Guest Author: Eliana Bonifacino, MD MS, Academic Hospitalist, MWHC

Problem representation is the mental model or understanding of a patient’s clinical condition that forms in a clinician’s mind as they encounter a patient and is iteratively refined over the course of the encounter. It is expressed verbally, either in written or oral form, through a summary statement or a one-liner. Although only one part of a complex process, the development and articulation of a precise, concise, and accurate problem representation is a key skill in diagnostic reasoning and can provide educators with insight into a learner’s thinking that is otherwise difficult to observe.

By convention, teaching problem representation should first involve clearly delineating its foundational components, including:

1. Demographic characteristics of the patient, which include age, gender, and pertinent comorbidities or risk factors for disease

2. Temporal course of the presenting illness

3. Description of the salient components of the clinical syndrome

For learners to improve their problem representations, feedback is essential. Educators can consider committing to asking learners to present a summary statement during rounds or in case presentations (e.g., morning report, problem-based learning sessions), role-modeling their own summary statements when discussing a case, giving timely feedback on the summary statements, and engaging learners in deliberate practice.

Feedback on a learner’s problem representation should focus on qualities that are associated with improved diagnostic accuracy and expertise, including:

1. Following the 3-part structure described above

2. Improving how key clinical findings are selected and prioritized

3. Synthesis of the data into meaningful groups (i.e., fever, leukocytosis, tachycardia = SIRS)

4. Attention to the accurate portrayal of the case

5. Inclusion of information that helps promote differential diagnosis formation

6. Exclusion of extraneous information

To learn more, please review the following resources:

Problem Representation. Exercises in Clinical Reasoning. Accessed May 15, 2026. 

Trowbridge RL, Rencic JJ, Durning SJ, editors. Teaching Clinical Reasoning. Philadelphia, PA: American College of Physicians, 2015. (book)

Connor, Denise & Dhaliwal, Gurpreet. (2015). When less is more for the struggling clinical reasoner. Diagnosis. 2. 10.1515/dx-2015-0014.

McQuade CN, Simonson MG, Lister J, et al. Characteristics differentiating problem representation synthesis between novices and experts. J Hosp Med. 2024; 19:468-474

Bonifacino E, Olson A, McQuade CN. Ch 10: Teaching clinical reasoning. In: Aronowitz PB, Keenan C, editors. Teaching and Coaching in the Hospital. (book) Philadelphia, Pennsylvania: American College of Physicians; 2025.