Presentation
Presenting patients is an important skill upon which you will be graded. In fact, in most cases, it is THE skill upon which you will be graded - many attendings only see you rarely, and the main method by which you communicate with them will be the case presentation.

In addition to helping to determine your grade, case presentations serve another, more important purpose - they are the primary means you will use to communicate with other physicians. When you are discussing a patient with another clinician, it is important that you be able to describe the patient to that other physician in a clear and concise way. By doing so, you make it possible for the other person to understand what you're thinking and why you're talking about this patient. Primarily, though, you're giving them the information they need to be able to make decisions.

Oddly enough, it's not a skill they teach you much (at least not directly) in medical school. We're hoping to change that here. Unfortunately, the only way to gain skill in presenting isn't by reading web pages - it's by practicing. Hopefully this will give you the tools to get you started...

If you want a more flowery version of the basics of presentation, read this article.

The Basics:

There is one fundamental rule in presenting: Only say those things that are important to an experienced clinician - and say them all. The fact that this is the fundamental rule is what makes teaching presentation skills so difficult - there's no way to predict what things might be important about a specific patient until you (a) know the patient and (b) understand enough about your patient's medical condition to recognize the significant facts. Finally, you need to be able to tailor these concepts to the occasion - sometimes the amount of important information is larger than it is at other times, even with the same patient.

The first part, knowing the patient, is really all that's expected of you during your clerkship years. We'll talk about some tricks you can use as we go along.

The second part, understanding enough about your patient's medical condition to recognize the significant facts, is harder. Obviously, you're not yet the experienced clinician upon which the fundamental rule is based, so how can you be expected to know which facts are important? Realistically, you can't be expected to know that at this stage. That's why knowing the patient will save your hide. If you know enough facts, you'll be able to answer the important questions about your patient, even if you don't yet have the experience to recognize that they're important.

The last part, tailoring the presentation to the occasion, is something that we can just give you some easy groundrules for. You can just modify those rules so that they work with whichever attending is feeling nitpicky on any given day.

Know Your Patient:

As a medical student, if you know your patient, you're doing a good job. If you don't know your patient, you're not doing a good job. This is the unbreakable rule of success in medical school.

The amount that you can theoretically know about a person is probably infinite, so what do we mean?

An excellent way to answer this question is by thinking about the information we put into an admission history and physical (H&P). The things that get covered in an H&P represent exactly the minimum baseline information you're expected to have at your fingertips (plus some things we'll cover in a minute). In fact, if you keep the H&P in mind, it also makes a good format for organizing you when you give a full, formal case presentation. In brief, here are the areas that get covered in an H&P:

So what did we do with this presentation? We gave a story that made the attending think the patient was having an MI. We gave supportive information to support that (family and social history). We told him what else we were thinking about (PE) and then we proved what it was with labs and results of therapy. We didn't take 30 minutes to do it, but we covered the important information, and answered in advance the questions we thought the attending might have. Of course, this doesn't mean we're safe - there are always things that you'll forget or miss, but if you stick to the format, those will hopefully be few.

The trick to being able to rattle this off is simply being able to keep as much information as organized as you can. Gathering the information is simple enough. Hopefully, you'll be there when the patient is admitted, and you'll get to gather and write the H&P. If not, make sure you find it, read it, and re-gather the information yourself by spending time with the patient. Next, keep a log with daily vitals, labs, and progress. There are tons of forms available in a variety of places (I like the one here, in Excel format, by Erik Rupard - there's also a good new patient admission worksheet here, also in Excel format) that can help you keep this organized - pick one and stick with it. It's a nice touch if you can whip a sheet out of your lab coat and answer any question about the patient - bonus points for the med student.

Many people recommend practicing your presentations before you give them. Our feeling is that this makes things more formal and tense than they need to be, but especially in the early stages of your career, practice can really help.

Understanding Your Patient's Medical Condition:

This is really what the rest of this web site is for. There are an almost infinite number of resources available to you - on the web, your PDA, in textbooks and journals, in your notes from med school, in the brains of your colleagues and residents and attendings - that your only excuse for not knowing something is that you haven't yet had time to read about it. And you can correct that when you do get free time, by reading. It's a maxim of clerkship life that you should be reading every day and focusing that reading on your patients' conditions. Case-based learning is probably the best way (certainly the most relevant) to learn, and if you keep up, it's also got the highest immediate yield, in that you'll always be up on the topics your team is discussing. In fact, you'll probably have more textbook-based information than the more senior members of your team.

Read.

The "Secrets" series (Surgical Secrets, Medical Secrets) is a good fast reference. Harrison's is an excellent in-depth reference. Something like Ferry's is typically just about right for helping you understand what's going on and giving you some pathophysiology and other pimping material - you should keep a copy in the pocket of your lab coat, at least during your internal medicine months. You can just about count on the fact that the majority of the questions you get asked will be about conditions your patients have, since most attendings and residents are too tired to come up with novel topics all the time, and its easier to just pimp you on the stuff they're already thinking about with the patients on your team. This is easy bonus points - if you do a little work, it pays off.

Understand that even knowing a lot about your patients' medical conditions doesn't guarantee that you'll get an accurate feel for what's important to your attending. You'll get a feel for that as you gain familiarity with handling various disease states, and as you become familiar with your attending's individual style. There's just no shortcut for experience.

Tailoring the Presentation to the Occasion:

There are about 5 basic presentation types.

The full, formal presentation is the one you will use during teaching rounds. These rounds typically occur in a classroom setting, with someone recording pertinent points on a board. Their purpose is to review thought processes and disease presentations, usually as a springboard for teaching the fundamentals of that disease or its management. Use the format we've outlined above, usually with even more detail. It's common for people to refer to their written H&P's during these presentations, in order to provide the type of detail that might not be easily remembered (ages of siblings and children, medication dosages, dates of surgeries, etc.). You can announce each topic area as you arrive at it - "Chief Complaint: shortness of breath. HPI: She had been in her usual state of health until..."

The introductory presentation is one you might use during morning rounds (walking from room to room to visit patients) to explain who the new patient on your team is. It also follows the H&P format we've outlined above, but should be limited to about the depth of information we gave in the example. It's for practical, not educational purposes, so keep it focused on the issues you and your team will be focused on while you treat this patient. The goal is to get the team familiar with the patient, what you're doing, and why you're doing it (what you're thinking).

The review presentation is one you might use during morning rounds when the team already knows the patient. You refresh the team's mind about who the patient is, then review events and findings that have arisen since rounds the day before. Should take about a minute for uncomplicated patients.
     Mr. Jones is the 44 year old man we admitted 2 days ago for MI. He's been afebrile with stable vital signs since admission. His potassium was low to 3.3 as a result of the lasix we've been giving him for his edema, so we replaced with 40 yesterday and it's returned to normal. I'll order lytes again this evening to make sure it's stable. He's got a stress test pending - it should be this afternoon - and if that and his lytes are OK, he'll be discharged in the morning. He'll be following up with Dr. Smith in 1 week. He'll be leaving with captopril, hydrochlorothiazide, aspirin, and niacin.

The bullet presentation may be the one you'll use most commonly. It skips the niceties and focuses on essential information for someone who might need to make treatment decisions. You would use this format to sign out when another team will be covering, or to quickly explain who a patient is when you call for a consult or other help. State the disease states, the treatments, and either the possible concerns or the question you have. If you're signing out, you should include code status.
     Mr. Jones is a 44 year old man who came in with MI. He's been stable since standard treatment on admission. His potassium has been a little low, but we've been replacing. Please check the labs when they come back this evening and replace his potassium if he needs it. You might get called for chest pain - do the full workup, including EKG and enzymes. He's full code.

The specialty presentation is used when speaking to a specialist. The classic example is when you need to present a patient to a radiologist - either for special teaching rounds or for help in interpreting images. Limit your presentation to those factors that might impact the specialist. For example, in the case of radiology, psych issues wouldn't typically be on the top of your list of things to discuss.
     Mr. Jones is a 44 year old man who came in 2 days ago with MI. He has no history of lung or heart disease. We thought he sounded wet when he came in, so we ordered this chest film to look for signs of failure.