As an attending gastroenterology consultant, I have heard many a presentation from medical students, residents, and fellows that start something like this:
This is a 64-year old woman with Afib, hypertension, diabetes, congestive heart failure, osteoarthritis, cholelithiasis, and depression, whom we were asked to see because of melena.
Intrinsically, there is nothing “wrong” with the presentation…but unfortunately attendings and other docs have a lot on their minds (How long is this presentation going to be? What is Mr. Brown’s creatinine today? Did I leave the stove on?). In the first 30 seconds the attending (as well as most other people on the team) have zoned out.
Simply put, there was too much information in the first several words with no firm “anchor”. Although the presenter was trying to be diligent by presenting the co-morbidities up front, it actually confused the story. The team members now have to remember all of the co-morbidities without knowing if they are germane to the problem at hand.
So how could this presentation have been improved? Follow Rule Number One: Present the reason for the consult before anything else. The format is very simple:
“[Doctor] asked us to see [patient] because of [symptoms].”
As an example:
“Dr. Jones from Cardiology asked us to see Mrs. Smith because of melena.”
Then the remainder of the presentation can proceed in a typical fashion. The rest of the team has something to anchor on when listening.
After that, follow Rule Number Two: Only present the medical history in the HPI if it is relevant. Although it is tempting to tell the team everything you know about the patient in the first sentence, it is much more informative to frame the co-morbidities in a way that make sense in the patient’s history. For example:
“She is a 64-year old woman with a history of underlying ischemic cardiomyopathy, who was admitted to the hospital because of progressive dyspnea, thought to be related to the development of atrial fibrillation, and was placed on warfarin. Subsequently she developed 3 episodes of melena, without abdominal pain. Of note, she takes frequent ibuprofen for osteoarthritis of her knee and has never had evidence of GI bleeding in the past.”
Following these two simple rules will obviate the need to go back and revisit parts of the medical history that didn’t seem important at the time.