A Brief Refresher

April 15, 2018
by Mark David Siegel

Hi everyone, 

Maybe a hidden curriculum is to blame, or maybe it’s just been too long since we’ve discussed this topic, but I’m worried that we’re straying from the “Yale Way” of presenting.  We don’t want haphazard, tedious presentations, so let’s refresh ourselves and review best practice:

1. State the Chief Concern (CC) in a crisp, full sentence.  A word or two, like “GI Bleed,” fails to convey context, time course, and necessary detail.  Too much information is even worse.  No one can follow a run on sentence like: “The patient is a 67-year-old man with BPH, gout, COPD, Type 2 DM, CAD, and CKD, presenting with one day of hematemesis.“  Instead, aim for a focused sentence like: “The patient is a 67-year-old man with multiple medical problems, presenting with one day of hematemesis.” 

2. End your HPIs with a concise summary of the ED course and reason for admission. Describe the HIGHLIGHTS of the ED course: key exam findings, test results, and interventions, but leave out useless detail like normal vital signs, exam findings, and lab results.  Here’s an effective example: “Upon presentation to the ED, the patient’s heart rate was 134 and his blood pressure was 84/60.  He had pale conjunctivae, epigastric tenderness, and melena on rectal exam.  He had an H/H of 7.1/20.5 and a BUN/Cr of 65/1.5, all off from his baseline.  Two large bore IVs were placed and 2L of LR were given, after which his BP rose to 110/70.  A Type and Cross were ordered and he was admitted to the SDU to manage his GI bleed.” 

3. Don’t confuse “pertinent positives and negatives” with the “review of systems” (ROS).The ROS is an inventory performed to screen for issues unrelated to the HPI.  For example, your patient with a GI bleed may also have postnasal drip or a rash.  In contrast, pertinent positives and negatives highlight the issues targeted by your Chief Concern.  For example, if a patient has a GI bleed, you need to address the presence or absence of coffee grounds, melena,  BRBPR, abdominal pain, bleeding elsewhere, use of ASA or NSAIDs, and prior GI bleeds.  Pertinent positives are usually included in the HPI’s narrative, whereas pertinent negatives can be summarized in list form.  For example, you can say “The patient had no prior GI bleeds, didn’t take ASA or NSAIDs, and denied abdominal pain, melena, or BRBPR.  You will know you presented well when the audience doesn’t need to ask clarifying questions.  Don’t leave it to your audience to ask if your patient with a GI bleed had abdominal pain.  Nothing is more tedious than enduring a barrage of clarifying questions.  Present the salient details up front and move on. 

4. Filter out non-contributory data.  Oral presentations should be crisp and streamlined.  Don’t recite every detail included in your note.  We don’t need to hear that your patient with pneumonia also has Tinea pedis.  Use the phrase “is notable for” to signal that you’re only including important details.  How much information to include depends on the setting.  You may need to share more information if your team is going to be managing multiple issues- for instance if your patient with pneumonia also has difficult-to-control hypertension.  In contrast, the audience at a teaching conference doesn’t need to hear extraneous detail.  You need to decide what to include and what to leave out.

5. Expand and contract physical exam findings depending on the central problem.  If a patient has melena, you need to describe thorough abdominal and rectal exams.  If the rest of the exam is normal, just say so, but include pertinent negatives (e.g., no telangiectasias, no spider angiomata, no ascites, no hemorrhoids, etc.).  

6. Streamline the laboratory presentation.  In the MICU, patients have so many abnormalities that it generally makes sense to give all the results- just ask the team what they want to hear.  In contrast, for stable floor patients and in report, you should just say “the chemistries and coags were normal” if that’s the case.  

7. Stay in sequence when your patient had an active overnight course.  It makes no sense to describe follow up CBCs before telling the team that the patient bled.  Give your full admission presentation, including your initial assessment and plan, and then describe overnight events, new findings, and, if necessary, a revised impression and plan. 

8. Be brief.  Long presentations are boring and hard to follow, particularly when they are unstructured.  Salient facts inevitably get buried in mounds of random detail.  Present from memory whenever you can: this pushes you to highlight the key facts and makes it easier for everyone to focus.  Most importantly, brief presentations free up time for clinical reasoning and teaching.  

I’ve attached copies of the Yale Way documents, which describe how to present new patients and those with active overnight courses.  You should follow the structures outlined in these documents, but remember that they describe a framework for formal presentations, like a New England Journal CPC.  While adhering to the overall framework, you also need to decide what to include and what to leave out.  Your mission is to master structured presentations while remaining focused and keeping your audience engaged.  

Have a great Sunday everyone, 

Mark

Submitted by Mark David Siegel on April 15, 2018