Making SOAPS SAFER

1. Making SOAPS SAFER A model for Teaching and Evaluating Oral Case Presentations

2. Eric H. Green Linda DeCherrie Mark Fagan Warren Hershman Brad Sharpe Jeffrey Wiese In absentia Jeffrey Greenwald Sandhya Wahi-Gururaj Nancy Torres-Finnerty Faculty For more information contact Eric H. Green MD, MSc ergreen@montefiore.org 718-920-5619

3. Context • Increasing emphasis on patient-doctor communication. • ACGME competencies. • USMLE Clinical Skills Assessment. • Premium on accurate, pertinent and cogent MD to MD communication. • Dizzying pace of clinical care. • Frequent patient ‘handoffs’---RRC Work Hours Regulations, Night Float Systems.

4. “This is not easy” • Presentation skills are a complex synthesis: • Knowledge and experience. • Clinical reasoning. • Speaking skills. • Expectations.

5. What are your experiences?

6. RIME: Framework for Student Progress • Reporter: Consistently good in Interpersonal skills: reliably obtains and communicates clinical findings • Interpreter: Able to prioritize and analyze patient problems • Manager: Consistently proposes reasonable options incorporating patient preferences • Educator: Consistent level of knowledge of current medical evidence; can critically apply knowledge to specific patients

7. Our Model: Making SOAPS SAFER

8. Teaching & Evaluating Oral Presentations is a complex process • Bad presentations are obvious • “I know it when I see it” • Next questions • What was good and bad about it? • What knowledge, skills or attitude deficit caused this pattern? • How can this deficit be remediated? • Challenges • Many things wrong • Where to start

9. Schematic model: What usually occurs How can it be fixed? Recommend changes

10. Schematic model: Proposal What is good and bad? Cite specific examples What caused this? Clarifying Questions How can it be fixed? Recommend changes

11. Identifying Strengths and Weaknesses • 5 basic qualities of an oral presentation • SOAPS • Frame evaluation and feedback • Provide a basis for didactic instruction

12. 5 Basic Qualities of an Effective Presentation: SOAPS • Story: Identify and describe complaints • Organization: Facts are where the listener expects. • Argument: “Makes the Case” for assessment and plan • Pertinence: Only includes information relevant to the assessment and plan • Speech: Fluent, well spoken

13. Story • Key elements • Accurate • Detailed • Chronologic • Problems: • Hard-to-follow

14. Organization • Key elements • Standardized • Logical • Problems • “All over the place” • “Worksheet”

15. Argument • Key elements • Commits to a patient-specific assessment/plan • Presentation leads listener to this conclusion • Problems • “Scavenger Hunt” • generic

16. Pertinence • Key elements • Relevant facts included • Irrelevant facts excluded • Problems • “All inclusive” • Smorgasbord

17. Speech • Key elements • Speed and tone • Spoken, not read • Problems • “Garbled” • Read

18. Schematic model: Proposal SOAPS What is good and bad? Cite specific examples What caused this? Clarifying Questions How can it be fixed? Recommend changes

19. What deficit caused this • Most problems in presentation can have multiple etiologies • 5 potentially correctable deficits (SAFER)

20. Possible Correctable Deficit: SAFER • Speaking: Poor elocution skills • Acquisition of Knowledge: Topic specific knowledge deficits (facts or experience) • Facts: Reports incorrect facts or omits facts • Expectations: Unaware of needs of listener or standards • Reasoning: Omits or incorrectly applies clinical reasoning

21. What deficit caused this • Most problems in presentation can have multiple etiologies • 5 potentially correctable deficits (SAFER) • Use iterative questions

22. Speaking • Clarifying questions • Tell me in your own words what you think when…. • Potential areas of remediation • Insufficient preparation time • Anxiety

23. Acquisition of Knowledge • Clarifying Questions • Explain for me how…? • Potential areas of remediation • Knowledge deficit (basic science or beyond) • Over reliance on previous experience (n=1 trials)

24. Facts • Clarifying Questions • Did you obtain any information about…? • Potential areas of remediation • Poor data acquisition (Hx or PE, “night float”) • Poor data retention (memory, notes, fatigue, patient volume)

25. Expectations • Clarifying questions • What information do you think the attending needs to… • Potential areas of remediation • Incomplete or conflicting knowledge regarding conventions • Inaccurate beliefs regarding needs of the listener

26. Reasoning • Clarifying Questions • How did you interpret…? • Potential areas of remediation • Poor understanding of clinical reasoning techniques • Incomplete understanding of appropriate applications for clinical reasoning

27. Schematic model: Proposal SOAPS What is good and bad? Cite specific examples +/- SAFER What caused this? Clarifying Questions How can it be fixed? Recommend changes

28. Schematic model: Proposal SOAPS What is good and bad? Cite specific examples +/- SAFER What caused this? Clarifying Questions learner suggests remediation strategies Support and follow-up

29. Pearls for the learner • Story: • Think of the oral case presentation as building a case as an attorney wouldin a court of law.  You are providing information to allow others to come tothe assessment and plan you did.  You are also providing enough informationto have them help you care for your patient.

30. Pearls for the learner • Organization • Starting with the chief complaint orients your listeners and prepares them for what follows. • “Don’t eat the dessert before the salad” – never change the basic format of the presentation – it is always the same. (ID, HPI, PMH, MEDS, ALL, SH, etc.). • Use standard headings to keep your listeners oriented. The relevant past medical history is... On physical exam I found… In summary... • If you put family history, social history, or parts of the review of systems into the history of present illness, there is no need to repeat it later in presentation

31. Pearls for the learner • Argument • An oral presentation is supposed to be a bedtime story not a suspense thriller. Everything is designed to support an assessment and plan that should never be a surprise. • Pertinence • If you’re not sure if a detail is relevant leave it out of the oral presentation. Your listener can always ask for more. • Think of the oral presentation as the “Cliff’s notes” version of the written H&P – it includes all the details you need to understand the plot but not much more.

32. Pearls for the learner • Speech • Practice your presentation at least once before giving it. • General: • If you lose people's attention, think about what part of the presentation lost them. • If preceptors keep asking for the same types of information after your presentation then include it! • The assessment and plan is a wonderful opportunity for you to demonstrate your clinical reasoning and medical knowledge. Don't miss this chance to shine! • Always know what your listener is expecting to hear – 2 minutes or 7 minutes? All of the labs or just the abnormal ones? • Never “act out” the physical exam while you are presenting. Use your words, not your hands.

33. Pearls for the teacher • Teaching • Remind learners this is a standard of the medical profession that they will be using throughout their careers. This is not the teacher’s personal style or just another requirement to pass a rotation. • Try to avoid teaching solely by example (“you could say it like this . . . “). Instead, identify the deficit and have the learner try again.

34. Pearls for the learner • Evaluation • Use your interactions with the learner outside of the presentation to help inform you as to which deficit they have. • Allow the learner to identify their weaknesses before you comment • Concentrate on identifying the biggest problem in the presentation and start to intervene there. • Feedback • Take notes during a presentation. When providing feedback, refer to specific things the learner said.