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The Presentation Series (The Chief Concern)

July 04, 2021
by Mark David Siegel

Hi everyone,

Chief Concerns (CCs) are like newspaper ledes: we use them to spark interest, frame presentations, and highlight the patient’s core problem. Effective CCs share essential facts while staying concise.

“Chief Concern” is a Yale-ism. Several years ago, we stopped using "Chief Complaint" so patients wouldn’t think we were calling them complainers. The purpose is the same and, miraculously, the initials are the same too.

CCs should be expressed in full sentences that incorporate the patient's name, age, gender (man/woman, not male/female), relevant social, ethnic, and medical background, and a main problem. For example:

  • Ms. Washington is a 34-year-old homeless woman with a history of Type I diabetes, presenting with three days of polyuria and polydipsia after running out of insulin.
  • Mr. Adams is a 67-year-old man with a history of poorly-controlled hypertension and hyperlipidemia, presenting with two hours of severe substernal chest pain.
  • Ms. Jefferson is a 29-year-old marathon runner, presenting to the ER after losing consciousness at the New Haven Road Race.

I think you’ll agree these CCs grab your interest, highlight the patient’s core issue, provide context, and frame the presentation to come.

CCs fall off the tracks when they include too little or too much information. Some of you probably learned to limit CCs to one word, like “cough,” “headache,” or “dysuria,” but this approach lacks context. Consider these two patient with cough:

  • Mr. Madison is a 20-year-old man with a history of asthma, presenting with three days of non-productive cough, wheeze, and shortness of breath.
  • Mr. Hancock is a 74-year-old man with severe COPD, presenting with three months of cough, productive of bloody sputum.

Don’t play coy with your CCs. Tell your audience what they need to know.

Too much information is also a problem, weighing down the CC with gunk:

  • Ms. Livingston is a 53-year-old woman with a history of CAD, s/p PCI 10 years ago with DES to the LAD, left breast cancer s/p lumpectomy and XRT, sickle cell trait, and IBS, presenting with a bull’s-eye rash following a tick bite.

If you’re like me, you lost focus after the PCI. The CAD, breast cancer, sickle cell trait, and IBS are irrelevant. Just say “Ms. Livingston is 53-year-old woman presenting with a bull’s-eye rash following a tick bite.” File the other details in the “Past Medical History.”

Finally, some special considerations.

The MICU uses a version of the CC called the “Critical Care Chief Concern“ (CCCC). This is another Yale-ism, dating back to my days as MICU Director. The purpose is to highlight why the patient was admitted to the ICU. Consider these examples:

  1. “Mr. Franklin is a 59-year-old man presenting with fever and cough.”
  2. “Mr. Franklin is a 59-year old man presenting with fever, cough, and hypoxemic respiratory failure.”

Version one suggests Mr. Franklin could be seen in clinic; version two signals that Mr. Franklin is critically ill.

Some of you were taught to use race in the CC. Doing so is rarely appropriate, unless your point is to convey a social determinant of health (e.g., a Latino meat packer exposed to COVID-19). On the other hand, ethnicity may be important if it implies genetic heritage as a disease risk factor (e.g., a Swedish man with hypercalcemia and hilar adenopathy).

Some of you were taught to use the patient’s words in the CC. Unfortunately, it may not be feasible or helpful to use patients’ words. Few patients can report lab abnormalities (e.g., a patient with end stage renal disease presenting with a potassium of 8.3.). Similarly, the patient’s concern may not be the concern demanding your attention. For example, a patient may come to the ER for a twisted ankle but require admission for alcohol withdrawal. Of course you will attend to the ankle, but your focus should be on the DTs. Finally, some patients can’t express a concern, for example if they’re unconscious.

It’s amazing how much attention we can devote to one sentence, but the effort is worth it. Your listeners and readers need you to convey Chief Concerns that are concise, targeted, memorable, and, most importantly, useful.

With that, I wish you a Happy 4th of July. Weather permitting, I hope to see some of you tonight at the fireworks celebration at East Rock Park.

Enjoy your Sunday, everyone,


PS We’re leaving tomorrow for summer vacation. Here’s a picture of an old family trip to Howe Caverns. I’m in the center, with my brother, Ed, cut off to my right, and my friend, Michael, to my left. A 1970s selfie.


Submitted by Mark David Siegel on July 04, 2021