Concise Summaries Only, Please

August 27, 2017

Hi everyone:

Effective assessments begin with a concise summary statement.  To illustrate: imagine you just admitted a patient with chest pain and EKG changes, you’re finishing your H&P or presenting on rounds, and you’re about to launch your assessment.  Which of the following summaries should you use?

  •  #1: "In summary, this is an 90-year-old man with CHF (EF 22%), s/p ICD (June 2017), CAD (s/p DES to LAD, Cx), NIDDM (HgbA1C 8.3), CKD (Cr 3.2), ETOH use disorder (1 pint vodka per day), cigarette smoking (2ppd for 56 years), and COPD (FEV1 34% of predicated), now presenting with substernal chest pain radiating down the left arm, associated with nausea and ST segment elevations in II, III, aVF, persisting despite 3 doses of sublingual NTG, admitted for serial troponins.
  • #2: "In summary, this is an elderly man with a history of CAD and systolic heart failure, presenting with chest pain and inferior EKG changes unresponsive to NTG, admitted to ROMI.

I’ve seen too many summaries that look like #1, but don’t you agree #2 is better?  It's succinct and easy to follow, and it neatly summarizes the salient issues while guiding the audience towards an appropriate plan.  Effective summaries are concise: they filter, consolidate, interpret, and synthesize.

  • Filter: Summaries should exclude information unrelated to the patient's presentation. The ICD, CKD, NIDDM, ETOH use, cigarette smoking, and COPD belong elsewhere, but not in the summary.  You’ll have to deal with them, but they don’t form the core of the current problem.  
  • Consolidate: After presenting extensive data, you need to consolidate the information into a succinct, pithy, and digestible statement.  In the summary, the many features of this patient’s chest pain can be expressed simply as “chest pain.” The fact that the pain persisted “despite 3 doses of sublingual NTG” is best expressed as “unresponsive to NTG.” The number of doses of NTG and the route used is TMI.
  • Interpret: Help your readers and listeners.  A 90-year-old man is elderly.  An EF of 22% is systolic dysfunction.  ST-segment elevations in II, III, and aVF are inferior changes.  Give the primary data in the HPI and results sections. The summary demands interpretation.
  • Synthesize: The summary is the beginning of your argument towards a specific diagnosis.  Make your concerns obvious.  In summary #1, buried in a pile of data, is a concern about MI, which is only tangentially implied by the plan to draw troponins.  Be explicit: This man with a cardiac history, chest pain, and EKG changes is being admitted to rule out MI.

Creating concise summaries is one of the most challenging but most important skills you will acquire in training.  Let’s start by acknowledging their importance. The summary is your opportunity to highlight the crucial issues needing your attention.  Effective summaries filter, consolidate, interpret, and synthesize.  Your team and your patients will benefit, and your reward will be clarity, efficiency, and a sense of purpose.

Enjoy your Sunday everyone. It's beautiful outside and I'm leaving for a bike ride.

Mark

PS Let’s pause for a moment today to send good thoughts to our neighbors in Texas, enduring a once-in-a-lifetime flood.  Let’s hope for minimal injury and loss of life, a quick cleanup, and a rapid return to dry weather.

Submitted by Mark David Siegel on August 27, 2017