How To Suck Less As A Med Student | AMA 36

Here's my most crucial advice for the health care padawans.

[briangu]

Sounds like there was a med student on rounds today that got wrecked

[lpsoxfan]

The problem with this is that most MS3s are at the reporter stage in their education - that is, they don’t yet have the clinical knowledge and experience to filter and interpret the information that they have collected or organize it into an illness script. So to ensure accurate transmission of information, the default is just to dump everything out. I agree that presentations need to be shorter and more focused, but it is on the attending/resident/fellow on the receiving end of that presentation to set that expectation that the presentation is concise, and that they can ask clarifying questions as needed to the presenter. The truth is that presentations on rounds are one of the few things attendings can evaluate students on, so it incentivizes the students to present all of the information so as to appear more thorough.

Also, as another commenter said, there’s no bonus points for presenting from memory. As a student and intern, I didn’t have the mental framework for the patients and problems I was presenting to be able to recall everything from memory (that skill came with experience and repetition), so using my notes allowed me to more accurately and thoroughly retain and transmit information.

[trc]

Another case of an attending forgetting how it was to be a medical student/intern/resident... What a nightmare

[greymedic]

When ever I had pediatric patients I always asked what their favorite color and/or sport was. When I have report in the ED, I would always end with their favorite color/sport. The astute nurses would use that as an ice breaker with the patient. The mean nurses would reply, "why the hell do I need to know that?"

[yehonatankane]

As a trainee progresses from MS3 to PGY-Only God knows, s/he acquires the clinical judgement to know which positives and negatives are the most pertinent to that patient's outcome. Yes, they're at all different levels at the start. Overall, they should deliver the patient story from memory, but if they have to check their notes, there's no extra credit for knowing things by heart.

[foryou]

I present my history taking back to the patient while using my notes

1. Patient would feel understood/heard
2. I get an opportunity to present
3. Preceptor gets the 2nd round of my presentation without notes

[farazr]

100% disagree on the "by memory" point. At the student level, we're still learning and expected to pick up new patients every day, learn about them, take histories on the spot, and present them that day. The format and expectations of presentation are also attending and rotation different. Surgery's expectations are different than OB/GYN than IM, and the format as well as pertinents follow from that. 

The thing most students REALLY need to work on, is their organization of information and knowledge base, so that the pertinent positives will stick out naturally, rather than attempting rote memorization.

[Docinaplane]

I first realized how stories can profoundly reach others in my surgical residency. I was telling a kind friend a story about some very sad thing that had just happened to me, and she started to cry. I expressed how sorry I was to tell her about myself when she said, “No, I’m not crying because of what happened to you. Your story reminded me of something that had happened to me, and that is why I am crying!”

Tell stories, listen to stories, teach with stories, learn from stories, write stories, read stories, because… we were made for stories!

[kts]

Also essential thing to warn me - if patient/family/etc is mad/sad/frustrated when you spoke to them this AM. Protect your seniors from walking into a shitstorm.

[jefftube]

As an associate prof teaching residents and students....couldn’t agree more. But please be nice....

[stephanienethers]

I agree 100%!!! I write down notes with each patient. However, I have been condescended on several occasions where nurses have put me down and laughed at me for doing handoff this way. I know my patients and their stories 100%

[tdog]

Not a medical person, my wife is. She showed me doc Vader, but I've been hooked since. Zdogg is a great resource for non-med spouses who just want to understand why my intern wife is asleep at the dinner table. Also great tips as well, I have to present pre-shift meetings everday. Everything he was saying is true. Knowing the material really does improve engagement and improves peoples confidence in you. Much respect Z, Dark side for Life.

[fbchappp]

This is the most real thing out here. Working in EMS sometimes we have in-hospital providers who don't really LISTEN to our report, asking us the same question 3 times. We have to listen to each other for better pt care, easier transfer of care, and better long-term outcomes.

[TheVasMan]

ATTENTION MED STUDENTS AND RESIDENTS!
While what an attending wants will of course vary somewhat depending on the situation, I am a firm believer there is a right way to communicate a patients story in actual practice and it is very formulaic. Get this down and your communications with that angry GI doc in the middle of the night will go infinitely better.
I would actually disagree with zdogg here, and argue for more organized thoughts, go ahead and sort them out on paper. You do want to tell a story, but the story is a medical story. You do not want to get into a forest of social nonsense, personal drivel, or meaningless details. I lam actually a big fan of having some (limited) notes, and access to the computer. --how else are you going to answer a question about the hematocrit if who ever you are presenting to asks? It is not your job to sell an interesting story about the patient's cat to enthrall the listener. I also don't think memorizing trivia should be the goal. It IS your DUTY to convey the correct medical information.
Here is the formula:
1) Unless you are calling the trauma team or the OB doc to come catch a baby take 2 minutes to compose your thoughts. Scratch a few things down if needed.
2) DIAL THE PHONE YOURSELF--nothing makes me angrier than getting interrupted at work or woken up to be put immediately on hold while the nurse goes to hunt down the ER resident who paged me. Did you think I would be hard to find at 2AM on Tuesday?
3)Say this verbatim "Hello, I am sorry to bother you, I am sure you are very busy. I would like to take 5 minutes to tell you about a patient that I would like a consult on/need you to see/ have a question about/ would like to transfer to you/want you to admit- etc)"--omit the introduction if face to face, but it is good to tell the specialist that you would like a couple minutes of their time to actually tell them the story, and also let them know right up front what you are hoping to get from them.


THEN This is the presentation
"This is a (number goes here)---year old (gender), with a past medical history of (everything pertinent to the issue at hand) who comes in with a (timeframe) history of (chief complaint). Very brief description of chief complaint and pertinent ROS.
Pertinent social history
Pertinent family history
Vital signs
Pertinent physical exam
Labs/studies
What you have done so far
Lastly- you should have some impression and a distinct question or request of whomever you are calling.
You should be able to really go through all of this in 2 minutes


Example:
This is a 63 year old gentleman with a past medical history of uncontrolled hypertension, coronary artery disease with stenting 4 years ago, dyslipidemia, heart failure with last known EF of 40, and COPD, who comes in to the ER with 1 week of increasing dyspnea on exertion.
He is severely short of breath, minimal coughing, probably some mild wheezing that is chronic, no fevers or chills, no sputum. There is orthopnea that is new.
He is a 2 pack a day smoker, is not a drinker
He is tachycardic to 115, Respirations 30 other vitals are stable
On exam he is short of breath but not in distress. He has some end expiratory wheezes, heart rate is regular, he has pitting edema up to the knees
cardiopulmonary exam otherwise unremarkable
BNP is severely elevated, troponin is negative, CXR shows some congestion and small effusions. EKG shows sinus tach, no ST changes from previous.
It looks to me like he is having a CHF exacerbation, I gave him 40mg of Lasix here in the ER. I would like you to admit him, I think he probably looks like he needs a step down bed.


See how easy that is? There is no role for let me see, yeah Frank here is a frequent flier, yeah, I actually saw him 3 weeks ago, he is a pretty nice guy, he lives down by the river." You don't want all that crap in there. You gotta be a little more formal. Also no good is "I got a CHFer for you" See how you can give a whole lot more information about a complex patient if you take maybe 1 extra minute? Be precise and concise.

[atoceansmercy]

Dr. Z, nursing students are taught to write down all the PMH, meds, and etc... The way you presented it was different than what we were taught. It takes time and practice to get that style down of story.

[deanspeer]

Those last two pointers only prove you are a well rounded mad genius.

[pogonlife]

Dr. Damania/Vader, as a clinical teacher I agree with you 100%

[IdkIdk-pvmx]

@zdogg So you’re saying OPQRST SMASH-FM FED TACOS doesn’t lead to organized, cohesive thinking?

[tnwnl]

"Hand eye connection" You forgot the automatic encryption that is called doctor's handwriting 😉

[benadams]

While a patient at Shriner's in St. Louis (teaching hospital), even as a teenager, I would witness that, if a resident couldn't communicate to the other doctors in rounds, s/he couldn't communicate with the patient (me) or the parents.


Also, KU Med Center (Kansas City, KS), the same a teaching hospital where, if a resident couldn't communicate with the staff, s/he wasn't going to be able to talk to me very well.