Hi everyone:
In days of yore, we interns presented from memory. They weren’t the days of the giants (I was as short then as I am now). The challenge was practical: charts sat at the nurses’ stations, and if we carried notes around, they’d get crinkled and stained, if we didn’t lose them.
There were advantages to presenting from memory. Rounds were shorter since we could only remember so much—the important bits—and we knew our patients extremely well, even the K of 3.3 and AST of 33.
It wasn’t that hard: not because our patients were less complicated, or because we had larger hippocampi. We could present from memory because we used a consistent, curated approach which you should adopt too:
- Lede (the “Chief Concern”): Ms. Thomas is a 47-year-old woman with metastatic breast cancer, presenting with two days of shortness of breath and a new right-sided pleural effusion. A simple, concise opening introduced the core problem and deliberately excluded tangents (hypertension, gout, etc.).
- Narrative: She was in her usual state of health until two days before admission when she noticed shortness of breath while climbing stairs. The symptoms worsened until the day of admission when she experienced shortness of breath at rest and came to the ED. Note the story’s clear start, progression, and culmination in the ED.
- Pertinent positives and negatives: She also reported right-sided chest pain, which worsened with inspiration, as well as difficulty lying flat. She denied cough, fever, and leg swelling. Pertinent positives and negatives are distinct from the “review of systems” (ROS), which is an inventory of questions we ask every patient (rash, headache, weight loss, etc.).
- ED course: In the ED, she was found to have an SpO2 of 84% on room air for which she was placed on 2L NC, which increased her SpO2 to 92%. A chest radiograph showed a new, large right-sided pleural effusion, and she was admitted to the hospital for evaluation and management. Highlight what was done before you were called and why she was admitted.
- Concise medical/social/family history; substance use; and ROS: Decide what to share and what to leave out. If your team demands more detail, they can ask. Here’s where you can elaborate on the patient’s cancer treatment and other diagnoses (asthma, hypertension), social history (lives with husband and children), family history (mother and sister have breast cancer too), substance use (none), and ROS (weight loss, anxiety).
- Exam: She was afebrile and had normal vital signs. Her breathing was shallow but she was speaking in full sentences without accessory muscle use. Her SpO2 was 94% on 2L NC. She was frail and cachectic appearing. There was no lymphadenopathy. Her right hemithorax was dull to percussion with diminished breath sounds. The left hemithorax had normal percussion and clear breath sounds. She had no JVD, peripheral edema, or evidence of ascites. The rest of the exam was normal. Highlight pertinent positive exam findings as well as pertinent negatives (e.g., no signs of volume overload).
- Key test results: The CBC was notable for a hemoglobin of 7.2, unchanged over the past 6 months. Chemistries were normal. Bedside POCUS confirmed a large right pleural effusion. Depending on your audience, you may be pushed for more detail, including the rest of the CBC, chemistries, EKG, and prior test results. As a rule, if a test is abnormal, share the result. If you anticipate a normal test result would interest the team, share that too. For example, if you’re going to propose a procedure, state that the patient’s platelets and coags were normal.
- Summary and Synthesis: In summary, this is a middle-aged woman with metastatic breast cancer, presenting with two days of worsening shortness of breath, hypoxemia requiring oxygen supplementation, and a new large right-sided pleural effusion. Note the reiteration of the chief concern, which now includes key findings and consolidated facts. You don’t need to rehash the decreased breath sounds, which are explained by the pleural effusion.
- Clinical reasoning: In a woman with metastatic breast cancer, I am most concerned about a malignant effusion. Other considerations such as hemothorax, empyema, parapneumonic effusion, hepatic hydrothorax, heart failure, and pulmonary embolism are less likely. Hemothorax is unlikely in the absence of trauma and given the gradual onset and stable hemoglobin. Empyema and parapneumonic effusion would be rare in the absence of fever or pulmonary infiltrates. Hepatic hydrothorax is ruled out by the absence of cirrhosis and ascites. Heart failure would be unusual with a unilateral effusion and no signs of volume overload. Finally, although PE is always a concern in patients with cancer, PEs do not typically present with large unilateral effusions. Note the balance of thoroughness and selectivity. You can’t (and shouldn’t) list every cause of pleural effusion, but if someone asks about other causes (chylous, lupus, etc.), you can respond.
- Your plan: We will proceed with a diagnostic and therapeutic thoracentesis. We will send the fluid for chemistries, cell count, culture, and cytology. Note the clear, focused diagnostic strategy, which will answer the key question: why does this poor woman have a large effusion?
In these days of WOWs on rounds, I fear we’ve become beholden to the tyranny of the EMR. If we’re not careful, our presentations degrade into rote recitations of random rubbish instead of coherent, compelling narratives. We can do better, and while I do not think it would be fair to ask you to start presenting from memory tomorrow—especially without fair warning—I would encourage you to step back from the computer and tell the riveting stories your teams yearn to hear.
Enjoy your Sunday, everyone. I have one more week left in the SDU, so it's time to pedal down to New Haven!
Mark
P.S. Our hearts go out to the victims of last week’s devastating earthquake in Venezuela. Our colleague Dr. Clemente Britto has shared an opportunity to assist with the effort to help survivors.
P.P.S. What I’m reading:
- America’s Greatest Food Export By Ellen Cushing
- The Covid Czar People Still Trust By Rachael Bedard
- Is AI ruining our skills? Early results are in — and they’re not good By Mariana Lenharo
- Doctors Thought It Was Asthma. A.I. Flagged a Serious Heart Problem. By Gina Kolata
- How Phones Alerted Millions Before Quakes Shook Venezuela By Amy Graff and Martín González Gómez