I just finished another inpatient service stretch at our community hospital with some great cases and lots of good medicine. While attending rounds may have changed a lot in the last 40 years as highlighted in a recent Annals of Internal Medicine article, some things have not changed – the focus on medical student presentations during attending rounds. Students spend hours through their call nights preparing for the visit by the attending to show them how much they have learned about medicine and the case at hand. Since my students were on their first month of their 12 week general medicine rotation, they asked me what tips I had for history and physicals as well as oral presentations. This time, as opposed to recite my thoughts from memory, I decided to write them up and share them as food for thought.
- Do talk to your attending to ask them what they want – Alas, every attending is DIFFERENT and may have a different way of wanting you to present. Some want bedside presentations, others want you to memorize your presentation, some will say no more than 5 minutes or when I say done. You need to know what your attending’s expectations and style are first to understand how to put your best foot forward.
- Do talk to the nurses every day – they can be your best friend or your worst enemy so make sure they like you. They can help you decipher the cryptic notes in the med record (were the morning meds held or given? Did the labs get drawn or was the patient refusing? Was the patient a difficult stick?).
- Do review only the relevant Review of Systems – Any patient can have a ‘grossly positive ROS’ in all categories. However, if you say the patient is reporting chest pain or shortness of breath here – keep in mind your attending’s eyebrows will raise in panic and wonder why this wasn’t mentioned earlier and whether the patient is having a heart attack. So if it is a major symptom that requires workup, mention it as part of the history of present illness and don’t bury it in the ROS. Reserve the ROS for things like more chronic in nature that don’t require massive workup.
- Do prioritize your differential in order of likelihood and limit it to the top 3 things that could be going on with the patient. There is nothing worse than getting through an entire student presentation knowing the patient likely has pancreatitis but going through a long list of every possible esoteric differential diagnoses including all the black box of every possible rheumatologic vasculitis.
- Do note down everything you don’t understand on rounds to look up later – If you restrict yourself to learning only about the patients you care for, you will miss out. Pay attention on patients that you not following so that you can read on the conditions and ask insightful questions.
- Don’t worry that your attending or resident can’t keep up with you Remember that your attending and resident can remember more information than you do – doctors are usually fast talkers and are used to the ‘rattle’ of patient care. In fact, you’ll notice that your residents present much faster than you do. Attendings may write very little but they are listening to what you are saying so don’t focus on what they are writing down. It’s important to be thorough but also concise – especially when everyone is watching the clock so the residents can get out on time. Just a warning that some attendings even use a stopwatch to time students!
- Your admission H&P is a snapshot — don’t forget to integrate the updated events from the night before rounds the next day. The patient likely has a diagnosis by the next morning so while you saw them they may have ‘abdominal pain’ but by the time you present, maybe their CT showed diverticulitis or their lipase returned as high consistent with pancreatitis. You should curbside your resident to review the new information and update your plan prior to attending rounds. So your oral presentation should not be just ‘reciting your H&P’ but synthesizing your H&P with the updated plan given any new information.
- Don’t trust ‘chart lore’ There is a lot of information in the chart that may or may not be true. This is especially true with cut-and-paste – and more paste that often happens with electronic health records. Verify any comorbidities with the patient and using available diagnostic information to ensure the most accurate information. For example, if a patient carries the diagnosis of COPD, has it been documented by PFT’s? Is the patient aware of the diagnosis and if so, what are their main symptoms? Are they still smoking?
- Don’t just read the Med List Anyone can read a laundry list of conditions or medications. This does not highlight your understanding of the patients comorbidities and which therapies are used to manage their disease. Instead, try to give a snapshot about the condition (baseline level of control or how and when diagnosed), with associated complications and what medications they are on. For example, for a patient with diabetes, you may want to report how long they have had it, what their last hemoglobin A1c was, if they have any complications (retinopathy, neuropathy, nephropathy, etc.), and the medications they are taking at home (insulin etc.).
- Don’t spend too much time trolling for esoteric papers on PubMed It’s more important to read a general text and prepare for your shelf exam. Our students are lucky to have a book authored by our clerkship directors “From Symptom to Diagnosis” to read and is a real winner. Review articles are also helpful especially if you find one in NEJM, Annals In the Clinic, or American Family Physician among others.
Lastly but definitely not least, be a team player. Offer to help the team members with any task no matter how small. By integrating yourself on the team, you’ll be more likely to have a more rewarding experience! Happy rounding.
–Vineet Arora, MD