Remind Me Why I'm Going To School Again: Problem Lists

As the year has gone on, I've become progressively more disillusioned with school. It seems like a lot of what we do is memorize and regurgitate copious volumes of information. And the worst part is, I don't even remember a good portion of it past the exam.

I'm tired of memorizing. Besides, you can look just about anything up on the internet these days, or if you are more old-fashioned, in a book.

I've had two brilliant professors remind me this past week of why I'm here and what I'm ultimately supposed to be learning.

The first introduced my class to POMS, the Problem-Oriented Medical Scheme. As part of this, we learned a mnemonic for coming up with differential diagnoses, DAMNIT-V. It stands for:
Degenerative (chronic, progressive)
Anomalous (i.e. congenital abnormality)
Metabolic (systemic metabolic derangement)
Neoplasia
Infectious, Inflammation
Trauma, Toxin
Vascular (compromise blood flow to an organ)

I'm thrilled to have been given a more systematic way to approach cases and have started trying to come up with differential diagnoses using this scheme every time I hear/see/read about a case.

He also introduced us to the concept of a problem list, which comes before the differential diagnosis. A problem list is made from the initial abnormality list and has to account for every single abnormality in the smallest number of possible listed problems. It is also critically important that the problems do not include any assumptions and are only "defined to the highest level of understanding," not beyond.

Then on Friday, in our Function/Dysfunction Rounds, the professor (a different one) started by emphasizing the importance of a problem list to us again. He said that one of the most important skills we can develop as students is the ability to generate a good (i.e. concise yet complete) problem list, because from that one can then quickly come up with a list of differential diagnoses that does not miss anything.

And as it turns out, not missing anything is the name of the game. And my Achilles heel. I want to jump straight to the most likely scenario/differential diagnosis based on my clinical experience. And that is the biggest pitfall I have to learn to avoid. Tunnel vision is not just my problem, it plagues all veterinarians at various times and judging from my professors' stories, can lead to some truly horrific mistakes.

The professor lecturing on Friday said that something like 80% of cases could be diagnosed by someone who compiled a list of signs and used the internet. It's the other 20% that are tricky. But if you always go straight to the most likely diagnosis without making a list of differential diagnoses and ruling in/out/down each one then you will miss that 20%.

I guess it's a good enough reason to keep memorizing in the meantime.

But what I'm really interested in is the analytical thinking. One year and at the very end I finally get to the problem list. The tantalizing part. Now the question is how to get good at generating one. Of course, part of that is oodles more memorization so that I can actually come up with differentials that I don't even know now (yay for my bacteriology, virology, parasitology class next year).

At least I know that some analytical, critical thinking lies ahead, thank goodness.