Theory and technique of problem-oriented therapy

Problem-oriented therapy (POT) features the following essentials: problem orientation, eclecticism, patient orientation and brevity. These ingredients, above all the eclecticism, are detailed: diverse psychotherapeutic interventions are administered to foster awareness, modification of thought patterns, modification of behavior, emotionality, awareness of the body, ability to relax, and support. The required abilities of the therapist are mainly flexibility and transparency of his therapeutic actions. The definition of the problem which is negotiated together with the patient is decisive for the selection of the intervention strategy. An example illustrates the use of POT especially as in contrast to school-consistent traditional therapies.     

Subjective illness concepts and problem-oriented therapy

Subjective illness concepts mean the comprehensive psychological explanations about causes and functions of actual problems by the patient. These concepts are related to basic needs and they historically arise from interactions with the social environment. In respect to the actual situation they are constructed in a new way. They aim at reorganizing the needs of the sick individual as well as monitoring his experience of being ill. Often they do not accomplish this aim because they appear to be deficient for many reasons. In the therapeutic situation the patient is confronted with the scientific theories of his therapist. Both concepts represent different perspectives of the same problem. However, both have to be discussed in a cooperative manner and ultimately result in a complementary view which we denote as 'problem definition'.     

The problem-oriented approach to sports injury evaluations

The problem-oriented approach to sports injury evaluations is used successfully throughout the United States by various health care providers, and can be used by certified athletic trainers to enhance the evaluation and management of sports injuries. The problem-oriented medical record is used successfully to provide effective communications and as a learning tool in health-related education. In this paper, I present a problem-oriented system for evaluating and keeping medical records on sports injuries. The process of collecting data through interviews and organizing that information is the focus.     

Psychosomatic parameters and the problem-oriented approach to biopsychosocial management

While rigid systemization in the method of psychosocial management of patients in the general hospital is not recommended, guidelines to such management are of value to facilitate collaboration between members of the medical-surgical teams and liaison psychiatrists. The method utilizes psychosomatic parameters: biological, social, and psychological, in the framework of the problem-oriented approach. When used by the medical-surgical specialists, the method is conducive to facilitating diagnosis and decision-making for either the direct management by the physicians or selection of cases which may require more specialized intervention by liaison psychiatrists. The method also has considerable value for didactic and research purposes.     

The problem-oriented system and record keeping in the behavioral therapies.

The Problem-Oriented System (POS) provides systematic guidelines for health care record keeping. Behavioral therapy records share, with health care records in general a quality of inadequacy for contemporary needs. Likewise, behavior therapy training shares with other health care training inadequate attention to record-keeping. This conclusion arises from a search of recent journals and books concerned with behavior therapy issues. This article reviews the POS and proposes that is guidelines and advantages are suited for incorporation into behavioral therapy training. The expected result of such training should be records more amenable to audit or review for such purposes as third party payment, supervision, and peer review. Research is needed to help select the record-keeping training methods that would best meet these contemporary needs for increased quality in the documentation of health care provision.     

Effusion in the cat: classification of 396 fluids according to a problem-oriented scheme

An effusion is an abnormal accumulation of fluid within a body cavity (abdominal, thoracic, pericardial) and it is a common sign of several disorders in cats. Examination and classification of effusions can help to establish the cause of disease and to provide useful information for diagnosis and prognosis. The aim of this study was to classify feline effusions according to a problem-oriented approach in order to reduce the diagnostic differential. Three hundred and ninety-six thoracic and abdominal feline effusions were classified using both cytological criteria and refractometrical estimates of total protein concentration. This study revealed the high prevalence of lymphorrhagic effusions (23.2 %) and the rarity of bile peritonitis (0.3 %), mesothelial hyperplasia (0.5 %), and eosinophilic exudates (0.8 %) in the cat. Our problem-oriented classification scheme appears to be clinically useful, providing a reduced diagnostic differential, and drives the clinician to perform additional diagnostic tests.     

From a conceptual problem-oriented electronic patient record model to running systems: a nationwide assessment

BACKGROUND: The development of problem-oriented conceptual models for electronic patient record (EPR) systems can improve data communication between health professionals. But little has been done so far to investigate to what extent it is possible to implement such models in operational EPR systems. OBJECTIVE: In this paper, we measure the conformance between a conceptual model and the various ways it is implemented within general practitioners' (GPs') electronic patient records. METHODS: We started from a simple problem-oriented conceptual model and we defined an original discriminating method to assess its implementation. This method is scenario-based (dummy patient), functional, and relative (comparison between software systems). Each implementation is assessed by two evaluators and the final result is a "success/failure" score. The assessment was performed within the scope of the official Belgian accreditation procedure for GPs' electronic patient records, which is voluntary, publicly funded, and based on a dynamic quality improvement paradigm. Almost all Belgian GPs' software systems (17) were assessed. The robustness of our results was assessed through a sensitivity analysis. RESULTS: We found that 65% (11/17) of the software systems currently used succeeded in implementing the problem-oriented conceptual model with a high confidence level (error rate<10%). The results were widely accepted by the software developers. CONCLUSIONS: A problem-oriented conceptual model can be successfully implemented in many operational EPR systems. The quality of the implementation can be assessed. Our results could be used at the international level to improve semantic interoperability between patient information systems, for instance in relation to broader conceptual models such as the European CONTsys pre-norm.     

Evaluation of clinical relevance of problem-oriented teaching in undergraduate anatomy at the University of Pretoria

Problem oriented medical curricula claim to be based on the fact that the clinical sciences facilitate and encourage the understanding of basic sciences. The question was asked whether the correlation of gross anatomy in the Abdomen Block in the new Pretoria medical curriculum, with clinically relevant content (i.e. relevant physical examination, imaging anatomy, clinical procedures, clinical presentations and clinical case studies) facilitates the understanding of human anatomy and enhances the development of the clinical thinking fundamental to clinical practice. The clinical anatomy component of the Abdomen Block (11 weeks duration) in the third year was developed by using standardized patients, cadaver material, skeletons, X-rays, CT scans, MRIs and multimedia programs. Student perceptions were assessed by a Likert scale questionnaire. Most students thought that integrating the physical examination enhanced their understanding of the relevant anatomy (mean 3.55). A substantial number of students thought the clinical anatomy in the block laid a good foundation for imaging anatomy of the abdomen (mean 3.41). The majority of students thought the clinical anatomy laid a good basis for the understanding of surgical procedures relevant to the abdomen (mean 3.63). Students were mostly confident that clinical anatomy enhanced their understanding of clinical presentations (mean 3.68). Although slightly fewer, the majority reckoned that the clinical case studies gave them a better understanding of the relevant anatomy (mean 3.30). It seems evident that the integration of clinically relevant content facilitates and encourages the understanding of anatomy and thus aids in the development of clinical thinking.     

The application of a computerized problem-oriented medical record system and its impact on patient care.

The present computer system is the first of its kind based on problem-oriented medical record (POMR) design developed and operated in a hospital in Hong Kong. It went live in May 1996 with two workstations installed in the medical record office (MRO). Doctors have no direct access to it. They dictate medical notes on tape using either structured or free dictation format, and the tape is brought to the MRO for processing. The principal aim of this study is to study the impact of the computer system on patient care. Retrospective review of medical records and in-depth interviews were conducted to study the quality of medical records and doctor's opinions. A total of 400 manual and 398 computerized patient records were randomly selected for review. The completeness of the manual notes and computerized notes using free dictation format were about the same. The computerized records using structured dictation format may be more complete than those using free dictation format. The in-depth interview shows that most doctors preferred structured medical records but some disagreed with too detailed a level of structuring. They were not familiar with POMR, and some even thought that breaking down the record by problem was not possible. All felt that the present system would not directly affect patient care, but some said that it would facilitate research. In conclusion, since the utility of the information mainly depends on the doctors' efforts, commitment to the agreed structure and subsequent routine audit of computerized medical records are essential to make sure that diagnoses are accurately coded and information is correctly structured.     

Metastatic tumors in the ovary: a problem-oriented approach and review of the recent literature.

Metastatic tumors account for a significant proportion of the ovarian tumors that cause major problems in diagnosis for the surgical pathologist. This subject is reviewed with a consideration of the various patterns and cell types encountered in these tumors. The first two categories considered, tumors with endometrioid-like and mucinous appearances, include a variety of neoplasms originating in the gastrointestinal tract and its appendages that simulate closely primary ovarian endometrioid and mucinous tumors. Other important categories reviewed include several varieties of metastatic tumors with follicle-like spaces, small cell malignant tumors, and tumors characterized by cells with abundant eosinophilic cytoplasm. The review also includes a discussion of the general considerations that are helpful in the distinction of primary and metastatic ovarian tumors. Important recent reports in the literature concerning metastatic tumors are additionally summarized.     

Comparison of frontal teaching versus problem-oriented learning at the school of healthcare and nursing: nursing neurological patients

In view of conflicting opinions about the advantages and disadvantages of frontal teaching (FT) and problem-oriented learning (POL), we carried out a pilot project in which both of these methods were used for teaching one specific course namely, 'Nursing Neurological Patients'. The aim was to determine whether there are short- or long-term differences in student performance at examinations.The results showed that over a short term (4 weeks after completion of the course), students remembered very well what they had learnt in their frontal teaching course, but lost some of this knowledge in the long term (7 months after completion of the course). In contrast, in the long term, students retained better what they had learnt under the method of POL.     

Clinical anatomy as the basis for clinical examination: development and evaluation of an Introduction to Clinical Examination in a problem-oriented medical curriculum

Clinical anatomy is usually defined as anatomy applied to patient care. The question is asked whether students of a new horizontally and vertically integrated medical curriculum recognize the subject as the basis for clinical examination. A clinical anatomy practicum was developed in the special activity, "Introduction to Clinical Medicine," held in the second year of the Pretoria medical curriculum. The practicum was conducted on a station basis to anatomically prepare the student for the inspection, palpation, percussion, and auscultation of the cardiovascular, respiratory, abdominal, and urogenital systems. A total of 23 stations consisting of eight cardiovascular, seven respiratory, and eight abdominal/urogenital stations were designed. Standardized patients, cadavers, skeletons, prosected specimens, x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), multimedia programs, and clinical case studies were used as resources. A Likert-type questionnaire was used for student evaluation of the practicum. Most students realized the importance of surface anatomy for a family physician. More than two-thirds thought the practicum improved their understanding of the anatomical basis for clinical examination. The minority of students were stimulated to do further reading on clinical examination. The students' response to their ability to integrate the clinical examination with the radiological anatomy was average. Most students were continuously aware of the appropriateness of the practicum for their future career. We conclude that medical students recognize the importance of anatomy as the basis for clinical examination when exposed to an appropriate integrated presentation format.