Presenting in the patient's roomD

[swoopyswoop]

I've done this before on outpatient rotations and it has been extremely simple, straightforward, which is mostly because outpatient medicine is much more simple/straightforward, and is usually just an HPI + Physical to present.

But on inpatient... it seems so awkward to go through the SOAP style presentation, or worse, the entire h&p on a new patient, in front of them. Especially when it comes to presenting labs where half the values are not important for the patient to be aware of, but which the team might need to have a lengthy discussion about. Or patients interrupting and asking about parts of the plan when you're not done presenting/discussing. It just seems very awkward.

Then at the end when you go to present your plan, you haven't discussed it with the attending, so half of it is wrong, and they obviously will correct your plan and make sure the patient understands the ACTUAL plan which, in my mind, just leaves the patient not trusting this med student who was suggesting incorrect things to do.

Sorry for the rambling. Just a combo of having a really complex psych patient ( on medicine, w/o a psych rotation done yet!) + an attending who responds to patient interruptions with "let us finish talking, and then we;ll answer your questions" (aka AWKWARD).

---

Members don't see this ad.

 

[Elixir6]

I'm surprised any attending would want you to present a patient IN their room. Especially a psyc patient. What are you going to start talking about their personality disorder and delusions in front of them???

 

[Kaustikos]

I'm surprised any attending would want you to present a patient IN their room. Especially a psyc patient. What are you going to start talking about their personality disorder and delusions in front of them???

Uh... Every inpatient did that here. But I always discussed my plan with the intern/resident beforehand.

 

[styphon]

I had multiple rotations as a med student were you presented in the room. Some comfortable and helpful (pediatrics) and some more degrading (surgery).

 

[Elixir6]

Not that I'm that far into the third year, but we have always table-rounded or presented the patient in the hallway or nurses station before going into the room to do real rounds. Included in my experience is several inpatient places. If its not a new patient sometimes we had a discussion in the room with the patient, but I wouldn't consider that a formal 'presentation'. As has been clear on SDN, different people and places do it differently.

 

[Snoopy2006]

The trend of patient centered rounds is growing. I agree there are some pitfalls, but in general it seems to make patients and families feel more involved and see more of the time that's invested in their care. It could potentially lead to less "The doctor billed me $500 and he was only in the room for 2 minutes!" NY-Times-type comments, although I'm not overly optimistic on that front.

The main thing is communicating well so the patient has appropriate expectations. When I'd pre-round in the morning, I'd explain that I'd return later in the morning with members of the team and present to them what we'd just discussed, and that we'd work together as a team and collaborate to come up with the best possible treatment plan for them. People seemed to respond well to that and enjoyed the collaborative approach. We used this on several rotations, and I can remember only 1-2 patients or family members that interrupted enough to disturb the flow of the presentation.

The main pitfall, in my mind, was having to explain your full thought process and DDx when malignancy was on your DDx but further down than another (far more likely) cause. As a new M3, I was generally uncomfortable with alarming patients unnecessarily - many patients hear nothing else after the word "cancer." Don't mention it, and you look like the med student with the weak differential. Eventually you learn to finesse your way through it, and most attendings are understanding.

On the rare occasion that I suspected a patient wasn't being completely forthright, secondary gain, etc., I'd just ask my attending if we could talk for a couple minutes outside before entering.

It's actually a neat system and I found I had better rapport with patients/families on the rotations we did this on.

The keys:
1) Ask your resident if you can take 10 minutes before rounds to discuss your plans with them (the good residents will set aside time for this)
2) Confidence and delivery is key when you're presenting in front of the patient. It'll come with time, but until then - fake it.

 

[FutureInternist]

I had an ICU attending who did this, to the point of us pulling up CXRs etc in the room & discussing them

It was weird at first but it does show the family just how much work goes on for their loved ones care & that makes it more likely for them to accept your recommendations

The pts are the ones that gave us the H&P so they are not hearing anything about themselves they don't already know and if that situation does present itself (pregnancy etc) then experience will teach you how to navigate through that

For unsure Dxs (cancer etc) that would scare the pt, you can just point to your written Dx or use big words that the pt may not know (eg VDRL is (+) instead of syphillis)

 

[SouthernSurgeon]

I had an ICU attending who did this, to the point of us pulling up CXRs etc in the room & discussing them

It was weird at first but it does show the family just how much work goes on for their loved ones care & that makes it more likely for them to accept your recommendations

The pts are the ones that gave us the H&P so they are not hearing anything about themselves they don't already know and if that situation does present itself (pregnancy etc) then experience will teach you how to navigate through that

For unsure Dxs (cancer etc) that would scare the pt, you can just point to your written Dx or use big words that the pt may not know (eg VDRL is (+) instead of syphillis)

We do it for our ICUs as well. We don't typically pull up CXRs (sometimes will if there is something specific to show the family).

But we do big multidisciplinary rounds with the MDs, nurses, pharmacists, nutritionists, and respiratory therapists all present. The bedside nurse grabs the family and they come listen. Usually either the attending or the fellow will hang back for a minute after we finish to explain in lay terms and/or answer questions while we move on to the next patient.

Families really like it.

 

[KnuxNole]

The thing that irks me about this is when you make the wrong plan, and you screw up in front of the patients....at least with table/walking rounds if you screw up, the patients won't know :/

 

[FutureInternist]

We do it for our ICUs as well. We don't typically pull up CXRs (sometimes will if there is something specific to show the family).

But we do big multidisciplinary rounds with the MDs, nurses, pharmacists, nutritionists, and respiratory therapists all present. The bedside nurse grabs the family and they come listen. Usually either the attending or the fellow will hang back for a minute after we finish to explain in lay terms and/or answer questions while we move on to the next patient.

Families really like it.

Don't know what year Resident you are but you should definitely try to do the "lay person talk" yourself
I just started a hospitalist job and have already seen several attendings ask about "code status", "CPR", "resuscitation" etc
Patients are not going to admit when they don't know what things mean for fear of being seen as stupid & this can lead to miscommunication down the road

 

[SouthernSurgeon]

Don't know what year Resident you are but you should definitely try to do the "lay person talk" yourself
I just started a hospitalist job and have already seen several attendings ask about "code status", "CPR", "resuscitation" etc
Patients are not going to admit when they don't know what things mean for fear of being seen as stupid & this can lead to miscommunication down the road

I've had more lay person talks than I need.

Just the way the ICU rounds are structured it naturally falls on the attending or fellow as they are the only ones without an assigned task. The residents are all either presenting or entering orders or doing notes. Everyone has an assigned job on each patient.

 

[Kaustikos]

The only time I hated this is when we were outside a room discussing the mri results showing Mets and terminal diagnosis. The attending made everyone go in when it should have been just the attending and student who had the patient. It was awkward. He made it worse when we walked out and said "someone's gotta be the bad guy sometimes". I wanted to punch him.

 

[SouthernSurgeon]

The only time I hated this is when we were outside a room discussing the mri results showing Mets and terminal diagnosis. The attending made everyone go in when it should have been just the attending and student who had the patient. It was awkward. He made it worse when we walked out and said "someone's gotta be the bad guy sometimes". I wanted to punch him.

If I have to have a conversation like that, I take at most one person in the room with me. If the attending is having the conversation, I come with them as the senior resident and at most one more person.

I also don't do it during work rounds, but rather at a point in the day where I have the time and attention that the patient/family deserves.

 

[Kaustikos]

If I have to have a conversation like that, I take at most one person in the room with me. If the attending is having the conversation, I come with them as the senior resident and at most one more person.

I also don't do it during work rounds, but rather at a point in the day where I have the time and attention that the patient/family deserves.

I thought I was the only one that thought that. Thanks. It's nice to know that some people realize the gravity of the situation and try to take the appropriate measures to deliver said news.

 

[KnuxNole]

If I was the attending, I'd probably only bring in the senior most resident, an intern if it's their patient, and myself. Leave all students out and interns/residents that weren't actively part in their care. It's better to have a small group discuss this vs. the whole team.

 

[FutureInternist]

If I was the attending, I'd probably only bring in the senior most resident, an intern if it's their patient, and myself. Leave all students out and interns/residents that weren't actively part in their care. It's better to have a small group discuss this vs. the whole team.

I think it is important for the interns to be in all the discussions since there are so many different situations that arise that the more they are exposed to them the more they can hone their skill in doing complicated medical discussions with ease

The most extreme form of this (& I agree with this as well) was when attendings would have us code patients in front of families since most people have no idea how violent the process is & I have seen a lot of families make people DNR as soon as they have seen one

Having, unfortunately, been on the other side of the bed, so to speak, with my dad, it definitely helped my mother when discussions were done with her in the room

For me the best is to straight up ask the family what they want, specially when coding or pronouncing

 

[Kaustikos]

If I was the attending, I'd probably only bring in the senior most resident, an intern if it's their patient, and myself. Leave all students out and interns/residents that weren't actively part in their care. It's better to have a small group discuss this vs. the whole team.

I agree. Which is what I thought was most appropriate. This was just awkward and sad. Live and learn

 

[pdxhopeful]

My last rotation often did patient centered rounds, and it generally went fine. What we would typically do if there was something the attending needed to know but shouldn't be said in front of the patient is, before entering and with the door still closed, quietly say just that bit of info. "Before we go in, Dr. ___, you ought to know that the patient is claiming X, but < contradictory info >."