Ryan, D., Kocks, J.W.H., Williams, S. et al. npj Prim. Care Respir. Med. 35, 14 (2025). https://doi.org/10.1038/s41533-024-00410-w
Abstract
The asthma diagnosis jigsaw puzzle is a clinical practice and teaching concept conceived in clinical practice and refined through an expert multidisciplinary consensus process by academics and clinicians with an interest in primary respiratory care. The concept incorporates guidance to facilitate the effective diagnosis of adults or children with asthma in primary care where misdiagnosis is common. The jigsaw puzzle metaphor teaches a problem-solving approach to diagnosis, introducing the concept of diagnosis over time and in no particular sequence. Puzzle pieces can be collected from the domains of presentation, history, symptoms and physical examination, as well as objective tests. The clinician’s challenge is to complete the diagnostic jigsaw puzzle testing the likelihood of a picture which can be recognised as asthma. This approach aligns with symptom-based pattern-recognition approaches taught to primary care clinicians which gets easier and more reliable with experience. Relational continuity, or informational continuity through the patient record, is integral to the process of puzzle completion. Where non-fitting puzzle pieces are encountered, alternative or additional diagnoses should be considered and/or referral to secondary care pursued. As a metaphor, ‘puzzle completion’ may be used within clinical communication encounters, addressing the importance of partnership working (‘completing the puzzle together’), uncertainty (deciding ‘which pieces fit’) and changes in symptoms over time (enabling the ‘puzzle picture to become clearer’). Adaptation of this teaching concept has started through translation of educational resources, including puzzle pieces. Supporting case vignettes developed locally will contextualise the jigsaw puzzle teaching concept. The Asthma Diagnosis Jigsaw Puzzle teaching concept has been piloted in North Macedonia and is also developed for educational workshops by primary care health educators in Malaysia, India and Uganda.