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Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

What’s The Problem?

Takeaway

Systematically formulating a clear statement of the patient’s problem can be incredibly helpful. This may improve your diagnostic reasoning and ability to formulate more effective therapeutic plans.

Clinical Reasoning | September 1, 2021 | 2 min read

By Ben Roberts, NP, Johns Hopkins Medicine

Charles Kettering, inventor, medical philanthropist, and head of research at General Motors said, “A problem well-stated is a problem half-solved.” I heard this quotation on an episode of the Core IM podcast during my early training as an adult-gerontology acute care NP. I was struggling to integrate exam techniques, labs, images, and differential diagnoses with the illnesses facing my patients. Kettering’s quotation resonated: I was attempting to problem-solve before I could problem-define. Defining this problem was half of the solution.

 

I brought the quotation to my mentor. Over the semester, he’d instilled in me the importance of developing crisp problem statements as the first step in a systematic approach to healing the whole patient. First, this would give me structure for developing comprehensive assessments and plans for my patients. In turn, through effective documentation, I could then lay the groundwork for an efficient hospital course across clinicians, maximizing their understanding of my reasoning and minimizing communication errors and needless interventions.

 

My mentor suggested an intuitive, high-yield format for creating my plans. It provided much needed structure and helped me be focused, organized, and thoughtful while communicating clearly with my colleagues.

 

Problem One:

1. Likely due to x given a, b, and c

2. DDx also includes y and z, but less likely due to d, e, and f

3. Plan: treatment, assessment of the treatment’s effectiveness, and further workup

 

This simple format revolutionized my ability to define a problem, organize my diagnostic reasoning, and ensure my treatment was appropriate and testable. After a few weeks of incorporating the format into my notes, I noticed a qualitative shift in my cognitive approach to patient encounters. What had once felt like playing whack-a-mole against innumerable poorly differentiated symptoms now had a slower tempo. I could more readily see a clear pathway to addressing why the moles reared their ugly little heads to begin with.

 

Assessing, diagnosing, and treating a patient can be done without first clearly defining a problem, but doing so is like reading in dim light. It takes greater effort and time to yield similar results at best. Treating symptoms alone, or aspects of multiple semi-defined problems, can temporize the patient’s suffering but can lead to unnecessary interventions and delayed definitive treatment. Stating problems well, like Kettering implies, illuminates the root cause. Or, at least, a method of discovering the root cause of our patients’ illnesses.

 

Having now completed my AG-ACNP training, I will venture into the role of a palliative care specialist. Doing so will challenge me to define an entirely new set of problems regarding seriously ill patients’ symptoms such as pain, dyspnea, and nausea. Though palliation doesn’t typically reverse underlying pathology, I’ll certainly continue to use my mentor’s format: crisply stating the problem, diagnosing the most likely and possible causes, and planning interventions and re-assessments to promote my patients’ quality of life.

 

NOTE: Admittedly, Kettering’s solutions to his well-stated problems generated significant new problems for the future of climate change: his automotive innovations, including electric-start ignition systems, lightweight engines, leaded gasoline, and cooling refrigerant, to name only a few, contributed to and arguably enabled the automobile and fuel consumption boom in the mid-20th century.

 

 

 

This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.