Presenting patients: Why?

[Speed Racer]

In short, why do we present patients to seniors and attendings? It is not a skill that we need when we graduate. We already know how to sign out and call in consults/admission.

For me personally, looking at the patient gives me a huge chunk of the information I need for dispo/diagnosis.

So why focus on it? Why is it part of our evaluated skills? Why waste time sitting at the desk for 5 minutes painting the picture to some one about a complex case?

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[docB]

You're not presenting for the sake of presenting. You're presenting to get input and education about the management and disposition of the patient.

 

[Apollyon]

Because, by definition, the senior is more experienced. If you knew everything, you wouldn't need to be a resident. It may be straightforward to you, but there could be something you're missing. Also, when the senior or attending goes and sees the patient, and they find something you didn't mention, they wonder if you saw it at all.

 

[southerndoc]

In short, why do we present patients to seniors and attendings? It is not a skill that we need when we graduate. We already know how to sign out and call in consults/admission.

For me personally, looking at the patient gives me a huge chunk of the information I need for dispo/diagnosis.

So why focus on it? Why is it part of our evaluated skills? Why waste time sitting at the desk for 5 minutes painting the picture to some one about a complex case?

Unlike you, most interns and junior residents don't know all there is to know about medicine. Even as an attending I am still learning a lot. When I was an intern and a junior resident, I learned a lot from my seniors and attendings.

 

[txterp98]

In my last year of residency, one of our best attendings gave me a pointer on presenting patients to consultants. He recommended during busy times to start off with.....Mr. Jones, a patient of Dr. X in the community, has XYZ.....

By mentioning the patient has a private doctor, it may be construed that the patient has some means of providing compensation. Not a foolproof method, by any means, but it can help. Consultants hate getting slammed....at least they know that some of their work will be compensated and they're not only providing charity ER care.

Bear in mind, I mention this anecdote because it was something I learned from presenting to my attending. Try to learn as much as you can while you still have the opportunity...not just medicine, but the whole picture.

 

[gutonc]

In short, why do we present patients to seniors and attendings? It is not a skill that we need when we graduate. We already know how to sign out and call in consults/admission.

For me personally, looking at the patient gives me a huge chunk of the information I need for dispo/diagnosis.

So why focus on it? Why is it part of our evaluated skills? Why waste time sitting at the desk for 5 minutes painting the picture to some one about a complex case?

Not sure if your post is a joke or not but in addition to the previous posts, I'd add one reason that should be very obvious if you've practiced medicine in the US for more than about 45 seconds. It's a medico-legal issue. You are NOT the physician of record as a resident or fellow, your attending is. If they are to legitimately put their attestation in the medical record that they evaluated the patient and discussed the plan of care with you, you have to give them the opportunity to do so.

Of course being able to learn something and expand your (clearly already considerable) knowledge base and skill set is a good reason too.

 

[NateintheED]

Have you ever called a consultant? What do you say to them - "I have a patient, come see them", and hang up? No. You present the patient to them with pertinent positives/negatives/etc. If you don't do it right, the consultant may refuse to see the patient. Granted, consultant presentations may not be in the depth that some of your seniors and attendings ask, but if you can present to them, then they know you can present to the consultant.

 

[Speed Racer]

Hmm... I should have written a longer more explicit post.

I am not saying we should not present (ie discuss the case with) a senior or an attending.

My point is that the actual skill of the presentation seems a bit pointless if when I myself am an attending I will not be presenting to anyone. Consults and admissions are a different skill set IMHO.

Would it not make more sense to give a brief one liner, what you found, and what you plan to do, then have the senior go see the patient and then have the education/discussion. The time you have with your supervisor is so brief it just seems more efficient.

 

[Apollyon]

Hmm... I should have written a longer more explicit post.

I am not saying we should not present (ie discuss the case with) a senior or an attending.

My point is that the actual skill of the presentation seems a bit pointless if when I myself am an attending I will not be presenting to anyone. Consults and admissions are a different skill set IMHO.

Would it not make more sense to give a brief one liner, what you found, and what you plan to do, then have the senior go see the patient and then have the education/discussion. The time you have with your supervisor is so brief it just seems more efficient.

As you move on, you will learn the "pertinent positives", and can give the "A & P" in one line. That is part of the teaching method - as I tell the interns and med students, in the ED, I should know in the first 10 seconds why the patient is there - the opposite of the IM presentation.

 

[Arcan57]

My point is that the actual skill of the presentation seems a bit pointless if when I myself am an attending I will not be presenting to anyone. Consults and admissions are a different skill set IMHO.

I'll agree with that statement to a point. "Selling" an admission is definitely a unique skill, but the ability to succinctly summarize a patient's condition to another physician never stops being useful. If you don't have the good fortune to go into your job being on a first name basis with all the hospitalists, your ability to present is going to have a huge impact on how you're perceived.

 

[Hercules]

Would it not make more sense to give a brief one liner, what you found, and what you plan to do, then have the senior go see the patient and then have the education/discussion. The time you have with your supervisor is so brief it just seems more efficient.

One other thing you'll learn is that the attending/senior will let your presentations become more brief and focused as you progress clinically. As a senior resident discussing patients with the attending, it's usually in the form of running the board with 1-2 lines per pt. Your attendings and seniors aren't going to give you that amount of respect or confidence until you've earn it.

 

[roja]

Presenting, as a skill in and of itself, is a very valuable endeaver.

One- as has already been pointed out, you will be presenting for the rest of your career. You will be presenting admissions, consults, etc.

Two- and probably more importantly- the act of presenting forces you to organize your thoughts, be systematic, and think in a logical fashion. It gives you the cognitive framework that will allow you to make more rapid decisions as it becomes ingrained in your habit.

 

[FLTDOC1]

All the educational issues aside, as the attending, the ultimate responsibility( legally and medically) of every patient in the department lies on my shoulders. If there were a bad outcome, the attending would always be implicated if he saw the patient with the resident. The attending would be hung if he knew nothing about the patient.

I dont know how it is run in other departments but it is a rare occasion that a patient is discharged from my department without me at least laying eyes and/or hands on them.

 

[Jeff698]

I dont know how it is run in other departments but it is a rare occasion that a patient is discharged from my department without me at least laying eyes and/or hands on them.

I will occasionally "moonlight" as an attending at our teaching hospital up the road. I am expected to see every patient, no exceptions, just like at your place. I'm pretty sure that's the way it is everywhere. I'm also pretty sure that you're committing Medicare fraud if you bill a Medicare patient without having seen them.

I disagree that presenting to ED attendings and consultants is a different skill set. You want something from both and are crafting your message in a way designed to get what you want. You want your attending to agree with your plan so you feed him/her the information they want, in a way they want it. You want your consultant to admit the patient with minimal fuss so you do the same for them.

Take care,
Jeff

 

[SoCuteMD]

I will occasionally "moonlight" as an attending at our teaching hospital up the road. I am expected to see every patient, no exceptions, just like at your place. I'm pretty sure that's the way it is everywhere. I'm also pretty sure that you're committing Medicare fraud if you bill a Medicare patient without having seen them.

I think on my FM rotation I was told that level IV and V visits could be seen/discharged by a resident. Most ED visits don't fall into those categories, though.

 

[Jeff698]

I think on my FM rotation I was told that level IV and V visits could be seen/discharged by a resident. Most ED visits don't fall into those categories, though.

That's one of the differences between clinic and ED. This is done often in the clinic setting but not allowed in the ED.

Take care,
Jeff

 

[Arcan57]

In residency, we would have an attending dedicated to the fast track. It was not because they were really needed for medical decision making, but it allowed the group to bill for all those level II and III visits from the Medicare patients using us as a primary doctor.

 

[Febrifuge]

You practice presenting now because in the future, others will be presenting to you -- and you will be responsible for making sure they can present the information YOU need, in a way that is succinct yet complete. You want their presentations to be useful to you, and you'll be teaching them how to make them so.

 

[KYTNOH]

I've had several attendings ranging from IM to EM to surgery tell me that the best skill set to have to boost your reputation among other physicians is the ability to efficiently convey the complete picture of a patient. Rightly or wrongly, judgements are made about compentency with the patient presentation. I can easily think of times when I was very impressed or unimpressed by a student/resident/attending based purely on their presentation, and I'm sure that's not going to stop happening.

While I haven't yet started residency, I can say that I have caught mistakes or omissions in my differential, assessment and plan during my rotations while I was giving my presentation. I just finished a peds rotation (my last one of med school!) and one of my attendings told me she continued to "present" patients in her office to herself for the first several months after she was out of residency because it was a very useful way to logically think through a patient.

 

[GeneralVeers]

A lot of complicated answers to a simple question.

If you don't present the patient, how else will your attending know that you are competent to graduate residency?

 

[Jeff698]

Take a call from a doc at an outside hospital wanting to transfer them to you and you'll see the value of a solid presentation.

I took one yesterday. The doc literally started the conversation with "I have an 80 year old with a WBC of 14" and then began listing off a litany of labs. I had no confidence at all that this doc had any clue what was going on with the patient but was pretty clear that us accepting them would be a good thing. Preferably quickly.

Take care,
Jeff

 

[xaelia]

I received a patient in transfer who had spent a month at Community Hospital, had two small bowel resections, sepsis, intubation, TPN, and an ICU stay - and her transfer summary was half a page of 14-point type.

Luckily, I had 100 pages of photocopied labs and nursing notes to "help" "clear up" "the picture".

Being able to distill any amount of information into a concise assessment never goes out of style.

 

[peerie]

It's interesting to read the comments here about presenting patients. I have sometimes wondered about this as well, and have sort of felt like the OP.

For me one of the biggest things I have struggled with in school has been presenting, and it really is interesting how much weight people put on your ability based soley on your presentations. Many thought I did an excellent job, but then the next day an attending would say I was a complete mess and had no idea how to present, etc. So it can definitely be variable according to the attending. Some people were incredibly harsh with me in the beginning and it was definitely upsetting to be ripped to shreds on rounds. I still have a huge sensitivity to the whole presenting thing that I need to work on.

Anyway, I do agree that it is an excellent skill to have and of course we all need to do it well. For me, I just wish I had been able to learn it better early on and I know it will take some effort to overcome the early negative experiences I had and to feel really confident. But, it is do-able, and I look forward to overcoming this sensitivity and being a smooth and competent presenter in whatever situation I find myself in.

 

[Arcan57]

Take a call from a doc at an outside hospital wanting to transfer them to you and you'll see the value of a solid presentation.

I took one yesterday. The doc literally started the conversation with "I have an 80 year old with a WBC of 14" and then began listing off a litany of labs. I had no confidence at all that this doc had any clue what was going on with the patient but was pretty clear that us accepting them would be a good thing. Preferably quickly.

Take care,
Jeff

This would make a pretty good topic on its own. The disconnect between what is described over the phone and what actually shows up in my ED is staggering. My favorite has to be the transfers of patients with lower back pain sent to us for neurosurgery to eval. I'm not sure if there's anything in the literature about a 1.5 hr ambulance ride being curative for cauda equina, but if not I have a pretty good case series. Also, how do you respond when you know the doc on the other end of the phone is lying?

 

[GeneralVeers]

For me one of the biggest things I have struggled with in school has been presenting, and it really is interesting how much weight people put on your ability based soley on your presentations. Many thought I did an excellent job, but then the next day an attending would say I was a complete mess and had no idea how to present, etc. So it can definitely be variable according to the attending. Some people were incredibly harsh with me in the beginning and it was definitely upsetting to be ripped to shreds on rounds. I still have a huge sensitivity to the whole presenting thing that I need to work on.

When I work with residents I want them to vary their presentation based on the complexity. If they're seeing a simple pharyngitis, I don't want a whole ROS, PMH, socH, and physical exam. I want to know what the diagnosis is, why they think it's pharyngitis, and what the plan is going to be.

In contrast if it's a 70-year old with abdominal pain, I want the WHOLE story, but told as concisely and with as few unnecessary words as possible.