Posts tagged clinical pearl
Tailored Presentations.
Dr. Cranquis made a comment about presenting a patient to various specialties. I briefly touched on this subject in Need-to-know Basis but I think it is worth revisiting in full.
Every doctor would like a summary of information, but your delivery of it cannot be a one-size-fits-all package. A good case presentation requires delivering the information that is pertinent to the specialty and “selling” or driving the attending to the diagnosis you have in mind. Here are some quick pointers that I go by.
Identifier: A good presentation begins with a short summary of who the patient is. This includes things like age, gender, ethnicity, and functional status (independent, bed bound, institutionalized etc.). Other pertinent points included here may be if the patient has been generally healthy or has multiple co-morbidities. Finally, if a patient comes in with a condition that is associated with risk factors, you can list them here if they apply.
“This is a 56 year old independent caucasian man with a history of hypertension, dyslipidemia, smoking, and obesity who presents with shortness of breath on exertion and retrosternal pain.”
Beyond this basic structure, a hospital specialist will require additional information along with the focused problem when you present the case. An obstetrician will want to have the patient’s gravida status, blood type, and screening status up front; a neurologist will want to also know the handedness of a patient and the baseline neurological status; a surgeon just wants to know what the problem was and the diagnosis. The clinical years become an exercise in learning these differences.
This is of course all well and good when you are presenting to your attending. However, once you need to consult someone, be it the specialist or the ER, keeping the presentations clear and succinct becomes key. No one has time to listen to a fifteen minute presentation over the phone.
The first step is to make your intentions clear. This usually happens either before you present your patient or once you have given them an idea of who they are dealing with.
“This is a 40 year old man previously healthy man with no past psychiatric illness, currently experiencing significant personal and financial stressors who was found by police after ingesting unknown quantity of tylenols within the last four hours. He is currently stable and being treated per protocol and we are waiting for the next liver panel. We are consulting psychiatry ahead of time for suicidal ideation and risk assessment.”
The next step, following what has already been described above is to discuss the pertinent points of the history. This includes the identifiers but also the patient’s condition and what has been done or course in hospital that is relevant to the case.
Sometimes that little snippet of information is enough. Sometimes they may require more so always keep everything within arms reach and present information as they require them. Maybe they do have time to listen to a full presentation, perhaps only a few snippets.
If you can keep your audience and the issues in mind - identifier, specialty tailored points, reason for consultation, pertinent history and current plans of action - you will be able to deliver a well formed presentation every time.
Next pearl: ?…
Previous pearl: And Stuff Like That…
And Stuff Like That.
Previously, I spoke about summarizing information and conveying efficient data in writing. This time, I would like to talk about conveying efficient information in words.
Our day-to-day conversations are often filled with extraneous words, interjections, and flourishes that add very little to the content. As an exercise, just listen to some of your friends or family members as they talk. Actively listen to how you speak. What words could you have removed and still get your point across?
“This patient did not have any fevers or chills and stuff like that,” is an example. “Um, the patient looked a little short of breath and maybe a little sweaty, you know?” is another.
Take a moment and think about what you want to say and how you want to say it. Get to the heart of the matter without embellishing facts. A good place to start practicing is in your daily conversations. On the ward, dictating is a practice that forces you to be conscientious of your word choice. Regardless, it takes time, patience, and insight to break the habit.
Eventually, you can present information to your colleagues and attendings succinctly, clearly, and professionally.
This patient had no fever or chills. He was mildly short of breath and diaphoretic.
Next Pearl: Tailored Presentations…
Previous Pearl: Impression…
Impression.
Once I have gathered all of the information from a patient, presenting it is always easier. I can list off the history and physical as I would a bullet pointed list. What is always more of a struggle is formulating my impression and plan.
No one ever taught me how to write or present an appropriate impression. This is the part of any report that summarizes the findings and presents reasons for or against different diagnoses and the issues at hand. This is what I do.
Begin with a one or two sentence summary identifying the patient, including history that is relevant to the chief complaint. Then, proceed to address the problems.
When tackling a patient’s problems, begin by considering them in three ways:
- Predisposing factors: What aspects of the patient’s presentation put them at increased risk of their chief complaint. For example, in a patient who comes in with an acute COPD exacerbation, it is important to preface your impression with identifying the patient as a heavy smoker.
- Precipitating factors: What are the events or reasons the patient’s chief complaint presented. For example, an intoxicated patient who is coming in with multi-system trauma secondary to a motor vehicle accident, the precipitating factor is prior alcoholic consumption.
- Perpetuating factors: What aspects of the patient’s presentation places them at risk of repeat incidence. A patient with type I diabetes who is noncompliant to insulin can put them at risk for diabetic ketoacidosis.
Present the issues along with these factors as appropriate and then dive into a differential, starting with the most likely/working diagnosis first. Be able to list some reasons why a diagnosis is on the differential list, the findings that are favourable or unfavourable to it, even if it is only to rule out fatal conditions that could passably be related.
Next pearl: And Stuff Like That…
Previous pearl: Efficient Data…
Efficient Data.
When it comes to writing notes, conveying information efficiently is a means to summarize and clarify data. Producing immediately interpretable data helps the next caretaker have a snapshot of what the situation is.
A picture is worth a thousand words. When a written description is too lengthy or fails to accurately portray the information, draw a diagram. I have left some examples of some of the common diagrams I draw.
Physical exam notes translate well into diagrams when you want to track your progress. At what level do you hear crackles in the lungs today? How is that compared to yesterday?
When it comes to laboratory investigations, each hospital often has their own shorthand but the trident and pitchfork method to blood work is a pretty standard affair. Abnormal values are circled, with the last value written beside it with an up or down arrow used to show the trend. Even without pulling up a computer or going through the chart, a caregiver can see what has been ordered and what the trends have been.
Doctors often time use these diagrams in practice. The caveat is of course not every doctor or hospital draws them the same way. It is only as powerful a tool as the consensus or legibility of the tool.
So give it a try. May it speed up your workflow.
Next pearl: Impression…
Previous pearl: Describe a situation…
Describe a Situation.
Applying to medical school is a year long process. It requires a lot of forward thinking and planning. Applying to residencies is no different. I am at that point now that making preparations for fourth year electives and planning for residency options becomes important.
One of the big hurdles of applying to residencies is the interview process. This is an opportunity for different program directors and residents to see how I willinteract with them, with situations. One of the most often asked questions goes along the lines of:
“Describe a situation where…”
In the clerkship years, make it a habit to take note of very specific situations that you can think back on for a future interview scenario. Remind yourself of that time you demonstrated integrity, or that other occasion where you saw how errors were made. You can write them down on a little notepad, or you can even send yourself an email on your phone for future reference. Over time, you will have accummulated a small catalogue of situations that will aid you in a future interview process.
Moments of Zen.
Stress is the darkness that creeps in the recesses of my mind. It gnaws at my conscience, like a parasite leeching on the fears and opportunities afforded by my lifestyle. I must never let it outpace me.
Despite trying to keep up the formalities and appearances, there is no denying that my class and I look exhausted. We are constantly stressed. We are constantly worrying. We are always tired. That is a recipe for burn out.
The first part of tackling stress is understanding your own limits. Know when enough is enough and when going another hour is too much.
The second part of finding a balance amidst the chaos is to find outlets that allow your brain to disengage from stressful situations. These are the ways I find my moments of zen:
- Study in bursts. I set short-term and long-term goals for the night. Get through X amount of topics. Take a break after Y amount of time or objectives. Then I study my heart out and focus until I am done. Take my break. Repeat.
- Pursue interests that fulfill me. I go read on a favourite subject or news of the day. Do some drawing. Make some crafts. Write (as I am now) on Tumblr.
- Sleep. Sometimes it is just a matter of sleep. Never underestimate the refreshing effects of a good night’s rest.
- Listen to some music. When I listen to music, I can forget everything for five minutes and cleanse my mind. For those five minutes, the world melts away.
- Travel. Not in the literal sense. Not always. Instead, I let my mind do the travelling. I bought this poster, Maldives by Peter Adams, some time ago and it still accompanies me. Occasionally I just look at it and focus on absolutely nothing. It is a place I let my mind wander to on those stressful days.
- Friendly Outings. As a band of medical students, we make every effort to find opportunities to have gatherings and have fun. We find the strength to overcome through numbers.
- Support and Love. Nothing fulfills me and recharges me more than getting to see my fiancée, listen to her laugh, and feel her hand in mine. She is my peace of mind.
Next Pearl: Describe a Situation…
Previous Pearl: The Day Night Continuum…
The Day Night Continuum.
The longer you immerse yourself into the life of a clerk, the more you find the days and nights bleeding together. Days become nights; nights become days.
Sometimes it is the baby that needs delivering in the dead of night, other times it is the last minute consult that takes you much longer to work up than anticipated; often it is just a call shift. These are the rites of passage that every doctor before you has gone through.
The best advice I have received about making it through the days is: “Sleep when you can.”
The day night continuum is endless. There is never a shortage of topics to learn or work to do. At some point, we must all draw the line.
We are all human beings and even the best surgeons cannot work relentlessly through the night. If you have a rare moment to sleep early one night, take advantage of it. If you can afford a moment while on call in between consults to get some shut eye, do so.
Sometimes it is not about waiting for the right moment to come but to create the opportunity yourself. Know your own limits. If you feel that you can no longer study for the rest of the night, why push yourself?
Go sleep.
Next pearl: Moments of Zen…
Previous pearl: Need to Know Basis…
Need-to-Know Basis.
In gathering information or a history from someone, it is important to be thorough but efficient. I need to gather all of the relevant pieces in a limited amount of time. This as it turns out is both your curse and your grace.
When a doctor asks me to “tell him about the patient,” it is not an invitation to regurgitate everything I have learned about him over the last 20 minutes; it is an invitation to tell the doctor what he needs to know to do his job. This concept is important when discussing with other team members. What is important to one doctor may be unimportant for another. It is is all a matter of perspective.
For example, an anaesthetist is not concerned about how a patient wound up fracturing his arm but would be interested to know that he is a smoker and has an arrhythmia; likewise a paediatrician will most certainly be interested to know that the household is financially stable and has three dogs but an internist would want to know about every condition, medication and surgery the patient has ever had.
So when seeing patients, think about why you were asked to see them and focus your questions around the problems. Summarize and present the relevant information as the meat of your discussion. If time allows or if the doctor asks for more information, provide the rest of the history as needed.
Next pearl: The Day Night Continuum…
Previous pearl: The Notepad…
The Notepad.
Every day, I rely on note taking to organize my thoughts, to write progress notes, to present to doctors, or to dictate a consultation. As I had mentioned in my first post of this series, packing light is essential and your notes need to be carefully considered in the same vein.
- Write on something that is easy to carry, to take out and to put away. I carry memo books that fit in my pocket though I have also seen folded pieces of printer paper, miniature binders, and agendas.
- Organize your information. Have a template in mind to organize your information on your page. Even if the patient does not give you the information in the order you had in mind, you can still slot them into the proper parts of your notes. This will help with your presentations.
- Sticker storage. You will find that once you are on the ward, every patient’s chart contains a set of stickers with their name and other relevant hospital information. Get in the habit of taking one of these and putting them in your notes when you see them. The sticker will let you find the patient should they be moved, to see who is still an active patient you should follow up on, and to access patient test results. When the patient is no longer in your care, just tear out the pages or cross out their name. This is an easy, visual way of tracking your patient load, which brings me to the next point.
- Sticker safekeeping. Those stickers are important for work but they also contain a lot of patient sensitive information. Dispose of them properly in the confidential documents bin or shredder. Make sure you do not lose your notepad!
Next pearl: Need-to-Know Basis…
Previous pearl: Food and Water…
Food and Water.
As a senior student had once told me: “sleep when you can, eat when you can.” Down time is a rare commodity on the ward. Sure there is time put aside for lunch but often unforeseen changes and engagements can quickly eat away that repose.
Always plan for the worst case scenario: a long shift with no breaks.
Keep some food and fluids on your person at all times. Eat or drink while walking through halls, going up or down stairs, or in the elevator. With the exception of small bottles of water, I usually carry with me single-serving foods like granola bars, juice boxes, and bags of nuts. The portions are small enough that I can finish them within a few minutes and wholesome enough to tide me over for a few hours.
- Page 1 of 2
- Next »
