Perspective: Whither the Problem List? Organ-Based Documentation and Deficient Synthesis by Medical Trainees

Abstract

The author argues that the well-formulated problem list is essential for both organizing and evaluating diagnostic thinking. He considers evidence of deficiencies in problem lists in the medical record. He observes a trend among medical trainees toward organizing notes in the medical record according to lists of organ systems or medical subspecialties and hypothesizes that system-based documentation may undermine the art of problem formulation and diagnostic synthesis. Citing research linking more sophisticated problem representation with diagnostic success, he suggests that documentation style and clinical reasoning are closely connected and that organ-based documentation may predispose trainees to several varieties of cognitive diagnostic error and deficient synthesis. These include framing error, premature or absent closure, failure to integrate related findings, and failure to recognize the level of diagnostic resolution attained for a given problem. He acknowledges the pitfalls of higher-order diagnostic resolution, including the application of labels unsupported by firm evidence, while maintaining that diagnostic resolution as far as evidence permits is essential to both rational care of patients and rigorous education of learners. He proposes further research, including comparison of diagnostic efficiency between organ- and problem-oriented thinkers. He hypothesizes that the subspecialty-based structure of academic medical services helps perpetuate organ-system-based thinking, and calls on clinical educators to renew their emphasis on the formulation and documentation of complete and precise problem lists and progressively refined diagnoses by trainees.

Accelerating the Benefits of the Problem Oriented Medical Record

“…Strict adherence to Weed's recommendations involves creating formatted problem-oriented progress notes. The use of such notes likely helps to improve clinical thinking, especially among trainees [12,13]. In theory, charting by creating problem-oriented progress notes on a computer allows others to view an organized document sorted by problem.…”

Essential Considerations for Equine Oral Examination, Diagnosis, and Treatment

“…3 Equine dentistry no longer needs to be seen as hard physical work with considerable risk to all involved. To be an effective equine dental clinician requires considerable investment in knowledge beyond the basic veterinary degree.…”

“…3 An accurate diagnosis will most satisfactorily serve the interests of the horse, client, and clinician. In formulating an accurate diagnosis, it is important to consider the animal in its entirety and as an individual, not one that necessarily has to conform to the mean.…”

“…Precise documentation of a working diagnosis with assumptions noted should allow for easier critical review and provide guidance for further case management decisions. 3 An accurate diagnosis will most satisfactorily serve the interests of the horse, client, and clinician.…”

Medical Students’ Opinion of a Web-based Module to Teach Clinical Reasoning and Knowledge

“…For the SQA, having the participants make a dynamic problem list is an important needed addition. 21 The term 'dynamic' denotes a problem list that is increased as new clinical data is presented from physical examination, laboratory and imaging data, etc. Also ancillary data including ECG, and radiography should be included in revised editions.…”