Reasoning on Rounds: Summary Statement or Problem Representation?

Dear Editor,

We read Penner et al.’s article, “Reasoning on rounds: a framework for teaching diagnostic reasoning in the inpatient setting,” with great interest. The authors describe several well-designed, actionable recommendations for fostering clinical reasoning-focused rounds. Their recommendations center around problem representation, a core clinical reasoning skill which all clinicians must master to diagnose patients accurately.¹ Making problem representation their educational intervention of choice is grounded in current clinical reasoning theory and congruent with previous recommendations for remediating struggling students.²

However, the terminology used in this article underscores emerging semantic issues in how we teach clinical reasoning.³ Problem representation is best described as the mental categorization model of a patient’s medical conditions that a clinician develops during the patient encounter.^1,4 Only after a clinician completes their initial evaluation do they express the contextualized patient problem(s) in a summary statement.¹ Cognitive skills like problem representation are inherently more challenging to teach than tactile skills like central line placement because we cannot directly observe them. Therefore, we often teach problem representation to trainees by having them write or speak their summary statements and then giving feedback.²

Recent educational parlance has called both written and spoken case summaries “problem representations,”^2,5 equating the mental and physical tasks. The authors suggest that rebranding one-liners as problem representations is necessary to distinguish the educational exercise of defining clinical problems from the casual recitation of relevant and irrelevant data one sometimes hears on rounds. Although we support an approach based on metacognition and deliberate practice, we suggest that rebranding-based efforts are incomplete for several reasons.

First, early studies on diagnostic expertise showed that data abstraction and semantic description are the keys to strong problem representation.⁶ A well-defined problem list (e.g., renaming “foot pain” as “acute monoarticular arthritis”) is therefore just as much a problem representation as is writing a sentence-long summary. Second, any exercise—whether called a problem representation, summary statement, or one-liner—can become educationally void if educators do not uphold high standards of performance among learners. Lastly, just as summary statements can take different forms (e.g., parsimonious for diagnosis, expansive for clinician-to-clinician communication), problem representations can and should change depending on the problem being solved (i.e., diagnosis vs. management).

The fact that different educators may call the same educational framework different names should prompt educators to standardize our language. Without standardized language, research to improve our pedagogy and recommendations based thereon will be mired in uncertainty.

Declarations

Conflict of Interest

The authors have no conflicts of interest to report.