Tips on Presenting

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

sariyu

New Member
10+ Year Member
Joined
May 11, 2011
Messages
7
Reaction score
0
I am looking for tips on presenting patients to attendings. I just started third year and I am on my first rotation. My biggest problem is going blank or not knowing what to say (and the accompanying fear of this happening). I probably have some underlying performance anxiety and fear of authority. I also seem to be increasingly forgetful with waning attention. It is actually quite distressing when I think about what seems to be a loss of memory function. I don't know the best way to deal with this but I am willing to work through it.

It happens when interviewing patients as well. If I am alone with them I am fairly comfortable. But add in the rest of the team (or even the attending with a student or two) then suddenly I am extremely uncomfortable.

Another problem referenced above is that sometimes my attention drifts off, missing something that the attending or patient might have said (especially if I am not involved in the conversation and just observing). It doesn't help that my hearing seems to be slightly diminished and a lot of patients/doctors speak very softly.

Members don't see this ad.
 
For any rotation, the number one thing you can do is to go through every patient systematically. You will hear many residents mixing the subjective and the objective, going back and forth based on what they think is important. That's OK to do... once you have significant experience. And even then, it's less than ideal. People who are listening to your presentation are listening for things to slot into place, and the way you do that is by presenting them in order:

First the subjective. For an H&P, that means go through your one line introduction, then the full HPI, pmhx, pshx, meds, allergies, soc hx, fam hx, relevant ros. In order. For a follow up note, present your one liner, then the overnight events, then your assessment of how the patient is doing.

Then the objective. Present the vitals, present your exam, present the relevant labs, present the relevant imaging, any relevant culture results

Then your assessment. Then your plan. Don't mix the assessment and plan.

Different specialties will expect different levels of detail and emphasis on different things. The internists will want more than the surgeons, but everyone will be happy if you systematically go through, and it is an excellent crutch if you ever get bogged down. You should never be wondering what comes next.
 
  • Like
Reactions: 2 users
Agreed. Would add that I still find it helpful to speak the names of each section.

blah blah with CHIEF COMPLAINT of blah
The PRESENT ILLNESS began blah blah blah
PAST MEDICAL Hx remarkable for blah blah blah
etc

The other thing is don't be afraid of forgetting to say something; just tell the story. If the attending has questions then they will ask, and their questions will help you realize what you should remember when evaluating/presenting that disease the next time.

Also, unless told, don't do that stupid thing so many people where they put ALL the past medical right at the top like "This is a 65 yo male with past history of CAD, COPD, HTN, HLD, PVD, Prostate CA, Sinusistis, pneumonia, humeral fracture......etc etc...." Just put the ones that are relevant to this present illness.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
be straight up with your attending and ask "how do you like patients presented?" They will sit you down and go over how they like it done; write down what they say and you have yourself a nice script! Go home, write it out on a cue card and keep it with you during rounds. Problem solved!
 
  • Like
Reactions: 2 users
I agree with the above, very much attending dependent.

Also as you go through the year you will start to see that many times saying less will make you look way smarter, particularly if your aware of the context. For example if you heard your upper level resident was just discussing your patient's night with the attending before rounds then later on when your rounding everyone is going to love you if you ask the attending "Seeing as we already talked about him, want me to just run through the plans for today real quick?" Then if attending says do a full presentation knock yourself out, otherwise you save the team some time and are a good team player.
 
  • Like
Reactions: 1 users
All of the above. And then also realize presenting is a somewhat useless formality in most grown up medical situations. It's designed to get you to be able to organize your thoughts about complex patient care, so that you can communicate them. Once you learn to separate objective from subjective information and how to itemize a patient problem list, then you're there.

The rest is just the formalities of court behavior for whatever lord you're addressing. Making too much of that is too exhausting. Unless you're trying to match derm something. Don't f'n sweat that small ****.
 
  • Like
Reactions: 1 user
good,.Then the objective. Present the vitals, present your exam, present the relevant labs, present the relevant imaging, any relevant culture results
wxlaO7
 
  • Like
Reactions: 1 user
Don't restate the data in the a/p. that **** is sooo frustrating to listen to. For each problem, either a definitive dx and tx plan, or a ddx with a work up and empiric tx plan. Hit us like that and we will kiss your feet like the fat man.


Sent from my iPhone 6 using Tapatalk
 
  • Like
Reactions: 1 user
Your presentation is not taking as long as you think it is. Don't try to finish it in one breath. Relax and speak in a conversational tone. You'll feel better and look better as long as you don't take forever.
 
  • Like
Reactions: 1 user
Just go really fast. Really fast. That way it's hard to discern if you forgot to say something or the attending didn't catch it.
 
  • Like
Reactions: 2 users
1. Please just don't read off a progress note/H&P. There are fewer things in life more boring than listening to an M3 read a progress note for 20 minutes. On my patient list, I would write vitals/labs/meds/problem list. You can glance at that if you need to.
2. Be formulaic and use transitions. Don't get fancy with the order. Break up your sections obviously: "With regards to the physical exam...with regards to the labs...etc".
3. Assessment and plan: Start with your assessment (should be short): "In summary, this is a 78-year-old male with history of CHF, CAD, HTN presenting with subacute dyspnea and edema suggestive of acute decompensated heart failure." Then problem list. When admitting a patient (before you have ruled out other things), I like doing my active problems by symptoms rather than diagnosis, i.e. "#1 Dyspnea" vs. "#1 ADHF". You don't know whether that dyspnea is from HF or pneumonia or ACS or whatever. But give your problem, a brief differential, and then your plan.

Always try to come up with a plan as an M3. It will set your apart from your colleagues and help develop your cognitive skills more than anything else.
 
  • Like
Reactions: 2 users
On family medicine now, and what I learned so far was just to ask what parts the interviewer wanted to hear.
 
#1 - Don't suck.
#2 - See #1.


Anyways, here's some real talk - Depends on what service you're starting off on. Medicine/Peds seem to want the full physical exam, while surgery's physical exam basically sounds like "Incisions are C/D/I, abdomen (or whatever general site was operated on) benign."

As you progress, you'll learn what's important and not important. However, at the very start of a rotation, most attendings will want something more in-depth before they realize that you're not just skipping over relevant details of the physical.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
There is a lot of good advice here (sprinkled with some bad).

One more thing I would add: Don't use acronyms, abbreviations, or terms that you don't understand.

I know that students try to blend in with the natives and talk the talk. But I've had students say things to me like "Our plan for today is to change the NG to DD, and d/c the JP". And on a little bit of probing I find out they don't know what any of those things mean.
 
  • Like
Reactions: 2 users
And NEVER lie to your intern/resident. If the intern is too busy to find out from hurrying here, and there, and everywhere, the upper level will definitely call you out on it. Should go without saying, but there's always one medical student out there who tries to make themselves look good at the expense of the patient. Don't do it. It's not worth it and you will get caught.
 
  • Like
Reactions: 1 user
I know that students try to blend in with the natives and talk the talk. But I've had students say things to me like "Our plan for today is to change the NG to DD, and d/c the JP". And on a little bit of probing I find out they don't know what any of those things mean.
:clap:
 
There is a lot of good advice here (sprinkled with some bad).

One more thing I would add: Don't use acronyms, abbreviations, or terms that you don't understand.

I know that students try to blend in with the natives and talk the talk. But I've had students say things to me like "Our plan for today is to change the NG to DD, and d/c the JP". And on a little bit of probing I find out they don't know what any of those things mean.

Doesn't end with students. If you don't know, ask.

We had an end of the year intern pull the JP instead of the penrose. He heard, "penrose drain", didn't know what it was and pulled the closest thing he could think of (the JP). *face palm*
 
There is a lot of good advice here (sprinkled with some bad).

One more thing I would add: Don't use acronyms, abbreviations, or terms that you don't understand.

I know that students try to blend in with the natives and talk the talk. But I've had students say things to me like "Our plan for today is to change the NG to DD, and d/c the JP". And on a little bit of probing I find out they don't know what any of those things mean.
Yeah,
I hate acronyms. Or abbreviations. Mostly because some of it can be made up or lingo that specialists use between each other and no where else. But definitely use these examples -
"Patient was all brb, I have to gtfo bc lol I'm sick. Amirite? LOL. You my bff, doc"


And NEVER lie to your intern/resident. If the intern is too busy to find out from hurrying here, and there, and everywhere, the upper level will definitely call you out on it. Should go without saying, but there's always one medical student out there who tries to make themselves look good at the expense of the patient. Don't do it. It's not worth it and you will get caught.

Lies are hit or miss. Sometimes you're not actively lying or even telling a lie, but the resident/intern just doesn't agree. Physical exams/ROS is where you're going to be called out on because someone disagrees with your findings. But don't try to lie when they ask you a question. So, agreed.
 
Lies are hit or miss. Sometimes you're not actively lying or even telling a lie, but the resident/intern just doesn't agree. Physical exams/ROS is where you're going to be called out on because someone disagrees with your findings. But don't try to lie when they ask you a question. So, agreed.
I'm not talking about disagreement on physical findings although sometimes these can even be lies if something is egregiously missed where you'd have to be blind or deaf to have missed it. I'm talking about stuff like -- saying labs were "normal", saying you checked the wound site or changed dressings (when you obviously didn't), making up numbers regarding amount of drainage, etc. Esp. on General Surgery, you'll get a through talking to by if not the intern, the upper-level resident.
 
On a different tangent. I think attendings could use a few tips on how not to make rounding a pain the ass that causes the residents' days to stretch way into the night. Some attendings want it done quick and dirty (properly) and everybody can get down to work in the mid morning so consultants can be called before late and everything else.

To me the varying ability of attendings to help the team get moving is way more important that the order and style of medical student reporting. By a long shot.

Instead of worrying so much about that inconsequential bull****, concentrate on what you do and how you do it. Because some attendings are awesome. And some make the day long and painful. Whereas medical students are either helpful or don't matter.
 
Last edited:
There is a lot of good advice here (sprinkled with some bad).

One more thing I would add: Don't use acronyms, abbreviations, or terms that you don't understand.

I know that students try to blend in with the natives and talk the talk. But I've had students say things to me like "Our plan for today is to change the NG to DD, and d/c the JP". And on a little bit of probing I find out they don't know what any of those things mean.

I made it my goal to never use real words on surgical notes:

44yo M, POD1, s/p SPK
NEON, Pn WC PCA HM, -NV/CP/SOB, -F/BM
AO, NAD, Resp CTAB, CV RRR -m/g/r, abd soft AT/ND, wound CDI, ext -c/c/e

not srs but i've come close.
 
I made it my goal to never use real words on surgical notes:

44yo M, POD1, s/p SPK
NEON, Pn WC PCA HM, -NV/CP/SOB, -F/BM
AO, NAD, Resp CTAB, CV RRR -m/g/r, abd soft AT/ND, wound CDI, ext -c/c/e

not srs but i've come close.

So here's the thing (not meaning to pick on you since I know you are kidding/exaggerating)...

There are a number of students whose notes do look a lot like this. And they are terrible student notes.

A student note is a non-billable note. The reason residents get away with their notes is that they are (a) necessary for the medical record and (b) everyone acknowledges that the residents are overworked. Now granted, this would still be a terrible resident note, but at least we let it slide (*caveat - our residents write brief, but nice, notes with a minimum of abbreviations. I have seen terrible abbreviation word salad at other hospitals).

But a student note is written for one reason, and one reason only - your education. Do you learn anything from regurgitating acronyms and abbreviations? Can a senior resident or attending tell if you understand what is going on with the patient and give you feedback? No. That note is worthless. Either write something worth writing or don't waste the time.
 
  • Like
Reactions: 1 user
I made it my goal to never use real words on surgical notes:

44yo M, POD1, s/p SPK
NEON, Pn WC PCA HM, -NV/CP/SOB, -F/BM
AO, NAD, Resp CTAB, CV RRR -m/g/r, abd soft AT/ND, wound CDI, ext -c/c/e

not srs but i've come close.

I understand maybe half of that
 
  • Like
Reactions: 1 user
I made it my goal to never use real words on surgical notes:

44yo M, POD1, s/p SPK
NEON, Pn WC PCA HM, -NV/CP/SOB, -F/BM
AO, NAD, Resp CTAB, CV RRR -m/g/r, abd soft AT/ND, wound CDI, ext -c/c/e

not srs but i've come close.

I need you to define the following, the rest of them I've got.
SPK
AT
HM - Hydromorphone?

Idk, I never used NEON (No events over night, I'm guessing) or Pn WC PCA HM (Pain Well Controlled on PCA hydromorphone? I'd rather spell that one out). I'm more OK with an acronym salad on ROS and CP, not in the subjective portion.

I think if you're a student and you understand all the acronyms you use, it's ok to use them. Obviously from a resident's perspective, it's a pain to make sure the student you're working with actually knows what they all mean (and thus asked the questions and did the appropriate PE.)
 
I understand maybe half of that

Here is the note in fullhand

44 year old male, Post-operative Day #1, s/p SPK (not sure what that is)
S: No (should include 'acute' here) events over night, pain well controlled on hydromorphone PCA, no nausea/vomiting/chest pain/shortness of breath, no flatus/bowel movement
O: Alert and Oriented, not in acute distress,
respiratory - clear to auscultation bilaterally,
cardiovascular - regular rate and rhythm, no murmurs/gallops/rubs,
abdomen - soft AT (likely 'appropriately tender' on second thought, which I despised using since as a student you have no idea what is an appropriate amount of pain; I would just use a pain scale in the note), non-distended. wound clear/dry/intact
ext - no clubbing (c'mon who checks for this really), cyanosis, edema

Then you would generally put your plan (although we also included in an assessment which was basically a rehash of the first line along with whether the pt was improving or not)
 
  • Like
Reactions: 1 user
Here is the note in fullhand

44 year old male, Post-operative Day #1, s/p SPK (not sure what that is)
S: No (should include 'acute' here) events over night, pain well controlled on hydromorphone PCA, no nausea/vomiting/chest pain/shortness of breath, no flatus/bowel movement
O: Alert and Oriented, not in acute distress,
respiratory - clear to auscultation bilaterally,
cardiovascular - regular rate and rhythm, no murmurs/gallops/rubs,
abdomen - soft AT (likely 'appropriately tender' on second thought, which I despised using since as a student you have no idea what is an appropriate amount of pain; I would just use a pain scale in the note), non-distended. wound clear/dry/intact
ext - no clubbing (c'mon who checks for this really), cyanosis, edema

Then you would generally put your plan (although we also included in an assessment which was basically a rehash of the first line along with whether the pt was improving or not)

simultaneous pancreas kidney transplant

appropriately tender
 
  • Like
Reactions: 1 user
I need you to define the following, the rest of them I've got.
SPK
AT
HM - Hydromorphone?

Idk, I never used NEON (No events over night, I'm guessing) or Pn WC PCA HM (Pain Well Controlled on PCA hydromorphone? I'd rather spell that one out). I'm more OK with an acronym salad on ROS and CP, not in the subjective portion.

I think if you're a student and you understand all the acronyms you use, it's ok to use them. Obviously from a resident's perspective, it's a pain to make sure the student you're working with actually knows what they all mean (and thus asked the questions and did the appropriate PE.)

Yep to the above. I'm on transplant now. (The other types = PAK: panc after kidney, PTA: panc tx alone)

As far as acronyms go we're in agreement. If you know what they mean and your residents/attendings use them, I don't see a reason why not.

Except for the first few days of a rotation, I've never had a problem using acronyms unless the resident found out you have no idea what it means. In that case, yes its a problem. However, I've been pimped multiple times on knowing specific acronyms during rounds and some attendings expect you to know and use them.

With regards to notes and education, ill play the devils advocate for a moment:

Except for coming up with a plan, nothing else in the note really serves any real educational value. The SOA portions of SOAP are so variable between residents and services, that the first few days of a rotations are essentially just figuring out what they want too see then rinse and repeat. S: what happened overnight, O: copy/paste VS/PE/labs/studies, A: one line summary. No real critical thinking is involved. Even then for most patients on surgery, the plan is usually the same for each patient unless they have serious complications. Pain control (PCA dose, switch to norco, etc...) Advance diet, Restart home meds, Abx PPx, DVT PPx (OOB, SCD, SQH/lovenox if morbidly obese), Resp PPx (Incentive spirometry), etc...

As far as education is concerned, as least in my experience, writing notes is pretty low yield after the first few days. Maybe I'm missing something though. :shrug:
 
  • Like
Reactions: 1 user
As far as education is concerned, as least in my experience, writing notes is pretty low yield after the first few days. Maybe I'm missing something though. :shrug:

Yeah,
The attending who reads your notes and yells at you for doing that.
But I don't mind. Only because I've found I can put things into these notes that no one can question... Like writing my HPI as a lord of the rings story when describing events... Using adjectives that are hilarious.
"patient commenced traversing the lands of Indiana by road with comrades toward the destination of X hospital wherein they commenced embarking on dismounting their vehicle and walking towards the doors of X hospital."
 
As far as education is concerned, as least in my experience, writing notes is pretty low yield after the first few days. Maybe I'm missing something though. :shrug:

Well you left off an assessment and plan in your original example, so you skipped the most educational part. ;)

And I think if you say there is no critical thinking involved in the A/P then you are missing something.

Here's my issue - many of my interns at the beginning of the year can't write a decent H&P or a decent D/C summary that accurately captures the relevant clinical issues. Their notes often betray that they don't really understand the reason for admission or the most likely complications that can/may occur that we worry about and try to aggressively treat. Their plans on daily progress notes do the same.

This is to say nothing of a consult note - a well written and succinct consult note is actually fairly nuanced.

So while you may not think it's "educational" to spend time on notes, it is something that a lot of interns are lacking skills in - so somewhere along the way they missed some education. Whether that is because they didn't do it enough as students, or didn't get adequate feedback, I can't say.
 
Well you left off an assessment and plan in your original example, so you skipped the most educational part. ;)

And I think if you say there is no critical thinking involved in the A/P then you are missing something.

Here's my issue - many of my interns at the beginning of the year can't write a decent H&P or a decent D/C summary that accurately captures the relevant clinical issues. Their notes often betray that they don't really understand the reason for admission or the most likely complications that can/may occur that we worry about and try to aggressively treat. Their plans on daily progress notes do the same.

This is to say nothing of a consult note - a well written and succinct consult note is actually fairly nuanced.

So while you may not think it's "educational" to spend time on notes, it is something that a lot of interns are lacking skills in - so somewhere along the way they missed some education. Whether that is because they didn't do it enough as students, or didn't get adequate feedback, I can't say.

I agree with your assessment. With regards to my own deficiencies, even. But I'm not convinced your plan addresses the real problem, for me at least. I'm responsible for documenting everything that goes on with 10 patients. It's just going to take a while before I can understand them quickly enough to keep up with my note writing responsibilities.

Probably by the time I leave medicine in 5 months, my notes might be marginally useful. But is it the volume of the notes that's the active ingredient or is is the pattern recognition of medical treatments. If I had 6 patients to write notes on I might have time to look more things up and have a better sense of a patient on day 1. But...yeah. I'm just barely keeping up right now.
 
Top