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

1. Making SOAPS SAFER A model for Teaching and Evaluating Oral Case Presentations Eric Green, MD, MSc, FACP Mercy Catholic Medical Center Drexel University College of Medicine

2. Eric H. Green Mark Fagan Warren Hershman Brad Sharpe Linda DeCherrie Rich Simon (for the 4C’s mnemonic) With thanks to… Jeffrey Wiese Jeffrey Greenwald Sandhya Wahi-Gururaj Nancy Torres-Finnerty Contributors

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. • Important observed “performance” for evaluation and feedback

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

5. Important skill but execution oftensuboptimal • Try to set high standards—present like Lincoln at Gettysburg. • Access to colleagues. Can open the door or… • Bad breath

6. What do we know? • Observations of student presentations1,2 • Students believe presentations are driven by formula while attendings see them as driven by context and content • Surveys of teachers and clerkship leaders3,4 • Concordance that ideal presentations both report HPI and interpret other elements in context of assessment and plan 1.Haber RJ. JGIM. 2001 2. Lingard LA, Acad Med. 1999. 3. Green EH, JGIM. 2007 4. Green EH. Teaching & Learning in Medicine. In press

7. Our Model: Making SOAPS SAFER

8. Teaching & evaluating oral presentations is complex. • Bad presentations are obvious to teachers • “I know it when I see it” • Feedback is often specific to presentation • Little formal instruction on performing or evaluating oral case presentation • Challenging for learners to generalize feedback • Ideal feedback should include generalizable points • Key is identifying core qualities of an oral case presentation and framing feedback around those

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 • Provide a basis for didactic instruction • Frame evaluation and feedback

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: 3Cs • Chronology • Start with “chief complaint” – reason the patient is “here” • Present the “facts” chronologically and in appropriate detail. • Core attributes • e.g. “OPQRST” – onset, palliate/provoke, quality, region/radiation, severity/associated symptoms, temporal aspects • Context of illness- the rest of the history needed to understand the most important problems in the A/P • Level of detail determined by the context of presentation

14. Context: 3 Key Elements • Audience -- • Who are they • What do they need to know • Purpose. • For clinical care typically “build a case” • In conferences, etc may want to “create a mystery” to generate differential diagnosis • Time- Occasion (setting and circumstances) • 1-2 line bullet. • 1 paragraph synthesis. • 3-5 min. targeted, formal presentation on work rounds

15. Context Drives Content • Hypothetical 60 year old with NSTEMI • Presentation to hospitalist – detailed, comprehensive, “builds a case” • Presentation to urology consultant - limited, focused, “builds a case” • Presentation to “night float” – limited, broad, “builds a case” • Presentation at morning report – detailed, comprehensive, “mystery”

16. Organization • Presentations are organized in a standardized format • A defined schema helps listener process large amounts of data efficiently • Key elements • Standardized: history before physical, etc.

17. Argument • Key elements • Commits to a patient-specific assessment/plan • Structures rest of presentation to make a coherent case for this • Presentation should include • a synthesis • problem by problem A/P

18. Pertinence • Key elements • Relevant facts included • Irrelevant facts excluded • Relevant facts • helps explain/support differential diagnosis • Characterize the severity of illness • Helps understand and address key issues in evaluation and management

19. Speech • Recognizes that this is spoken art form • Key elements • Speed and tone • Spoken, not read

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

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

22. Possible Correctable Deficit: SAFER • Speaking: Poor elocution skills • Intrinsic or situational • Acquisition of Data: H&P, review of records • Fund of knowledge • Expectations: Unaware of needs of listener or standards • Reasoning: Omits or incorrectly applies clinical reasoning

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

24. 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

25. Pearls for Learners • Story • Think of the oral case presentation as building a case as an attorney would in a court of law.  You are providing information to allow others to come to the assessment and plan you did.  You are also providing enough information to have them help you care for your patient.

26. Pearls for Learners • 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

27. Pearls for Learners • 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.

28. Pearls for Learners • Speech • Practice your presentation 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 or some of the labs? • Never “act out” the physical exam while you are presenting. Use your words, not your hands.

29. Remember the 4 C’s: A Mnemonic for Effective Oral Presentations • COHERENT • CONCISE • COMPLETE • COMPELLING

30. COHERENT • Introduction (one sentence!) • Subjective • Vital signs • I/O’s • Physical Exam (pertinent) • Drug list • New study results • Review of chart (nurses notes, etc) Assessment and Plan:

31. CONCISE ( 1-2 minutes) • Essential • Pertinent • Uncluttered • The student should be . . . brief and lucid • The student should speak . . . crisply and clearly without notes

32. COMPLETE • Symptom complex fully defined • Pertinent findings ( e.g. funduscopic exam, mental status) • Significant laboratory abnormalities (new trends!)

33. To be COMPELLING the student must . . . • Know the patient • Have a firm grasp on the differential diagnosis • Identify the specific problems • Make an ASSESSMENT • Outline the interventions in the PLAN

34. Pearls for Teachers • 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.

35. Pearls for Teachers • 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. • Decide when is the best time to give feedback

36. References • Green et alThe Oral Presentation: What Internal Medicine Clinician-Teachers Expect from Clinical Clerks. Teach Learn Med. 2011;in press. • Green et alUsing a Structured approach to Teaching and Evaluating Oral Case Presentations: the SOAPS method. Acad Int Med Insights. 2010;in press. • Green et al Expectations for Oral Case Presentations for Clinical Clerks: Opinions of Internal Medicine Clerkship Directors. JGIM. 2009;24(3):370-3. • Green et al. Developing and implementing universal guidelines for oral patient presentation skills. Teach Learn Med. 2005;17(3):263-7. • Kim et al. A Randomized-Controlled Study of Encounter Cards to Improve Oral Case Presentation Skills of Medical Students. JGIM. 2005;20(8):743-7. • Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered model for outpatient education. Acad Med. 2003;78(9):893-8. 

37. References • Wiese J, Varosy P, Tierney L. Improving Oral Presentation Skills with a Clinical Reasoning Curriculum: A Prospective Controlled Study. Am J Med. 2002;112:212-8. • Wiese J, Saint S, Tierney LM. Using Clinical Reasoning to Improve Skills in Oral Case Presentation. Sem Med Pract 2002;5(3):29 - 36. • Haber RJ, Lingard LA. Learning Oral Presentation Skills: A Rhetorical Analysis with Pedagogical and Professional Implications. JGIM. 2001;16:308-14. • Lingard LA, Haber RJ. What Do We Mean by "Relevance?" A Clinical and Rhetorical Definition with Implications for Teaching and Learning the Case-presentation Format. Acad Med. 1999;74 (Supp)(10):S124 - S7. • Kroenke K. The Case Presentation: Stumbling Blocks and Stepping Stones. Am J Med. 1985;79:605.

38. Contact Information Contact Information Eric Green, MD, MSc, FACP erichgreenmd@gmail.com or egreen@mercyhealth.org Warren Hershman, MD, MPH warren.hershman@bmc.org For 4C’s mnemonic: Richard Simons, MD rsimons@psu.edu