Paper written in 2004 in Ospital ng Maynila Medical Center Department of Surgery.
Presented in 4th Asia-Pacific Conference on Problem-based Learning in Health Sciences in 2004.
See also:
http://omsurg-pblconf04.tripod.com
Posted: December 18, 2011
Structured Management of a Patient Process – An Algorithm to Facilitate Problem-based Learning in Medicine
Janix de Guzman, MD
Anthony Adrian C. Yu, MD, FPCS
Reynaldo O. Joson, MD, MHPEd, MS Surg
Department of Surgery, Ospital ng Maynila Medical Center, Philippines
Structured Management of a Patient Process
Abstract
Problem-based learning (PBL) in medicine is essentially learning in the clinical context of problem-solving and decision-making (PS-DM) in patient management. As practiced globally, PBL is oftentimes free-wheeling without a structured framework for PS-DM, usually resulting in inefficiency in time management and exhaustion on the part of the learners. This paper reports on the use of a structured management of a patient process (SMPP) as an algorithm to facilitate PBL in the Department of Surgery of Ospital ng Maynila Medical Center. The algorithm focuses on rapport, diagnosis, treatment and advice processes. Pattern recognition and prevalence are the processes used in deciding on clinical diagnosis. Degree of certainty and comparison of treatment plan are the processes used in deciding on indication for paraclinical diagnostic procedure. Consideration of the benefit, risk, cost, and availability factors is the process used in deciding selection of paraclinical diagnostic and treatment procedure. Principles and procedures in establishing rapport and giving advice are spelled out. The insecurities and gaps in knowledge discovered while utilizing the SMPP constitute the priority problem-based learning issues. In the feedback, students affirmed universal applicability of SMPP to all types of patients. It simulating actual patient management process, SMPP was considered relevant promoting easy recall. It being structured with clearly formulated principles, processes, and procedures, SMPP facilitated learning of PS-DM in patient management thereby promoting effective and efficient patient care and time-management. With this experience, the authors recommend the use of a structured management of a patient process to facilitate PBL in medicine.
Key words: Patient Management Process, Problem-based Learning
Introduction
Problem-based learning (PBL) in medicine as an educational approach is essentially learning medicine in the context of an actual practice of medicine (1-3). Actual practice of medicine consists primarily of problem-solving and decision-making (PS-DM) of a patient with a health problem and continuous learning in the light of gaps and insecurities uncovered in the process of solving the patient’s problem.
As practiced globally, PBL in medicine as an educational approach usually focuses on the steps of the traditional PBL format of problem trigger – learning issues – independent study – information reporting – knowledge reinforcement – learning outcome evaluation with the hope of achieving the intended objectives of active and self-directed learning (4-6). It is oftentimes free-wheeling even for the PS-DM process (7). From experience of the senior author (ROJ) in his use of PBL in medicine in several medical schools in the Philippines, the absence of a structured framework for PS-DM usually results in inefficiency in time management and exhaustion not only on the part of the learners but also on the facilitators.
This paper reports on the use of a structured management of a patient process (SMPP) as an algorithm to facilitate PBL in the Department of Surgery of Ospital ng Maynila Medical Center (OMMC Surgery).
The specific objectives of the paper were to: 1) trace the origin and rationale of OMMC Surgery SMPP; 2) describe the OMMC Surgery SMPP algorithm and its use in PBL ; 3) present results of a formative evaluation done in July, 2004; and 4) identify areas of improvement and refinement.
Methods
The records of the OMMC Surgery that pertained to the development and utilization of SMPP were reviewed to answer the four specific objectives of the paper.
Part of the formative evaluation was a questionnaire used primarily to assess whether the SMPP facilitated PBL among the surgical residents of OMMC Surgery and their reactions to it. Respondents consisted of the 15 surgical residents of the Department. A 40-item structured questionnaire was utilized. Topic areas included concept of PBL, concept of SMPP, utility of SMPP in PBL, and attitude towards SMPP. Attitudinal questions were formatted as 5-point Likert scales. The questionnaire also included space for free-form comments. Through the formative evaluation, areas of improvement and refinement were identified and planned.
Origin and Rationale of Development and Utilization of SMPP in OMMC Surgery
The SMPP was initiated in 2001 under a new leadership of the Department. Prior to 2001, there was no structured patient management process with each resident and consultant having his own philosophies and way of solving and deciding on a patient’s problem. The usual ill-consequences encountered with such lack of standardized patient management process consisted of confusion and tendency towards irrational, ineffective and inefficient patient care.
The 2001 vision-mission for a model in surgical education and the core values of excellence, quality, professionalism, compassion, and teamwork also served as the driving forces for the development and utilization of SMPP by OMMC Surgery.
The SMPP algorithm focused on rapport, diagnosis, treatment and advice processes (See Table 1). Pattern recognition and prevalence were the processes used in deciding on the clinical diagnosis. Degree of certainty and comparison of treatment plan of the primary and secondary diagnoses were the processes used in deciding on indication for paraclinical diagnostic procedure. Consideration of the benefit, risk, cost, and availability factors was the process used in deciding selection of paraclinical diagnostic and treatment procedure. Principles and procedures in establishing rapport and giving advice were spelled out.
The SMPP algorithm was used by all the surgical residents in managing all patients they encountered in the hospital, during case presentations and discussions, during oral examinations using simulated patient management, and in all questions posed by patients, faculty, and hospital administration on the bases for diagnosis, paraclinical procedures, and treatment done or proposed.
In relationship to the PBL of the surgical residents, the SMPP algorithm was used in the problem-solving of a patient’s health problem. The insecurities and gaps in knowledge discovered while utilizing the SMPP constituted the priority problem-based learning issues. The SMPP was also used as a guide in the gathering and processing of data and information during the independent study and in the formulation of health-process-evidence-based clinical practice guidelines of OMMC Surgery.
All surgical residents were aware of the
concept and methods of PBL and its utilization in OMMC Surgery since 2001.
structured management of a patient process (SMPP) being utilized in OMMC Surgery since 2001.
All agreed that SMPP
and PBL were essentially the same in terms of problem-solving and decision-making in the management of a patient.
was structured in the sense that it had clearly formulated principles, procedures, and processes.
was generic and had universal applicability to all types of patients.
promoted easy recall as it simulated actual patient management process.
facilitated PBL in terms of providing a template in the problem-solving and decision-making during the problem-trigger phase and during the independent study.
provided standardization that went for effectiveness and efficiency (including time management) not only in patient care but also during the PBL sessions.
All were satisfied with the SMPP and would like it to be continued with refinements.
More training for those residents who have not imbibed SMPP, especially, the newer ones.
Training of more consultants on SMPP.
More training on SMPP for the medical students rotating in the Department of Surgery so that they can work synchronously with the surgical residents.
During the problem-trigger phase of the PBL, the self-discovered gaps in knowledge or competency can be categorized into uncertainties or deficiencies in data and information and insecurities in problem-solving and decision-making. The first category is straightforward which can be easily identified in the problem-trigger phase and collected during the independent study period. The second category is, however, more difficult. Their discussion during the problem-trigger phase and research during the independent study period involve problem-solving and decision-making activities which can be taxing and time-consuming for both faculty and students if there is no guiding template.
The principles of evidence-based medicine (EBM) and published evidence-based clinical practice guidelines (EBCPG) can be used as guides and resources for the problem-solving and decision-making. However, the complexity of EBM (8-10) and inadequacy and incompleteness of EBCPG (11-12) especially in the local community, hinder its efficient use in the PBL method.
The SMPP algorithm as utilized in OMMC Surgery is a template that can be used initially during the problem-trigger phase or first session in doing the problem-solving and decision-making on clinical diagnosis, paraclinical diagnostic procedures and treatment. Using the SMPP at this stage can facilitate rational problem-solving and decision-making even in the light of inadequacy of data and information. During the independent study period, EBM, EBCPG and other in-depth researches can be utilized. Where EBCPGs are not available and impractical to adopt, the SMPP can be used.
As manifested by the 15 surgical residents who had utilized SMPP from one to three years, the structuring and concretization of all known patient management processes being done by practicing physicians into clear-cut guidelines with accompanying philosophies and principles facilitated easy and efficient learning on patient’s problem-solving and decision-making skills. Moreover, it facilitated actual patient care which is the ultimate objective of PBL. With such a positive experience, with its universal applicability, the authors recommend its use in PBL.
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Table 1. Framework of OMMC Surgery Structured Management of a Patient Process.