Posts tagged 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.

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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.

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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.

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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.

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