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trouble in case presentation

Discussion in 'Clinical Rotations' started by babyblue, Mar 7, 2007.

  1. babyblue

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    help!! i'm a visiting medical student, doing my rotation in IM. Since the very first week of my rotation here (it really is my very first one!) I already have to do the oral presentation of new patients. I'm really not used to it and I feel like I am humiliating myself in front of the whole team. Cause when I get nervous I start to stutter and it really gives the impression, as if I could not speak english at all! I know that my english is still far away from perfect, but i know that i'm not that bad either! and every time i have to do this, my knees start to shake and i can't even get the right sentences together! i'm starting to feel depressed now, cause it's really frustating to feel like this every day on the round with attendings! and i've asked the residents several times to help me with my presentation, they always say, "oh no you are good!", which i don't believe at all.
    i always have headache too after that and keep saying to myself that i should practice more at home. but still, i feel that i haven't been improving at all in my third week now!
    would appreciate any suggestions from you guys about how i can handle this better. thanks!
     
  2. Pox in a box

    Pox in a box 1K Member
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    Practice presenting your patient in front of a mirror. Record yourself presenting and listen to it and find places you can improve. Present in front of other medical students. Speak candidly with your attending that you would like to improve this skill. Remember, it's learned...you aren't necessarily born with it.
     
  3. OP
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    babyblue

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    hey thanks pox in a box! i'll try that one.
     
  4. Doc Ivy

    Doc Ivy Miss Understood
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    You are not alone. I felt the same way on my medicine clerkship-- and English is my first language:eek: it's like I couldn't get my act together... I would be up half the night staring at my alarm clock and obsessing about rounds the next morning.

    Practice makes perfect. You will get better. The best advice I ever got about presenting was this: It's nothing more than telling the story-- who, what, when, where, why. Don't stress about making it perfect, that will come with time. Just worry about what the team needs to know. Who is the patient? what are they here for? What happened overnight? Any new events? What's keeping them in the hospital?

    Have all the data, but only hit the high points. For example, don't say sodium 135, potassium 4.5, Chloride 110 etc. Rather say this am's chem was within normal limits WITH THE EXCEPTION OF an elevated Cr of 2.5. Some attendings are anal and want every lab, but in general when you bog the team down with too many details they lose the big picture, start interrupting you and then mess with your flow.

    One of my main problems was leaving out whole parts of the presentation like the exam, or vitals. So I would always have a set of five phrases I would use for every presentation:

    1) "In terms of overnight events..."
    2) "Review of vital signs shows..."
    3) "On exam the patient has..."
    4) "Todays labs/cultures/imaging are significant for..."
    5) "So I think the plan for this patient should be..."

    I liked to organize my plan in terms of systems CV, Pulm, GU/Renal, GI, FEN, Neuro/Pain, Psych, ID, Endocrine, Prophylaxis, Dispo. For me this was the best way to never forget any of the patient's issues, especially if they're complicated.

    Another tip-- I would try to have my note done before rounds so that I could refer to it during my presentation. Don't just read it, try to make eye contact, but having your note in front of you can help keep you on track.

    Hope it helps!
     
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  5. fang

    7+ Year Member

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    Great advice above. Another thing to keep in mind is that every attending has their own preferences. DocIvy's style is to just mention pertinent positives/negatives on the vitals and exam, some people like all the vitals and general exam findings every day, some people like "vital signs stable". So don't beat yourself up if you're corrected about these things-- just pick something to start with and adapt quickly.

    I'm not a natural public speaker myself, and my first presentations were pretty painful. I also memorized a "skelleton" presentation and transition phrases to help get from one part to another. I would use my H&P to make a large notecard with an outline of everything I was going to say, then practice once or twice. Inside the skelleton, think about telling a coherent story that can "sell" the A/P by mentioning items that are pertinent to the ddx. Also, try to get all of the really pertinent facts in early... much like the rhinoseros in that old far side cartoon, attendings do not like surprizes. Here's my outline:

    H&P:

    CC/Reason for admission:
    Mr. x is a 67 y/o man with a PMH significant for (add pertinent items and chronic conditions like DM, HTN, etc), who (explain in 1 sentence what the cheif complaint is, and how they got from home to the admission... such as "came to ED with SOB 4 days ago and was admitted to the CCU for management of an anterior MI, now transfered to medicine."

    In his usual state of health, Mr X *** (explain what the person was like before the sx started that brought him/her to the hospital).

    3 weeks ago, he began to notice **** (then tell the story of what happened to bring the pt to where he or she is now).

    Otherwise, he notes no leg edema, palpitations... (give a breif, pertinent ROS).

    In the ED, he was given *** (give a breif ED or ICU course.)

    PMH:
    In his past medical history, Mr. X has (list in order of relevance to the CC and give pertinent facts about each. In medicine, I list surgeries here as well.)

    Medications:
    His medications include **** (This makes more sense to the listener after the PMH).

    Allergies: He is allergic to X which causes Y.

    SH and habits:
    Mr x lives in Honolulu with his wife and 7 children. He works as a landscaper. He has a 12 pack year smking history, and drinks 1 glass of beer/night ... etc.

    FH:
    In his family hx, Mr. X's mother died at 55 of CLL, and his father died at age 72 of an MI. He has 2 siblings who are ***....

    ROS:
    On ROS, Mr. X notes L arm pain at his IV site. ROS is otherwise negative. (Everything important should be in the HPI).

    Vitals: (Pick a style-- list everything, pertinent only, VSS...)

    Exam: (same thing-- I always say at least a few words for the general impression, HEENT, resp, CV, GI, and extremities, and expand on anything else for pertinent + or - findings.)

    Labs: (I was taught to always list the WBC count, Hct, platelets, Na, K, BUN, and Cr in that order, then list anything else relevant.)

    A/P: So in summary, this is a (repeat same 1-line sentence you began with, plus the major points of other findings from your H&P. "a 67 y/o man with a PMH significant for DMII and HTN admitted with and anterior MI and a UTI.

    (then list your plan by system if in the ICU or on general medicine if they are complicated and by problem if in general medicine)
    1. Anterior MI - **
    2. UTI - **
    3. ...

    have fun-- it definitely gets easier!!
     
  6. jomed

    jomed Fear the hedgehog
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    If a resident wont listen to your case, maybe a sub-i will. When I was on my sub-i, I would listen to the M 3's because they were in your position, and were very nervous on rounds. The mirror idea is good, but practicing your presentation in front of people may make you less nervous the next time you have to present on rounds.
     
  7. Doc Ivy

    Doc Ivy Miss Understood
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    I totally agree with Fang's advice about surprises. I actually meant to mention that in my post. If the patient had positive blood cultures, or had some major finding on CT yesterday I would move that kind of thing up before the Subjective section of your SOAP note presentation. This helps them focus appropriately and listen for key info. I know technically these things should in the Objective section after physical exam and labs, but it's true that attendings and chiefs hate being surprised. When you ambush them while they are daydreaming then they have to go back and rethink everything you said before. The team starts to get panicked and they question your ability to prioritize. "Wait what were the vitals again?" "Did they spike a fever?" "Are they satting ok?". Suddenly the presentation is taken out of your hands and you lose your chance to shine.
     
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  8. reallyanon

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    I have two pieces of advice for case presentations. The first was given to our group of medical students before starting IM. DON'T BE BORING. Reading in a monotone directly off a page or listing every single lab is in violation of this rule. The second and I think MOST important part of giving presentations is to make a firm and detailed plan for the day or general plan for new patients. You will often be wrong. that is okay. I think the key is that it shows you have moved from simply reporting information to interpreting/managing your patients. I would always say something like "I believe the plan for the day should be" or "I think we should." I believe that much of my success in doing well in 3rd and 4th year came from not drifting off into the abyss of medstudent mumbling at the end of a presentation. good luck. on a complete aside if you have a serious fear of public speaking have you ever considered talking to your doc about meds? (beta blockers)
     
  9. Entei

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    The suggestions in this thread are all very good. This was something I struggled with a lot, and sometimes still do, to an extent. I'm generally a very quiet person, and don't like speaking in front of groups where they're hanging on my every word. I would get nervous overthinking "what do they want to hear? Is this even relevent?" and "am I talking too much, or am I leaving things out?" "How in depth do they want me to go?" "Why is it such a big deal to say 'female' instead of 'woman?'" and dopey things like that. Also, everyone has a different way they like to hear their presentations, and there's no way to please everyone all the time. So don't get caught up with having to be 'perfect' and don't psych yourself out. Lots of these things get better with time, experience, and repetition.

    Another tip, though, that helped me a lot that hasn't really been touched on yet in this thread is that sometimes it doesn't matter as much what you say but HOW you say it. People's ears perk up for important, specific parts of the presentation, and then their minds kind of wander putting this stuff together when you drone on through the stuff that's less important. For these less important parts, they pay less attention to your words, and more attention to your tone of voice. You'll give off the impression of being more intelligent and on top of things if you speak in an assertive tone of voice, not too fast, not too slow. Listen to your residents present to each other, and try to pick up on that sound.

    Above all, just be patient. It'll come with time.
     
  10. OP
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    babyblue

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    hey guys, thank you so much for the great advices and encouraging words. i do also think that the most important thing to be better is just practice, practice, and practice endlessly and also don't give up that hope that someday it definitely will get better. thanks and let's see how things work next week. :)
     

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