Academic OB/GYN

I have the pleasure of working with our resident GYN team for several weeks every few months, rounding on their patients and teaching each morning.  One of the best parts of this is hearing our medical students present their cases.

Presenting patients is a skill that takes a great deal of time to master.  Each student is taught the basic form of a medical presentation at an early ‘age’ – Subjective, Objective, Assessment, and Plan.  Each of these bits can be broken down into many subareas, such a Past Medical History or Social History (part of the subjective usually), Chest Exam or Labs (parts of the objective), or individually listed problems (each parts of the assessment and plan.)

This sort of structure is both an aid to great presenting and a hinderance.  It helps because it gives the presentation a structure that is easy to follow, and over the years of hearing such presentations the listener has created little boxes in their mind, and had developed the expectation that these boxes will be filled in a specific order.  By following this structure, the student fills those boxes and thus creates a structured narrative that fits the listener’s expectations.  This can be very functional and efficient.  The downside is that if the student follows that structure too tightly, the presentation sounds stilted, like a person reading a spreadsheet.  This creates a presentation that is technically correct, but lacks grace.

When I was a student, I heard experienced attendings talking to other attendings about patients and noticed that they presented a bit differently.  It seemed to me that they were just telling stories, in the same way that one might tell any story.  For a bit of time I became convinced that all of this structured presentation was just a thing we did in medical school and residency, but that once we were more experienced we drop it.  Eventually I realized that the story telling is not a different style of presentation, but rather the final evolution of the structured presentation.

If one listens to a great presenter, it’s not a stilted structured presentation.  It flows from beginning to end.  They setup the presentation with a narrative of how the patient came to be ill or in the hospital.  Then, without verbal header, they weave in the bits of their past that are truly relevant to the case.  Eventually we move onto the vital signs and objective findings.  Finishing that we get to what the presenter thinks is wrong, and what we need to do about it.  No headers, no stilt – just a story.  But a story with structure.  Its like a paper mache sculpture built on a frame.  From the outside its a beautiful piece of art, but in its construction there are spars and frames holding each piece together, and each of structural members are placed according to the laws we learned from the beginning.

When I was learning one thing I noticed about such presentations is that the traditional order of things sometimes gets intentionally messed up.  Initially this seems wrong, but over time one realizes that strategic reordering of the elements can greatly improve the presentation.  For example, consider the two following openings:

“The patient is a 45 year old man who presented with chest pain in the central chest that was worse after he ate a fried oyster sandwich..he gets this often when he eats….Past medical history: he has a history of coronary artery disease with two prior bypass surgeries.”

or

“The patient is a 45 year old man with a history of coronary artery disease with two prior bypass surgeries and a high fat diet who developed crushing substernal chest pain while eating.”

The information is the same, but in the first we are leading the listener to an assessment that the pain is GI in origin, and the second we are leading the listener to believe that the patient is having angina.  

In this reordering we see the key to a great presentation – foreshadowing.  One’s goal is to tell the story of the patient in such as way that the listener is already thinking what the assessment is going to be before the presenter gets there.  It is one’s hope that the listener comes to the conclusion that the patient has X at the exact moment that the presenter says that the patient has X.  Such timing can be difficult, but the best presenters do it often.  As an attending, hearing the end of such a presentation is like getting to the end of a great thriller and having one’s suspicions confirmed.  Having a conclusion that is not what one expected can also be fun, but only if one can look back over the presentation and realize that all the pieces were there.  Ending a presentation with a conclusion that wasn’t supported up front at all is just jarring, and ultimately doesn’t work.  Its like ending Harry Potter 2 with the bad guy actually being Scabbers the Rat.  Huh?  How were we to guess that?  Not satisfying.

Another important element is the use of notes.  In the beginning, notes can be necessary to keep information that needs to be reproduced during a presentation.  However, any presenter needs to endeavour to remove this crutch as soon as possible.  Reading off a paper is never a great presentation.  Its functional at best, but never great.  Some seem overwhelmed by the idea of memorizing all these little facts and reproducing them, but I ask this?   Do you find it hard to retell an interesting story that you know?  Are you struggling to remember each part of the story?  The answer of course is no, and therein lies the answer.   Move from regurgitating quanta of data to telling the patient’s story and remembering the details is no longer difficult.  If its hard at first, practice.   A student that never jettisons the note cards will never be an effective presenter.

So if you are a student, work hard on your presentations.  Start with structure, but work on making that structure the underpinings of a great story.  Once you can do that, you’ll find presenting easier, and you might even make honors.