Posts tagged clinical pearl

Case Study.
Studying in the clerkship years is a challenging task. Study times gives way to working time; working time gives way to sleeping time. Somewhere in between we need to create time for ourselves to build our knowledge.
The transition into third year requires quick adaptation to studying on the go. Bring a pocket book or load an ebook onto your phone or tablet computer. If you have few minutes to catch your breath, take out your study material and read a little. 
The best way to maximize your learning in these circumstances is to read around the cases you see each day. Was there something you did not understand about the pathophysiology for patient A’s condition? Not sure what the management plan should be for patient B? Make a case study out of these patients and read around what you do not know or cannot remember. Not only does this help you relate your readings to an actual experiences that help solidify your knowledge, but it will help you manage that patient’s care better. It is a win-win.
Next pearl: ?…Previous pearl: Photos & Videos Prohibited…

Case Study.

Studying in the clerkship years is a challenging task. Study times gives way to working time; working time gives way to sleeping time. Somewhere in between we need to create time for ourselves to build our knowledge.

The transition into third year requires quick adaptation to studying on the go. Bring a pocket book or load an ebook onto your phone or tablet computer. If you have few minutes to catch your breath, take out your study material and read a little. 

The best way to maximize your learning in these circumstances is to read around the cases you see each day. Was there something you did not understand about the pathophysiology for patient A’s condition? Not sure what the management plan should be for patient B? Make a case study out of these patients and read around what you do not know or cannot remember. Not only does this help you relate your readings to an actual experiences that help solidify your knowledge, but it will help you manage that patient’s care better. It is a win-win.

Next pearl: ?…
Previous pearl: Photos & Videos Prohibited…

Photos & Videos Prohibited.
Following last week’s post about digital confidentiality over the phone, today I would like to spend some time talking about the state of photo and video sharing.
In this day and age, sharing photos and videos has become easy and instantaneous, from the likes of Instagram to medically oriented applications like Figure 1.
However, in the medical field, confidentiality is still the bottom line. A photo or video shared to your friends of an interesting finding without the expressed consent of the patient, despite taking care to make sure the patient is not identifiable in the picture, is still a breech in confidentiality. Patients are humans, not specimens, and have a right to their own bodies.
But I need it for a case presentation. What do I do?
Typically, photos and videos are taken for a reason, such as research, academic, or educational purposes. The limits should be explained to a patient, particularly what you would like to use, how you will use it, and who will be seeing it. Furthermore, remember to explain that non-contributory information will remain private and anonymized to protect their identity. If all of this goes well as the saying goes, “Document it!” Make a note in the chart, and print an information release form for them to sign to make it official.
In the instances where I have taken photographs of patient findings, it was for use in case study presentations, and all of the above procedures must have their blessing. It is tedious work and perhaps rightly so. As it becomes easier to share, we tread on thinner ice.
Next pearl: Case Study…Previous pearl: Digital Confidentiality…

Photos & Videos Prohibited.

Following last week’s post about digital confidentiality over the phone, today I would like to spend some time talking about the state of photo and video sharing.

In this day and age, sharing photos and videos has become easy and instantaneous, from the likes of Instagram to medically oriented applications like Figure 1.

However, in the medical field, confidentiality is still the bottom line. A photo or video shared to your friends of an interesting finding without the expressed consent of the patient, despite taking care to make sure the patient is not identifiable in the picture, is still a breech in confidentiality. Patients are humans, not specimens, and have a right to their own bodies.

But I need it for a case presentation. What do I do?

Typically, photos and videos are taken for a reason, such as research, academic, or educational purposes. The limits should be explained to a patient, particularly what you would like to use, how you will use it, and who will be seeing it. Furthermore, remember to explain that non-contributory information will remain private and anonymized to protect their identity. If all of this goes well as the saying goes, “Document it!” Make a note in the chart, and print an information release form for them to sign to make it official.

In the instances where I have taken photographs of patient findings, it was for use in case study presentations, and all of the above procedures must have their blessing. It is tedious work and perhaps rightly so. As it becomes easier to share, we tread on thinner ice.

Next pearl: Case Study…
Previous pearl: Digital Confidentiality…

Digital Confidentiality.
In this age, we rely on technology in our day to day lives to facilitate work and play. One of the important topics in medicine as more of our interactions become digitized is confidentiality.
Nowadays, it is not enough to simply be vigilant when talking to someone in person. We need to take measures to protect our work and the sensitive information of the patients we see. I would like to discuss specifically the instance of using the phone.
If you cannot speak directly to the person you are looking for, a voicemail should not contain any patient identifiers. The same goes for text messages between members of your team or beyond.
This is an example of what not to do.
This is an example of what to do.
While this may seem trivial, students and doctors alike have had close calls before where too many details were given over the phone to the wrong recipient that confidentiality was in jeopardy; in other instances, there have been actual breeches. 
For everything else digital, use your years of acquired digital common sense. In a public area equipped with computers, tablets, and USBs, sign out of your sessions, secure your patient files and password protect your accounts. 
Next pearl: Photos & Videos Prohibited…Previous pearl: On Stage Off Stage…

Digital Confidentiality.

In this age, we rely on technology in our day to day lives to facilitate work and play. One of the important topics in medicine as more of our interactions become digitized is confidentiality.

Nowadays, it is not enough to simply be vigilant when talking to someone in person. We need to take measures to protect our work and the sensitive information of the patients we see. I would like to discuss specifically the instance of using the phone.

If you cannot speak directly to the person you are looking for, a voicemail should not contain any patient identifiers. The same goes for text messages between members of your team or beyond.


This is an example of what not to do.


This is an example of what to do.

While this may seem trivial, students and doctors alike have had close calls before where too many details were given over the phone to the wrong recipient that confidentiality was in jeopardy; in other instances, there have been actual breeches. 

For everything else digital, use your years of acquired digital common sense. In a public area equipped with computers, tablets, and USBs, sign out of your sessions, secure your patient files and password protect your accounts. 

Next pearl: Photos & Videos Prohibited…
Previous pearl: On Stage Off Stage…

On Stage Off Stage.
Dr. Cranquis recently broached a very interesting topic that warranted discussion: that of personal address. Is it Dr. Smith? Or do I call him James like everyone else? What should I be called? It is never really discussed and it is something you feel out as the year goes on. However, there are some unspoken rules that always apply.
Imagine the hospital setting as a theatre, with both the stage - in front of the patient - and back stage - with your team. As long as the stage is set, and the patient or their family is involved, we play our roles, our characters in the hospital: Doctors are addressed as doctors; nurses are called by their first name etc. Back stage however is where the distinctions begin to blur.
Generally speaking, it is always a safe bet to address physicians as Dr. So-and-so until they give you permission to address them by their first name. The same can be said about resident doctors, who generally prefer their first name address backstage; often times they will make it clear when you first meet.
Nurses on the other hand always go by their first name for safety purposes and that makes it easy. They do not typically give out their last name in case patients become attached. Even if you do know their last name, avoid calling them Ms. or Mrs. So-and-so in front of a patient. 
For yourself, you can choose to be addressed any way you so choose as long as it fits your role. I typically will go by my first name off stage, and go by the title medical student on stage. Just make it clear you are not a doctor as that revelation after the fact can break your patient’s trust in you and your team.
The more challenging issue comes with seniors whom you knew before medicine or when work must be done off stage. What then? In the former case, the importance is to preserve your roles on stage in front of the patient. Everything else should be played by ear. In the latter case, when orders must be given and plans are being set in motion, regardless of how equalized the playing field was before off stage, “John the resident would like to order these tests,” becomes “Dr. Doe would like to order these tests.”
Remember that in order for us to do our jobs well in the medical system, the role we take on stage and off stage must be clear. There can be no ambiguity when work must be achieved. In the intervening times, the address becomes a grey area where no clear rules are given. Unfortunately, some of these moments you will need to take one at a time.
Next pearl: Digital Confidentiality…Previous pearl: Humanity…

On Stage Off Stage.

Dr. Cranquis recently broached a very interesting topic that warranted discussion: that of personal address. Is it Dr. Smith? Or do I call him James like everyone else? What should I be called? It is never really discussed and it is something you feel out as the year goes on. However, there are some unspoken rules that always apply.

Imagine the hospital setting as a theatre, with both the stage - in front of the patient - and back stage - with your team. As long as the stage is set, and the patient or their family is involved, we play our roles, our characters in the hospital: Doctors are addressed as doctors; nurses are called by their first name etc. Back stage however is where the distinctions begin to blur.

Generally speaking, it is always a safe bet to address physicians as Dr. So-and-so until they give you permission to address them by their first name. The same can be said about resident doctors, who generally prefer their first name address backstage; often times they will make it clear when you first meet.

Nurses on the other hand always go by their first name for safety purposes and that makes it easy. They do not typically give out their last name in case patients become attached. Even if you do know their last name, avoid calling them Ms. or Mrs. So-and-so in front of a patient. 

For yourself, you can choose to be addressed any way you so choose as long as it fits your role. I typically will go by my first name off stage, and go by the title medical student on stage. Just make it clear you are not a doctor as that revelation after the fact can break your patient’s trust in you and your team.

The more challenging issue comes with seniors whom you knew before medicine or when work must be done off stage. What then? In the former case, the importance is to preserve your roles on stage in front of the patient. Everything else should be played by ear. In the latter case, when orders must be given and plans are being set in motion, regardless of how equalized the playing field was before off stage, “John the resident would like to order these tests,” becomes “Dr. Doe would like to order these tests.”

Remember that in order for us to do our jobs well in the medical system, the role we take on stage and off stage must be clear. There can be no ambiguity when work must be achieved. In the intervening times, the address becomes a grey area where no clear rules are given. Unfortunately, some of these moments you will need to take one at a time.

Next pearl: Digital Confidentiality…
Previous pearl: Humanity…

Humanity.
Articles like this one constantly remind me of what is at stake as we move through medicine. As learners, we learn through role models and by example. Without taking the time to consider what is right and wrong, we can soon become that which we try so desperately to avoid.
A good bedside manner comes inherent to all of us; keeping it is always the harder task than building upon it as the constant pressures of hospital life threaten to erode its foundation.
Take time to reflect, to ask yourself what practices are worth keeping and what practices can go the way of the dodos, and find your own path. If a doctor is open to change, a conversation about the art of medicine can be therapeutic and beneficial to both parties; others may not be as receptive. Remember always that just because someone does it one way, does not necessarily make it the only way.
At the end of the day, your relationship with your patients will be stronger, more honest, and more beneficial. Kindness to your colleagues and support staff can offer greater rewards when it comes to making your job and your life easier. From patients to nurses, from volunteers to transcriptionists, a simple please and thank you can go a long way.
“…To the transcriptionist, thank you very much for transcribing this consultation. End dictation.”
“Do you always say that?”
“Why not? They work hard too trying to make sense of our individual dictation quirks.”
Next pearl: On Stage Off Stage…Previous pearl: I Need Backup…

Humanity.

Articles like this one constantly remind me of what is at stake as we move through medicine. As learners, we learn through role models and by example. Without taking the time to consider what is right and wrong, we can soon become that which we try so desperately to avoid.

A good bedside manner comes inherent to all of us; keeping it is always the harder task than building upon it as the constant pressures of hospital life threaten to erode its foundation.

Take time to reflect, to ask yourself what practices are worth keeping and what practices can go the way of the dodos, and find your own path. If a doctor is open to change, a conversation about the art of medicine can be therapeutic and beneficial to both parties; others may not be as receptive. Remember always that just because someone does it one way, does not necessarily make it the only way.

At the end of the day, your relationship with your patients will be stronger, more honest, and more beneficial. Kindness to your colleagues and support staff can offer greater rewards when it comes to making your job and your life easier. From patients to nurses, from volunteers to transcriptionists, a simple please and thank you can go a long way.

“…To the transcriptionist, thank you very much for transcribing this consultation. End dictation.”

“Do you always say that?”

“Why not? They work hard too trying to make sense of our individual dictation quirks.”

Next pearl: On Stage Off Stage…
Previous pearl: I Need Backup…

I Need Backup.
When we work, we do not do it alone. We are in the company of people working towards a common goal. We are surrounded by backup.
One of the biggest fears of going into any new situation is that you might not be equipped to deal with what you see. As a student learning, seeing, experiencing foreign and exotic subjects for the first time, it can be even more daunting.
Remember that you can always find help in your classmates, your senior residents, your attending. They can help give you a starting point, walk you through tricky topics, or see the patient with you. 
Never feel bad about enlisting the help of your allies: the nurse, the physiotherapist, occupational therapist, the dietician, the pharmacist, the social worker etc. They are masters of their own domain, areas that overlap with your own and can provide you with significant amounts of support and collateral information that you may not have the capacity or time to explore on your own.
More often than you think, a difficult situation is remedied by asking for help. It is never a sign of weakness to seek help; it is a strength to be able to recognize your boundaries and limitations. That, at the end of the day, is how we become better care providers.
Even in the dire circumstances where you might have to call someone in the middle of the night when no other help is available, that is still a better alternative than allowing patients to deteriorate beyond help.
In any situation, always ask yourself: “Am I in over my head? Do I need backup?”
Next pearl: Humanity…Previous pearl: Tailored Presentations…

I Need Backup.

When we work, we do not do it alone. We are in the company of people working towards a common goal. We are surrounded by backup.

One of the biggest fears of going into any new situation is that you might not be equipped to deal with what you see. As a student learning, seeing, experiencing foreign and exotic subjects for the first time, it can be even more daunting.

Remember that you can always find help in your classmates, your senior residents, your attending. They can help give you a starting point, walk you through tricky topics, or see the patient with you. 

Never feel bad about enlisting the help of your allies: the nurse, the physiotherapist, occupational therapist, the dietician, the pharmacist, the social worker etc. They are masters of their own domain, areas that overlap with your own and can provide you with significant amounts of support and collateral information that you may not have the capacity or time to explore on your own.

More often than you think, a difficult situation is remedied by asking for help. It is never a sign of weakness to seek help; it is a strength to be able to recognize your boundaries and limitations. That, at the end of the day, is how we become better care providers.

Even in the dire circumstances where you might have to call someone in the middle of the night when no other help is available, that is still a better alternative than allowing patients to deteriorate beyond help.

In any situation, always ask yourself: “Am I in over my head? Do I need backup?”

Next pearl: Humanity…
Previous pearl: Tailored Presentations…

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: I Need Backup…Previous pearl: And Stuff Like That…

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: I Need Backup…
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…

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…

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…