Hi everyone:
This is a good day to address common oral presentation errors, which cause confusion and inefficiency. We can do better, so let’s review:
Sex Instead of Gender: Veterinarians can call their cows, pigs, cats, and dogs “male” or “female,” but our patients are people, not puppies. Let’s respect their humanity by calling them “men,” “women,” or “non-binary.” Let’s call our patients what they call themselves.
Curious Chief Concerns: Why would a coughing patient be admitted to the hospital, let alone the MICU? Why not send them home with Delsym? The point of the Chief Concern is to telegraph why the patient was admitted. A 72-year-old woman with cough, fever, and hypoxemia belongs in the hospital. The same woman with cough, fever, and severe hypoxemia requiring intubation belongs in the MICU.
Misplaced PMHx: Why do we cram the patient’s whole past medical history (PMHx) into the Chief Concern (CC)? Like this: “This is a 63-year-old man with a history of hypertension, Type II DM, gout, localized prostate cancer, GERD, CAD s/p 3 drug eluding stents, ulcerative colitis previously treated with infliximab, and hyperlipidemia presenting with a sudden severe headache.” The gout, ulcerative colitis, GERD, and the number of stents distract us, obscuring the hypertension, diabetes, hyperlipidemia, and CAD, which probably matter. Share the crucial facts in the CC and send the rest to the PMHx.
Skipping Past the History: Osler said “the patient will tell you the diagnosis,” but not if you don’t ask or listen. Sometimes this is what we hear: “The patient developed chest pain and came to the ED.” But this is what we want to hear: How severe is the pain? When did it start? How long did it last? Has it happened before? Was it sharp, tearing, or squeezing? Did it travel? Were there associated symptoms like shortness of breath, nausea, palpitations, or lightheadedness? Did anything make the pain better or worse? The history will lead us to the diagnosis, like MI, PE, aortic dissection, pneumothorax, esophageal spasm, or costochondritis- but only if we search.
Skipping Prior Admissions and Evaluations: Patients are often admitted repeatedly for the same problem and many have had workups, like PFTs, echocardiograms, and CTs that don’t need to be repeated. Maybe we don’t need to rule out PE again on this patient’s 5th presentation with chest pain. Maybe we can be the ones who finally remove penicillin from the allergy list when we (safely) begin another round of Zosyn. Maybe we can stop saying the patient has COPD when we see that the PFTs showed restriction, not obstruction. Epic can be overwhelming, but a targeted search of old records, including Care Everywhere, can save everyone, including the patient, time, expense, and needless testing.
The Review of Systems is Not What You Think it Is: The Review of Systems (ROS) is commonly confused or conflated with the pertinent positives and negatives. For example, in a patient with fever, we sometimes hear that “the Review of Systems was positive for chills, nausea, vomiting, and right upper quadrant pain, and that it was negative for cough, sputum, shortness of breath, etc.” But those are the pertinent positives and negatives- the questions we should ask any febrile patient if they don’t tell us themselves. In contrast, the ROS is an inventory, a slate of questions we should ask all patients to screen for additional issues. For example, we might learn that a patient admitted for a diabetic foot ulcer noticed a lump in her breast, which will require prompt follow up after discharge.
From the ED to This Morning with Zero In Between: For unclear reasons, we often skip past overnight events when presenting holdovers. We hear that the patient presented to the ED with hematemesis and hypotension requiring admission to the MICU and by morning their vital signs are stable and GI is coming to do an upper endoscopy. But what happened overnight? What was the working diagnosis? How did the team treat the hypotension? Was the patient transfused? Why did GI decide the EGD could wait? The night team worked hard. Don’t leave out their part of the story.
Objective As Opposed to What: Am I the only one who wonders why we call the labs “objective data” as opposed to all other facts? Isn’t the history of cancer objective? Aren’t the vital signs and your physical exam objective too? The patient’s symptoms reflect their subjective experience, but everything else—the past history, the vitals, your exam—is objective if true.
What Are You Thinking: Before you launch into your plan, we need to know what you’re thinking so the plan makes sense. After you present your data you should 1) summarize the key findings, 2) generate a differential diagnosis, and 3) tell us what diagnosis you think is most likely and what else you don’t want to miss and why. Then we’ll understand your plan. If you think the patient has heart failure, it makes sense to start a diuretic. If you think the patient has a PE, it makes sense to get a CT.
Failure to Prioritize: In the quest to be thorough, we sometimes present our plans in rigid sequence instead of prioritizing the most important problem or system. For example, we may present “head to toe,” saying a patient requires no sedation while the team is dying to hear what you plan to do with the potassium of 2. Rigid sequences make no sense- you need to show that you’re prioritizing the key problems first, whether it’s fixing the hypokalemia, hypotension, or hypoxemia. Of course, if the patient is presenting in a coma, please start with the head. But if the patient’s toe is draining pus, please start down there.
The attached “Yale Way” guide to presentations is our standard. Let’s create crisp, efficient, orderly presentations that include all the key facts and leave out the clutter. Good presentations help everyone focus on the issues that demand our attention and bring us closer to the right diagnosis and plan.
Enjoy your Sunday, everyone. I’m going to hike up East Rock before heading for dinner with family friends down in Fairfield County. Tomorrow morning, it’s back to the SDU.
Mark
P.S. What I’m reading and listening to:
- The Known World by Edward P. Jones
- Attention Span: A Groundbreaking Way to Restore Balance, Happiness and Productivity by Gloria Mark
- How to Influence People—And Make Friends by Arthur Brooks
- “Do You Feel Safe at Home?” by our very own Lara Rotter
- "Exercise May Be the Single Most Potent Medical Intervention Ever Known" on “Plain English” with Derek Thompson