Author: Chris Keefer CCFP-EM, Assistant Clinical Professor University of Toronto

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After every single patient encounter in the ED learners present to their staff.  This is frequently a painful process for both learner and preceptor.  Too often the learner fails to paint a clear picture of what they think is going on and the preceptor is left picking up the pieces and doing the problem solving.  Educators infrequently focus on teaching the art of presentation and as a result the learner will often make this presentation style habitual and little progress is made in their clinical judgement and ability to communicate.

Einstein is famously quoted as saying “The definition of insanity is doing the same thing over and over again and expecting different results.”  What if patient presentation was taught and practiced in a deliberate manner so that it became the keystone for learners to develop expertise and unlock their full clinical potential?  What if we can teach our students the art of “Deliberate Patient Presentation”

The acquisition of expertise has long puzzled us.  Are experts born with innate talent?  Does practice make perfect?  How can we make sense of the enormous variation in performance within a given field?  How can we bring everyone within a field towards the performance of the top 5%?

Cognitive psychologist and preeminent expert on the science of expertise Anders Erricson has spent his career trying to answer the mysteries of talent through rigorous study.  In so doing he has described a framework for the development of peak performance that he calls deliberate practice.

Deliberate practice involves the following

• Choosing a specific skill for improvement
• Identifying what expert performance looks like
• Consistently going beyond your comfort zone to achieve it
• Developing excellent mental representations
• Receiving and implementing timely feedback
• Having a coach to guide your training

Erricson’s research demonstrates that experts perform better because they have well developed mental representations relevant to their field.  A mental representation is a construct of the mind that is not actually present to the senses.  Think of a chess master. Through years of study and practice she can look at the pieces on the chess board and identify a recognizable pattern (a mental representation) and figure out the next most advantageous moves and their consequences.

Emergency medicine is no different.  A good emergency physician is able to analyze the signs and symptoms of the patient in front of her and create a concise and accurate mental representation.  This representation allows her to plan decisively for diagnostic and therapeutic intervention and anticipate possible complications.

The following is an example of a mental representation: “Blunt polytrauma requiring decompression of tension pneumothorax and hemodynamic resuscitation prior to neuroprotective intubation.”

So what is deliberate presentation and how does it help learners to improve so quickly?  Deliberate presentation emphasizes hypothesis generation and efficient communication of a mental representation.  It demands early commitment to a diagnosis and management plan and intelligent organization of supporting information.

Efficiency is achieved by ruthlessly editing out extraneous information. It involves prioritizing supporting evidence by leading with the most relevant information.  A good way to think about this is building a case by starting with clinical signs and symptoms that have high +ve likelihood ratios. Similarly treatment plans should emphasize interventions in order of their clinical importance.

Think of Deliberate Presentation as an expository essay

• Thesis: Most likely diagnosis, differential diagnosis and treatment plan
• Paragraph 1: Supporting evidence for the most likely diagnosis
• Paragraph 2: Refuting evidence for the differential diagnosis
• Conclusion: A succinct mental representation of the clinical entity and plan.

A sample presentation template is included below.  Here is how I go about explaining deliberate presentation to my learners:

• Example
  • Goal and motivation
    • “Our specific learning goal today is to improve your patient presentation skills. This is going to be useful for you in two ways.  First, it will give you the opportunity to rehearse your judgement as if you were out in independent practice.  Second, it will help you develop better mental representations of common clinical problems. This approach is going to allow you to squeeze out all of the learning possible from your shift today and and improve your clinical acumen much faster.”
  • Demonstrate Expert Performance
    • “Here is a copy of the presentation template I’d like you to use today.”
      • (see presentation template below)
    • “I’m going to start off by demonstrating what I am looking for in a patient presentation.”
    • Give sample presentation
      • (see attached sample template below)
  • Explain comfort zone
    • “This change in your style of patient presentation is going to make you feel uncomfortable. You are likely going to be afraid of making mistakes and looking bad in front of me.  I am not concerned about whether you are right or wrong in fact I welcome mistakes as a learning opportunity and a chance for you to grow your clinical judgement.  All I care about today is that you commit to your diagnosis and treatment plan and learn to communicate with greater efficiency.”
  • Explain mental representations
    • “I’m going to encourage you to develop mental representations of the patient’s illness. A mental representation is a clinical snapshot such as the following.”
    • “New onset stable atrial fibrillation with rapid ventricular rate in a low CHADS score patient amenable to electric cardioversion”
  • Feedback
    • “I’m going to give you feedback on each of your presentations. We will be focusing on committing to the diagnosis and treatment plan,  We will also be focusing on becoming as efficient as possible at organizing relevant clinical information and editing out extraneous information.”
  • Coaching
    • “I am going to coach you by playing a game of catch. You will present to me and then I will take the information you provided me, edit it down and present back to you.  We will pass the information back and forth in this manner until we are satisfied that this presentation and your mental representation is as good and efficient as it can be.”
  • Consolidation
    • “At the end of our shift you will present your mental representation of each patient that you saw to me in one sentence. For example:
      • Pneumo-sepsis secondary to aspiration requiring early antibiotics, fluid and pressor resuscitation prior to intubation for anticipated decline
      • Unstable upper GI bleed requiring reversal of anticoagulation, blood product resuscitation and urgent endoscopy for definitive control of hemorrhage.”

This approach takes considerable effort on behalf of the clinical preceptor but comes with substantial rewards.  My hope is that ER educators can go the extra mile and take advantage of the opportunity that patient presentation offers us.  I believe that we can apply the latest principles from the science of expertise towards helping our learners to extract the most benefit from their clinical encounters and achieve their full clinical potential. Let me know how it goes.

 

Presentation Template for Learners

Intro (state your hypothesis in 3 sentences!)

• X is a XX year old presenting with a chief complaint of X. The most likely diagnosis (MLDx) is Y.  The differential diagnosis (DDx) includes 2-3 of Z.  

Plan (Investigations, Tx, Disposition Plan in 2-4 sentences)

• My plan is to order X investigations and treat with Y. The likely disposition is Z.

Prove the MLDx

• Brief narrative history (ie. Ms. X was doing Y when Z happened)
• History, Physical Exam, Investigations that support the MLDx: Arrange in order of High +ve LR’s

Disprove the DDx

• Historical, Physical Exam, Investigations that detract from the DDx: Arrange in order of high -ve LR’s

Summarize mental representation: (1 sentence)

• X is a patient with X diagnosis who requires Y investigations and treatments whose disposition is Z.

 

Key Points:

• I don’t care if you are wrong, I care that you commit.“Mistakes”=Learning opportunities
• Rehearse judgement, eliminate hedging statements “would, might”: Fake confidence
• Check lab boxes, write in imaging and treatment orders: Commit to Dx and Tx
• There’s nothing I can’t fix if we review before chart goes into order box: No harm done

Resources:

http://www.thennt.com/home-lr/

http://www.thennt.com/lr/acute-coronary-syndrome/

 

Sample Presentation for Learners

Intro (state your hypothesis in 3 sentences!)

• Jones is a 67 year old presenting with a chief complaint of Chest Pain. The most likely diagnosis (MLDx) is NSTEMI.  The DDx includes Aortic Dissection and Pulmonary embolism 

Plan (Investigations, Tx, Disposition Plan)

• I’ve ordered an ECG, Cardiac Labs, a repeat troponin at 6 hrs after onset of CP and given his age and smoking history a chest x ray.
• My treatment plan is 160mg ASA, 300mg Plavix and Nitro spray PRN for CP
• I’ve asked the RN to repeat an ECG and notify me if the pain recurs
• The most likely disposition is admission given the patient’s ECG changes and his suspicious history.

Prove the MLDx

• Jones was shoveling snow when he noticed a crushing pressure across his chest at 0730. He noticed that the pain radiated to both his shoulders.  He became sweaty and short of breath.  The pain lasted approximately 30 minutes and went away with rest.  He has a history of smoking, diabetes and a TIA last year.  His cardiac and respiratory exams were normal with no S3, and no rales or pitting edema.  His ECG is STEMI negative but he has new ST depression in the inferior leads compared to an ECG 2 months ago.  His initial troponin is still pending at this time.

Disprove the DDx

• In terms of the differential diagnosis Aortic dissection is less likely because the pain wasn’t sudden onset, nor was it ripping or tearing. The pain also did not migrate.  The physical exam revealed no pulse deficit, no diastolic murmur and no focal neurological deficit.
• In terms of Pulmonary embolism his Wells score is zero. The history is not consistent.  The pain in non-pleuritic and he has no signs of DVT.

Summary

To summarize I have a 67 year old male with a most likely diagnosis of NSTEMI who I’ve treated empirically and am awaiting labs prior to speaking with medicine regarding admission to cardiology.