Presenting on a consult service: Rule number three

In my most recent post, I discussed the first 2 rules of presenting on a consult service.  In this post, we’ll take the next step.  Actually, this rule could go for any type of presentation, even in the clinic.

Rule Number 3: When discussing a patient who has a chronic disorder, it is important to “frame” the patient’s pertinent medical history in the first few sentences.

This rule is specific to a situation in which the chronic disorder is strongly related to (or actually the reason for) the consultation, and is an extension of Rule Number Two.

Here is the framework I suggest:

  1. How/when the patient presented
  2. How the patient was diagnosed
  3. How the patient was treated
  4. How the patient responded to treatment
  5. What complications the patient has experienced
These 5 points can help you are “introducing” your patient to everyone who is listening. On GI consult rounds, I often discuss this framework when we have been consulted on a patient with IBD, such as in the following example:

“Dr. Jones asked us to see Mr. Smith because of diarrhea and a history of Crohn disease.  Mr. Smith is a 24-year old man with a history of Crohn disease, diagnosed 4 years ago after he presented with 6 weeks of right lower quadrant abdominal pain, diarrhea, and weight loss.  He underwent a colonoscopy, at which point numerous ileocecal ulcerations were found.  He was initially treated with Pentasa, but did not improve.  He was then treated with prednisone, and his symptoms improved, but he developed hyperglycemia and Cushingoid features.  He was unable to wean off steroids, so he was placed on 6-MP, but was switched to infliximab because of marked elevation of his transaminases.  Last year, he underwent ileocecal resection because of obstructive symptoms and the development of a distal ileal stricture.  Since then, his symptoms have been under very good control, until 3 weeks ago, when his diarrhea returned…”

Notice how the points are covered in a logical progression, and a complete medical story can be conveyed in just a few sentences.

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Presenting on a consult service: Rules number one and two

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.

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DDW Day 4

Well, it’s the last day of DDW.  I’m already here, so I’m actually creating this blogpost during one of the esophageal motility sessions.  I posted my video blog about yesterday’s sessions here.

The one study that I forgot to include on my video blog was a study out of Dan Sifrim’s group.  They investigated the effect of baclofen 10 mg TID x 1 week on rumination, aerophagia and supragastric belching.  In this small open-label trial, 75% of patients showed a reduction in symptoms and reflux/belching events.  There were several comments from the audience suggesting that the mechanism of baclofen was probably distinct from the effects on the lower esophageal sphincter, but overall this investigation revealed the potential for a new therapy in this group of patients.

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DDW Day 3

Yesterday was a good day for esophageal research and topics.  I attended a session on GERD pharmacotherapy and GERD diagnosis, and the poster session.  The video blog is (ahem) still uploading…I’ll get that link up here shortly.

The very brief outcomes were:

  • Although some of the new pharmacologic treatments studies, they have not been further pursued in the drug development pipeline
  • Many patients stay ON PPI therapy despite having negative Bravo pH or pH-impedance studies. (This is my argument for NOT doing study off therapy…the patients often remain on therapy even with a negative test, so there was little reason to actually do the test this way)
  • Subsquamous intestinal metaplasia (SSIM; aka buried glands) exist in the native state in Barrett’s esophagus pts in under the native squamous lining.  This is important since we often consider SSIM a result of ablation, but this gives further evidence that it already exists.
Two more full days of another great meeting!
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DDW Day 2

So my first day of live tweeting from DDW went fairly well.  I only attended 2 sessions and presented my poster.  Unfortunately I didn’t get to see any other posters because of the amazing foot traffic at my poster that I would love to relate to my methods, but probably was because I was the first poster that everyone saw upon entering the poster hall.

I also tried my hand at video blogging, I uploaded a video last night to YouTube.  I will continue to live tweet today, just follow my stream @RyanMadanickMD and the hashtag #DDW11.

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DDW Day 1

Today is the first day of DDW — Digestive Disease Week — in Chicago. This international 4-day conference is the biggest combined gastroenterology/hepatology conference. DDW attracts thousands of gastroenterologists, hepatologists, endoscopists, surgeons, and researchers from across the world.

This will be my first attempt at live tweeting from a major conference.  As my particular interest is in esophageal diseases, I choose to attend primarily sessions that pertain to GERD, Barrett’s and dysphagia.  I imagine that many of the tweets will deal with GERD and other esophageal diseases, although some of the sessions will be dealing with other topics.

On a personal note, I am also excited to be able to present my own research.  My research received a Poster of Distinction, a personal first.  I recorded a video of the summary of the research; as of right now I am not sure exactly where this will be posted.  I am hopeful that I get some good traffic and comments so that I can anticipate any concerns of the reviewers prior to submitting the final paper.

Well, this should be an interesting journey into #hcsm.  I’m going to meet up with Doctor_V today to get his perspective on the intersection of #hcsm and gastroenterology, since the field has a generally minimal presence.  Keep tuned to the blog and Twitter for updates!

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What do your patients fear?

As an academic gastroenterologist at a tertiary care university medical center, I often see patients who have failed traditional therapies that many of my colleagues in the community have tried.  Over the past several years my practice has evolved, from dealing with predominantly the medical aspects of my patients’ diseases to embracing the biopsychosocial model of illness.  One of my colleagues has been the world leader in patient care and research in the field of “functional gastrointestinal disorders” for several decades, and he has taught me aspects of caring for patients with these complex problems.

One of the most fascinating aspects I have learned to explore is fear.  “Health-related anxiety” is a theme that many of our patients express, whether or not they are able to state it consciously without initial prodding.  In my experience, health-related anxiety falls into one of the following categories, which can be remembered by the mnemonic MIDDLE:

Continue reading

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How much credit do you get for teaching?

I feel fortunate.  I work at a Medical School where the educators are superior.  Excellence in Medical Education is rewarded. However I cannot help but feel that we are far from equality in Academic Medicine.  The Clinician has the RVU; the Researcher has the grant and the paper.  What does the Educator have?  Some have discussed the Teaching or Academic RVU.  We have not espoused such a system, and I doubt that there are many schools of medicine that have.

I am among the fortunate few who have supportive Chairs and Administration.  But this was not always the case.  Just a few days after I began my first job, I was precepting a small group for first year medical students and I was told, “I’m not paying you to teach students!”  I realized right there just how big a mistake I had made.  I didn’t make my intentions clear enough to my boss.  And he saw my time teaching as time away from seeing patients (i.e., making money).

So now it comes to that…money.  Who will pay the Clinical Educator to teach? To lecture, to stand at the bedside and demonstrate professionalism, to create new content?  To be an innovator, to develop a new curriculum?  Just a few months ago I was asked to run a 4th year selective course in GI.  The course itself is mandatory, students can select one of any number of subspecialties that are participating.

I had to decline (for one of the first times in my career, I said no…).  Why? Not because I didn’t want to, but because my time to run the selective was not being reimbursed to my Division.  Like many other Clinical Educators, I am spread thin by my own choice.  But I could not in good faith take on other responsibilities without “protecting” my time from what I would otherwise be getting paid to do.

How can we prevent this?  I do not know.  A point here is that the course (the umbrella group that runs the mandatory portion) is funded, but the individuals who are asked to proctor the students and design a curriculum for them, are not.

My mentor says that we would never dare ask a researcher to run a few PCRs for free, but we don’t think twice about asking a doctor to just do this “one” lecture.

What ideas do you have?  Has your school come up with a great solution that you can share?

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It is Easy to Cure your Problems!!! The MadLib game…

Directions: Put cursor over the blank lines to see what the category you need to fill in.  See below for Suggested Responses.  Enjoy yourself!


I have uncovered the solution for ________________ !! The only problem is that ________________ doesn’t want you to know about it! That’s why they’ve been covering it up for so long. They make millions and billions of dollars promoting and selling their ________________ and are threatened by what is in my newest ________________, so they have done everything in their power to keep it under wraps…

Hear what this satisfied client has to say:

“I had so many problems with ________________…Thanks to your ________________, I have my life back again!! You are a lifesaver!” — John D., Walla Walla, WA

But now, for only $19.95, you can hear the truth about curing ________________!! And it’s 100% guaranteed to work! If you are not 100% satisfied, just call our offices at 1-800-555-HAHA for a full refund…

Suggested Responses:

  • Your Latest Problem:  acid reflux, arthritis, increasing credit card debt
  • A Group That is Trying to Suppress the Truth: a pharmaceutical company, big business, the government
  • Product or Service: ineffective drugs, financial services, propaganda
  • Publication: book, blogpost, study, testimonial
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Medical Education vs Medical Journalism

Medical educators (sometimes called clinician educators or academic clinicians) often think of their* jobs as teaching our own students…those who are in medical school, residency, fellowship…as well as those who attend lectures and conferences…etc.

Sometimes the best educators are not even known beyond their own school, because they are so focused on teaching their own local students that they have omitted the ultimate reach in medical education, the broad base of physicians, patients, and other interested parties that can benefit from their knowledge and expertise. So who has capitalized on this? Medical journalists. I have no problem with medical journalists for the most part, as they play an integral role in the dissemination of important health information to the general public.  Medical journalists have learned how to do this, and what skills are needed to do it effectively, whereas most medical educators come about it by picking up skills over time without formal training.

Somehow the twain need to come together. The explosion of social media, blogs, Twitter, and so forth, and their uses in healthcare (#hcsm) has provided an amazing opportunity for medical educators to learn about medical journalism. In this sense, I am not talking necessarily about publishing within scientific journals (as often those who publish here are NOT the best educators). #hcsm is just a natural extension of the broad role that medical educators have played over the last several decades. Let us embrace it.

*Even though I use the “third person” in this blogpost, it could really be written in the first person (either singular OR plural)!!

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