problem Framing

• John Middleton
• John Hart
• 3rd October 2007

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Aims Objectives

• Be aware of patients frame
• Be aware of doctors frame
• How this fits in with open problem solving
• How this fits with GP curriculum
• How this can be applied to practice

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Framing

• What is a frame?
• Buzz groups

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What is in the Frame?

• Group 1
• What is in the patients Frame?
• Group 2
• What is in the doctors frame?

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Cases 1 2

• Case 1
• A ten month old boy with middle-class parents.
  Mildly indisposed 2 days. Today has rash
  widespread small pink macules.
• Case 2
• A 39 year old man, off work with stress for 7
  days. Given Zopiclone to help restore sleep
  pattern. Now getting worse, tablets not
  working, increasingly irritable. Yesterday
  slapped partner in face she has now gone back
  to her mother. In the last few days has noticed
  an odd feeling in his right upper lip and pains
  in his right arm.

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Ignoring the Frame

• What might cause the doctor to ignore the frame?
• Or not be aware of the frame

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Framing

• RADAR

processor
Doctor
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Suspend Judgement and Observe

• What do we observe?

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Understanding Patients Frame

• What do they want?
• Ideas, concerns, expectations ICE
• Why? reasoning ICER

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Doctors Frame

• Medical models
• Organisational issues
• Various pressures
• Own agenda ICER

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Solving

• Initial hypothesis (assumptions)
• Testing out quizzing / examination
• Working diagnosis
• Further tests
• Revisit hypothesis
• Revisit patients frame
• Final diagnosis and negotiated plan

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Re-visit Patient and Doctors Frames

• Case 3
• A 7 year old girl, brought by mother, with 4th
  day of sore throat and runny nose. Had
  antibiotics on several previous occasions for
  similar. Apyrexial with follicles on red tonsils.
• Case 4
• A 37 year old woman for a 2 monthly review of
  her SSRI antidepressant which she has been taking
  for 11 months. Stable and not suicidal, but gets
  worse of the dose is reduced (Citalopram 20mg).
  Several previous episodes of depression and her
  mother has had similar.

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Factors for Success

• understanding patients frame without jumping
  hastily to conclusions
• sufficient information for initial hypotheses
• testing without prejudice (without ignoring
  information)
• flexibility to revise hypotheses at any stage
• safety netting
• use of time (not just this consultation)

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Relevant Models

• Hypothetical-deductive or guess and test
  (Elstein et al. 1978)
• Radar scanner and tube (Middleton 2000)
• Medical (history-examination-investigation-diagnos
  is-management)
• Face model - Patients agenda, doctors agenda,
  reconciled by communication skills, resulting in
  negotiated plan of management (Middleton 1989)
• ICE (from Pendleton et al 1984)
• ICER (from Middleton 2000)
• Safety netting and Housekeeping personal
  issues (from Neighbour 1987)

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References

• Elstein AS, Shulman LS and Sprafka SI (1978)
  Medical Problem Solving an analysis of clinical
  reasoning. Harvard University Press, Cambridge,
  MA.
• Middleton JF (1989) The exceptional potential of
  the consultation revisited. J R Coll Gen Pract.
  39 383-6
• Middleton J (2000) The Team Guide to
  Communication. Radcliffe Medical Press, Oxon
• Neighbour R (1987) The Inner Consultation. MTP
  Press, Lancaster
• Pendleton D, Schofield T, Tate P and Havelock P
  (1984) The Consultation an approach to learning
  and teaching. Oxford Medical Press, Oxford