Problems of research into medical problem solving: some remarks on theory and method

Investigators of medical problem solving, and of problem solving in general, appear to use the term problem solving to denote different concepts.
Medical problem solving sometimes refers to the doctor solving the patient's problem, whereas others use it to refer to the doctor solving his own diagnostic problem. Second, 'problem' is used by some in a subjective sense (something is only called a problem if the subject has difficulties with it), and by others in an objective sense (problem being nearly synonymous with task). Finally, there is the definitional question of whether knowledge and problem solving are regarded as independent or as intimately related.
What one means by problem solving, with one's research objectives (research may be aimed at medical education, medical practice or cognitive theory), constitute the major determinants of the choice of research design.
It is advocated that investigators, before selecting a research design, should clarify their own definitions and research objectives, and before adopting other investigators' definitions and research designs, should consider carefully their research objectives.     

Assessing a team's problem solving ability: evaluation of the Team Problem Solving Assessment Tool (TPSAT)

By employing group consensus development methods, this research identified the variables that experts in team problem solving believe are the most important to a team's problem solving ability. These variables were used to develop a quantitative decision aid to allow health care managers and practitioners to estimate how effective a given problem solving group or team will be at solving a problem. This decision aid can be used to assess a team's problem solving potential before the time and effort is expended to convene the team. This report presents the design and initial evaluations of this decision aid.     

Assessment of problem-solving ability

It is recognized that no problem solving can take place without a background knowledge. As the highest marks in PMPs are now being consistently achieved by those candidates who arrive at the correct diagnosis without accumulating excessive information and at the same time avoiding irrelevant or incorrect data the PMP may be measuring efficiency in problem solving ability. This would appear to be substantiated by the fact that reasonable correlations are obtained between each candidate's remarks in problems of widely differing system disease patterns.
The mark allocation is such that the problem solving ability relates to the field of general practice and no detailed specialist knowledge of any particular disease pattern is being measured. In measuring problem solving ability it is advisable to allocate a maximum positive mark for each section, this mark being the total of that awarded for information considered necessary to solve the particular problem. Any negative marks scored must be taken from the maximum positive mark allowed and not from the total positive score obtained, which may be considerably more than the former. In this way the efficient performer is appropriately rewarded whilst the more devious data gatherer is appropriately penalized.     

The nonexistent problem.

Effective assessment of problems is essential for the infection control practitioner to function optimally. Today's infection control practitioner not only learns problem solving on the job but is trained in both individual and participatory problem solving techniques. Correct response to a potential problem requires careful investigation and identification of causal relationships. Most literature, however, is directed at solving problems that exist. The phenomenon of nonexistent problems exists when the presented problem is not real but exists only in the perception of the presenter. In some cases, the nonexistent problem may partially represent a real problem, but the relationship may not be readily apparent. Time spent by infection control practitioners responding to nonexistent problems is significant. Without the ability to distinguish between nonexistent and existent problems, needless and ineffective actions may be taken. It is essential that the infection control practitioner understand both the dynamics resulting from the presentation of nonexistent problems and their characteristics.     

Problem solving and prior play experience: an observational study

One of the criticisms of previous studies of the effect of prior play on children's problem solving abilities, is that children have been instructed to play for relatively short periods. The present study looked at the quality of spontaneous play with sticks, nuts and bolts in 18 children (CA 44 months) over a four week period and the effect of this on a subsequent problem whose solution required two sticks to be bolted together. The most striking result was that children who had discovered the elongation principle during play were significantly better problem solvers than those who had not. Neither play frequency nor fantasy play was significantly related to problem solving.     

Counseling and peer review are key disciplinary procedures

The best approach to the problem of an employee with a disciplinary problem is not always termination. When performance slips at this hospital, supervisors work closely with the employee to bring about improvement. The secret to the system is early recognition of problems, followed by intense problem solving.     

Occupational Therapy: Is it the Creative Problem Solving Process which the Profession claims?

The process of creative problem solving, the acclaimed basis of occupational therapy practice, is examined. It is suggested that the fostering of creative problem solving or creative analysis skill requires a particular approach to progressional education — that is, adherence to a systematic problem solving framework together with encouragement of, and provision of opportunity for, individual and group experimentation with creativity enhancing techniques. The extent to which occupational therapy education programmes embrace such an approach is questioned. So too, therefore, is the claim that occupational therapists, by virtue of their professional preparation, are creative problem solvers.     

Importance-performance analysis as a guide for hospitals in improving their provision of services.

As a result of the 1990 National Health Services Act, hospitals now compete with one another to win service contracts. A high level of service quality represents an important ingredient of a successful competitive strategy, yet, in general, hospitals have little external information on which to base quality decisions. Specifically, in their efforts to win contracts from fundholding general practitioners, hospitals require information on that which these purchasers deem important with respect to quality, and on how these purchasers assess the quality of their current service performance. The problem is complicated by the fact that hospital service quality, in itself, is multi-dimensional. In other areas of economic activity, the information problem has been resolved by importance-performance analysis and this paper reports the findings of such an analysis conducted for hosptials in the Trent region. The importance and performance service quality ratings of fundholders were obtained from a questionnaire survey and used in a particular variant of importance-performance analysis, which possesses certain advantages over more conventional approaches. In addition to providing empirical data on the determinants of service quality, as perceived by the purchasers of hospital services, this paper demonstrates how such information can be successfully employed in a quality enhancement strategy.     

The effects of a preschool problem solving program on interpersonal behavior

The purpose of this study was to evaluate the effectiveness of an interpersonal problem solving skills program for preschool children. Twenty-three children were given the interpersonal problem solving program over a ten week period, while 23 children were involved in a contact control group. A behavioral assessment of interpersonal problem solving ability and a subjective assessment of perception of self were obtained prior to training and immediately following training. Results indicated that from pretest to posttest the problem solving trained children, relative to the contact control group children, demonstrated a significant increase in interpersonal problem solving ability and positive perceptions of self. Discussion focused on the implications of the durability of the skills learned, generalizability of skill acquisition, and needed future research.     

'Not wilting flowers again!' problem finding and problem solving in movement and performance

This paper outlines a process-oriented approach to teaching movement and performance that integrates the theoretical aspects of movement with a practical teaching method. The approach applies a play and problem solving model, which focuses on the creative process rather than creation of a product, to development of a method of teaching that encourages problem finding and problem solving. The teacher's role in this process is that of facilitator. Participants are encouraged to take responsibility for identifying a problem and solving that problem, and in the process, develop improved communication skills, interpersonal skills, and self confidence. Positive effects, as well as potentially limiting factors are discussed in terms of teaching the process to early childhood trainee teachers.     

Life versus disease in difficult diabetes care: conflicting perspectives disempower patients and professionals in problem solving

Conflicts in problem solving are known from diabetes research on patients with good glycemic control but have rarely been studied in the care of patients with poor glycemic control. Equally, the different perspectives of health care providers and patients have not been a focus in previous studies. The authors studied the interactions between health care providers and 11 diabetes patients with poor glycemic control in a grounded theory study at a Danish university hospital. Keeping Life and Disease Apart was identified as a core category. It involved a pattern of conflicts both between and within patients and health professionals, which disempowered them in problem solving. Three approaches to problem solving were identified: A compliance-expecting approach kept the pattern unchanged, a failure-expecting approach deadlocked the pattern, and a mutuality-expecting approach appeared to neutralize the conflict.     

Use of scheme-based problem solving: an evaluation of the implementation and utilization of schemes in a clinical presentation curriculum

CONTEXT: The University of Calgary has implemented a new curriculum which is organized according to 120 ways in which patients may present to a physician. Students are taught scheme-based problem solving rather than the more typical hypothetico-deductive or search and scan approach to problem resolution. OBJECTIVE: This study sought to determine the extent to which faculty and students were implementing and utilizing scheme-based problem solving. METHOD: All classes taught within the new clinical presentation curriculum were surveyed at the year end. Participants included four classes of first-year students and three classes of second-year students. Using a 5-point scale, students responded to survey items regarding scheme implementation and utilization. RESULTS: Data were analysed using MANOVA (multivariate analysis of variance) and revealed significant differences among classes in both first- and second-year students. Increments in scheme implementation and utilization by instructors and students were observed, although instructors' utilization of schemes lagged behind that of students. A levelling effect to the benefits of schemes for problem solving was also evident. First-year students reported schemes to be very useful for learning and organizing new information. CONCLUSION: Although it has taken time to implement curriculum change, the student response to schemes has been favourable. Faculty development and further generation of pictorial/spatial representations for all schemes, to ensure that all clinical presentations provide pathways that students can use for both learning and problem solving are recommended. Whether students who utilize schemes are more successful problem solvers is not yet known but will be the subject of study as soon as scheme delivery is predominant.     

Hospitals and union elections

This study examines union certification elections in hospitals from October 1994 to September 1997. Results indicate that union win rates were significantly higher in single-union elections and larger bargaining units. On the other hand, union win rates were significantly lower in church-related hospitals and hospitals that belonged to a health care system or had higher payroll costs. Unions also appeared to win elections at a higher rate in this period than in the past.     

Early Workplace Communication and Problem Solving to Prevent Back Disability: Results of a Randomized Controlled Trial Among High-Risk Workers and Their Supervisors

Purpose There is a clear need for interventions that successfully prevent the development of disability due to back pain. We hypothesized that an intervention aimed at both the worker and the workplace could be effective. Hence, we tested the effects of a new early intervention, based on the misdirected problem solving model, aimed at both workers at risk of long-term impairments and their workplace. Methods Supervisors of volunteers with back pain, no red flags, and a high score on a screen (Örebro Musculoskeletal Screening Questionnaire) were randomized to either an evidence based treatment as usual (TAU) or to a worker and workplace package (WWP). The WWP intervention included communication and problem solving skills for the patient and their immediate supervisor. The key outcome variables of work absence due to pain, health-care utilization, perceived health, and pain intensity were collected before, after and at a 6 month follow up. Results The WWP showed significantly larger improvements relative to the TAU for work absence due to pain, perceived health, and health-care utilization. Both groups improved on pain ratings but there was no significant difference between the groups. The WWP not only had significantly fewer participants utilizing health care and work absence due to pain, but the number of health care visits and days absent were also significantly lower than the TAU. Conclusions The WWP with problem solving and communication skills resulted in fewer days off work, fewer health care visits and better perceived health. This supports the misdirected problem solving model and indicates that screening combined with an active intervention to enhance skills is quite successful and likely cost-effective. Future research should replicate and extend these findings with health-economic analyses.     

大学生问题解决能力增强机制的探讨

目的探讨大学生问题解决能力的增强机制,进一步为压力管理干预实践提供依据。方法对372名大学生进行问题解决评价量表、一般自我效能量表以及前摄性应对量表调查。结果采用AMOS进行路径分析,结果显示一般自我效能、前摄性应对、反省性应对和支持寻求对问题解决能力的3个因素(问题解决信心、趋近-回避风格、问题控制)具有不同的影响效应和机制。结论增强大学生问题解决能力,应当考虑到不同的作用机制,采用前摄性效能增强策略是提高问题解决能力的关键。     

Relationships between family background problems and social problem solving skills of young normal children

Relationships between family background problems and social problem solving (SPS) skills were studied in normal third grade children. Twelve urban and suburban classroom teachers provided information about the presence of six family background problems for 243 children. Three problem solving skills were assessed: 1) alternative solution thinking, means-end thinking, and 3) social role taking. Overall, children with, one or more family problems, compared to those with no problems, generated fewer effective solutions and were less able to carry out a stepwise plan or to take the point of view of another. Differential reltionships were found between specific family background problems and specific problem solving skill deficiencies. Implications of the findings for school-based preventive programming were considered.This study was done with grant support from the N.Y.S. Education Department and the NIMH Experimental and Special Training Branch MH 14547-02. The authors acknowledge that support with gratitude. Reprint requests to the 3rd author, Department of Psychology, University of Rochester, Rochester, N.Y. 14627. Viviane Perez is now at the Jerusalem Psychoeducational Clinic, Jerusalem, Israel. Ellis L. Gesten is presently at the University of South Florida, Tampa, Florida. Bruce Rapkin is now at the Department of Psychology, University of Illinois, Champaign, Illinois.     

建立解决农村医疗人才缺乏问题的长效机制

该文认为人才问题是制约农村卫生服务质量提高的瓶颈 ,抓好农村人才问题是贯彻胡锦涛同志十六届四中全会讲话精神 ,注重公平性的具体体现 ;指出解决农村医疗卫生人才问题必须靠政府组织、支持 ,必须建立长效机制 ;最后提出解决农村医疗卫生人才缺乏问题的四点设想。     

A problem-solving approach to effective insulin injection for patients at either end of the body mass index

People with diabetes require skills and knowledge to adhere to medication regimens and self-manage this complex disease. Effective self-management is contingent upon effective problem solving and decision making. Gaps existed regarding useful approaches to problem solving by individuals with very low and very high body mass index (BMI) who self-administer insulin injections. This article addresses those gaps by presenting findings from a patient survey, a symposium on the topic of problem solving, and recent interviews with diabetes educators to facilitate problem-solving approaches for people with diabetes with high and low BMI who inject insulin and/or other medications. In practice, problem solving involves problem identification, definition, and specification; goal and barrier identification are a prelude to generating a set of potential strategies for problem resolution and applying these strategies to implement a solution. Teaching techniques, such as site rotation and ensuring that people with diabetes use the appropriate equipment, increase confidence with medication adherence. Medication taking is more effective when people with diabetes are equipped with the knowledge, skills, and problem-solving behaviors to effectively self-manage their injections.     

How we measure problem-solving ability

A review of some of the more recent literature on problem solving is presented. An attempt is made to identify factors which may lead to discrediting the PMP (Patient Management Problem) as a measure of problem-solving ability. A definition of competence in problem solving is proposed and the question of scoring is discussed. A possible method for future research is suggested.     

Good practices in managing work-related indoor air problems: a psychosocial perspective

BACKGROUND: Indoor air problems at workplaces are often exceedingly complex. Technical questions are interrelated with the dynamics of the work community, and the cooperation and interaction skills of the parties involved in the problem solving process are also put to the test. The objective of our study was to analyze the process of managing and solving indoor air problems from a psychosocial perspective. METHODS: This collective case study was based on data from questionnaires, interviews and various documentary materials. Technical inspections of the buildings and indoor air measurements were also carried out. RESULTS: The following four factors best differentiated successful cases from impeded cases: extensive multiprofessional collaboration and participative action, systematic action and perseverance, investment in information and communication, and process thinking and learning. The study also proposed a theoretical model for the role of the psychosocial work environment in indoor air problems. CONCLUSIONS: The expertise related to social and human aspects of problem solving plays a significant role in solving indoor air problems. Failures to properly handle these aspects may lead to resources being wasted and result in a problematic situation becoming stagnant or worse.