In medical school, you’re not taught how to give stellar patient presentations. Yes, you’re shown the traditional order of things: “Give an effective one-liner first, then tell the HPI [history of present illness] but only give pertinent info, etc.” Just exactly how to deliver the punch that impresses your attending is an art. And it’s an art that takes some time to perfect.
My very first time presenting a patient was terrifying, and it was during my neurology rotation. My attending was the head of the neurology and rehabilitation department, and I was the only first-year med student. On the team were two third-years, one fellow, and three residents.
David was a 21-year-old Asian male who came to the ER for upper extremity weakness. He and his mom spoke Cantonese to each other and me, so our interactions were assisted by one of the mobile translator stations. It had a tablet attached to a pole about 4 or so feet off the ground, and once you selected your language, an interpreter was online within a minute.
As is usual with new patients, students are the first to meet them and to gather the HPI. Then, the residents see the same patients, and with the students together formulate the differential diagnosis and management plan for each patient. The resident I worked with, Catherine, was wonderful, and an MD/PhD. Though, she notoriously had high expectations of students.
“Alright, tell me your presentation.”
“David is a 21-year-old Asian male who came to the ER this morning for a three-day history of upper extremity weakness in both arms.”
“Good. Keep going.”
“This is new to him, and he was not in an accident or any incidence of trauma recently or in the past.”
“No. What did you learn? OLDCARTS. Onset. Location. Duration. Character. Aggravating or Alleviating factors. Radiation. Timing. Severity. You already said onset, location, and duration. Did he feel any pain prior to or during his weakness? Does the weakness come and go? Anything he does make it better or worse? You have to go in order; if not I won’t follow you.”
I was ready to give it another go-around, but by that time the team phone rang and it was the attending on speakerphone.
“Good morning everyone. Ready for rounds?”
“Yes, Dr. Lezinsky,” said one of the residents.
“Great, meet me outside room 13-A.”
Wonderful. That’s the room my patient was in.
As I walked in the middle of the pack of alternating short and long white coats to my patient’s room, I felt my heart beat at an alarming rate. My watch even vibrated continuously, with the screen showing my heart rate above 100. I casually silenced my watch and also my head so that I could stop being so nervous.
At the door, we were greeted by my patient’s nurse and saw Dr. Lezinsky for the first time. He was a legend at the hospital and was also the neurology residency program director. I’ve heard stories of him being one of the best attendings you’ll ever have the pleasure of listening and learning from, but that he was also hard on students.
Without many words, he said, “Which medical student has the first patient?”
“That would be me.”
“Let’s hear the story.”
I have a bad habit of overly relying on handwritten or printed notes if I have them on hand. I remembered most of the beginning of the presentation, but slowly started to read off of my paper so that I wouldn’t say anything out of order or incorrectly.
About halfway through, I quickly glanced at my resident. Catherine gave me the look of, “What are you literally doing? Didn’t we rehearse?” In stark contrast, Dr. Lezinsky was devoid of emotion and instead nodded his head every so often. But was that an affirmative nod? Or a nod that meant, “Not right, but we’ll talk about it once you’re done presenting.”
In what seemed like an eternity with my palms now clammy, I concluded the presentation with the one-liner, my differential as to my thoughts on what could be causing David’s symptoms, and my proposed management plan.
“Is that all, T.J.?”
“I believe so, sir.”
“OK, Catherine, anything else to add?”
“Only that he is up to date with all of his vaccinations, and that he and his family only speak Cantonese.”
“T.J., can you get the … oh great! You have the tablet. I’ll let you introduce the team to the family, and we’ll have the interpreter join us to help.”
The team met David and his parents, and it was smooth sailing from there. Myasthenia gravis is what we thought he had because of his weakness worsening as the day progressed along with slurred speech in the evenings. Immunosuppressive treatment was soon started and David’s condition improved.
As we entered the elevator to the next patient floor, it was Dr. Lezinsky at the front and me right behind him. As the door closed, Dr. Lezinsky turned his body towards me.
“Was this your first time presenting?”
“Yes, it was.”
“That was really good. Over time, you’ll find yourself not referring to your notes, but relying more on your understanding of the patient’s history and possible disease etiology.”
“Thank you so much, Dr. Lezinsky. That really means a lot.”
Looking back to my first presentation, I’ve improved since then. After you do something so many times over, you start creating your own personal style. Yet, I know that there is always room to improve and the way you present a patient varies tremendously depending on the environment and the status of the patient. It all boils down to this: If you can give an effective and memorable presentation, you’re a better advocate for your patient.
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