[Methods for teaching problem-solving in medical schools]

The need to include in the medical curriculum instructional activities to promote the development of problem-solving abilities has been asserted at the national and international levels. In research on the mental process involved in the solution of problems in medicine, problem-solving has been defined as a hypothetical-deductive activity engaged in by experienced physicians, in which the early generation of hypotheses influences the subsequent gathering of information. This article comments briefly on research on the mental process by which medical problems are solved. It describes the methods that research has shown to be most applicable in instruction to develop problem-solving abilities, and presents some educational principles that justify their application. The "trail-following" approach is the method that has been most commonly used to study the physician's problem-solving behavior. The salient conclusions from this research are that in the problem-solving process the diagnostic hypothesis is generated very early on and with limited data; the number of hypotheses is small; the problem-solving approach is specific to the type of medical problem and case in hand; and the accumulation of medical knowledge and experience forms the basis of clinical competence. Four methods for teaching the solution of problems are described: case presentation, the rain of ideas, the nominal groups technique and decision-making consensus, the census and analysis of forces in the field, and the analysis of clinical decisions. These methods are carried out in small groups. The advantages of the small groups are that the students are active participants in the learning process, they receive formative evaluation of their performance in a setting conductive to learning, and are able to interact with their instructor if he makes proper use of the right questioning techniques. While no single problem-solving method can be useful to all students or in all the problems they encounter, teachers of medicine can improve their students' performance by adjusting these available methods to their particular needs and to those of their schools. The problem-solving methods described can help teachers shape the learning environment so as to develop in their students the most coherent, logical, concrete and complete set of skills possible. These methods can so be of value in improving the training of future doctors and the quality of their decisions to the benefit of their patients.