The Science behind the Art of the Clinical Presentation How to present a patient

1. The Science behind the Art of the Clinical Presentation(How to present a patient) Gregory W. Rouan, M.D. Associate Chair for Education, Department of Internal Medicine, University of Cincinnati College of Medicine

2. Goals/Objectives: Learn principles needed for interacting with patients. Understand what is the most useful and robust historical information. Discern how to synthesize this information into an organized and succinct oral presentation. Clarify how to convey a comprehensive account of the patients problems in a cohesive format.

3. Introduction/Background Inexperience results in an inherent tension between obtaining pertinent information and synthesizing it into a cohesive presentation. A solution is to understand fundamental aspects of the the principles and apply the process in a consistent fashion.

4. Introduction/Background The patient is a �poor historian� Translates to: (a) He is an impoverished history professor (b) He is a failed history student (c) Medical shorthand for �we did not communicate well.�

5. Presenter Classification The Medical Student The Intern The Resident The Chief Resident The Research Professor The Clinical Professor Presents too much information, only half of which is relevant, and does not know what most of it means. Obtains most of the information and probably know what most of it means but falls asleep presenting it. Presents all of the information and knows what most of it means, but prefers complaining about personnel and other physicians. Obtains all of the information and knows what all of it means, but is too busy dealing with the complaints of residents. Has forgotten what a case presentation is, but will consult another subspecialist to discern the answer. Could obtain all of the information but prefers to have others do it. He/she does know what all of it means.

6. The Science behind the Art . . . The INTERVIEWER rational well-organized and unemotional (but empathizing) style The PATIENTS vary in terms of background, personality and social norms The INFORMATION/DATA must be judged by criteria of precision, accuracy and completeness

7. The Interviewer Begin with the end in mind. (That tension again of inexperience resulting in a need to stick to the method.) The listener listens best to data that are anticipated. If data are juxtaposition to similar data such is more easily accomplished (order).

8. The Interviewer The listener will acquire an ear for the meaning of speech patterns and intent. He/she will also need to sort through dramatic expressions as this interferes with mundane features as the sequence, tempo or description of symptoms. In addition he/she will need to deal with the challenges of obsessive detail or lack thereof (minimization/denial of symptoms).

9. The Non-Psychiatric Patient The dependent, demanding personality The orderly, controlling personality The dramatizing, captivating personality The long-suffering, self-sacrificing personality The guarded, querulous personality The superior, very-important-person personality The aloof, uninvolved personality

10. The Information (Forests and Trees) The patients seldom speaks in medical terms nor sorts out eloquently what�s medically pertinent. Imbedded in the intrigue of the chief complaint and its tempo of onset, chronology, characteristics, quality along with modifying factors and symptoms that surround the c.c. is a diagnosis.

11. The History Sherlock Holmes: �Let him, on meeting a fellow mortal, learn at a glance to distinguish the history of the man and the trade or profession to which he belongs. By a man�s finger-nails, by his coat-sleeve, by his boot, by his trouser knees, by the callosities of his forefinger and thumb, by his expression, by his shirt cuffs--by each of these things a man�s calling is plainly revealed.� John H. Watson, M.D.: �What ineffable twaddle!� A. Conan Doyle, A Study in Scarlet That a physician created Sherlock Holmes makes perfect sense. Like Doyle�s detective, doctors search for the data. Yet mettle gathering the data is not enough. Collection of the facts must be succeeded by documentation and transmission of the facts. Doctors need the triple skills of interview and examination, writing and speaking. The latter is the most public of the three. That a physician created Sherlock Holmes makes perfect sense. Like Doyle�s detective, doctors search for the data. Yet mettle gathering the data is not enough. Collection of the facts must be succeeded by documentation and transmission of the facts. Doctors need the triple skills of interview and examination, writing and speaking. The latter is the most public of the three.

12. The �c.c.� Chief complaint: verbatim statement of the patient�s words? actual reason for the admission/visit?

13. The �P.M.I.� Present medical illness (descriptors): Onset-insidious or acute Intensity Progressive or diminishing Unrelenting or intermittent Exacerbating or relieving factors Degree of disability

14. The �P.M.I.� Associated Symptoms: pertinent associated factors and relationship to main problem describe course based upon intervention used by patient or other physicians

15. And the (dreaded) �R.O.S.� Other potentially pertinent and contributing issues: Past Medical History Social History/Habits Family History Allergies Medications Review of Systems

16. The �Physical Exam-P.E.� Data harden as you leave the history. The c.c. and PMI should drive the P.E. Observe and rely on the expressions of the body. Though the powers of examination and technology the data are more quantifiable.

17. Assessment (Incorporating the Art with the Science) Be explicit in stating each and every problem. Account for the fate each significant symptom, physical finding or laboratory finding in the problem list. Translating the problems to a diagnosis via a syndrome (a biochemical, physiologic or anatomic explanation) is the essence of the clinical art and science of medicine. Disparate elements of data are lumped or split. Gestalt is good based upon experience however keeping to the Lawrence Weed problem list compels us to consider all of the facts. A problem list is heuristic. Differentials not conclusions should be sought.Disparate elements of data are lumped or split. Gestalt is good based upon experience however keeping to the Lawrence Weed problem list compels us to consider all of the facts. A problem list is heuristic. Differentials not conclusions should be sought.

18. Finally, the . . . Plan First do no harm. Both diagnostic testing and therapeutic intervention carry fixed risks for morbidity and mortality. Consider the most likely and treatable diagnoses that are apt to most adversely affect the patient.

19. The Oral Presentation �Rehearse� the presentation Remember: 7 minutes total is the time frame that others will apt pay attention!!! 4 minutes for the history 2 minutes for the P.E. and labs 1 minute for the assessment

20. The Caveats Presentations demand some flexibility. Some attendings prefer to be told some data first followed by a visit to the bedside. Nevertheless, the format is a pragmatic one: Length: neither soporific nor skimpy Content: both essential and focused Order: adhering to sequence regardless of illness.

21. The Caveats Competent and confident clinicians will be attentive to (and relieved to hear) complete, concise and organized presentations. They will not interrupt; they will always ask appropriate questions for clarification upon the conclusion of your presentation; and they will seek further information based upon their insight and clinical experience.

22. Goals/Objectives: Interact with the patient to obtain the most useful and robust data. Synthesize this information into an organized and succinct oral presentation. Convey a comprehensive account of the patients problems in a cohesive format.

23. Conclusions View yourself as a debater or advocate: persuade or inform become a judge or critic of the merits of your argument take care not to become distracted by the information

24. Summary There will always be poor historians in medicine. My goal has been to have you become informed of and more deliberate in the science behind the art of clinical medicine. Thereby these poor historians will be less apt to be the physicians!