The Art of Oral Presentation

Chapter 9 The Art of Oral Presentation



Paul J. Schenarts, MD, Mary Ann Hopkins, MPhil, MD


Communication skills form the basis of medicine. Throughout your entire career, you will communicate crucial medical information with your colleagues. It is therefore critical to strive for effective verbal communication, with the emphasis on prioritizing and adjusting to the particular situation the amount of information transmitted.


Often the only presentation format medical students learn is the “History and Physical.” Presenting a case in this format in the middle of the night is not the most efficient means to present information verbally. Your job in verbal communication is to distill and synthesize the major points of the history and physical so that the listener can be focused from the beginning of the conversation, can visualize the patient whom you describe, and can understand your differential diagnosis and thought process. You may add or omit particular details depending on the setting in which the presentation is given. During teaching rounds, demonstrating your detailed understanding of the issues of the case will be appropriate, while in the middle of the night the ability to distill and synthesize the major points will be most effective and appreciated.


The ability to trim a presentation to the most essential elements requires that you understand which facts are high and low priority and when to incorporate them into your presentation. One trick is the appropriate use of “buzz” words, which will immediately focus the listener. Most surgeons, for example, will have an immediate response to statements such as “free air” or “pain out of proportion to exam.” Keep a small notebook of meaningful phrases and buzz words.



ADJUSTING THE LEVEL OF DETAIL


Your goal is to paint a clear and complete picture of the situation in a short amount of time. Every presentation should contain the most essential information. Depending on the context you may wish to expand your presentation to include finer points of detail (i.e., teaching rounds); however, even when giving condensed presentations, you should be able to demonstrate your complete knowledge of the case, in the event the listener asks for further detail.


When presenting orally, avoid getting lost in the details of the complicated medical history. Paint a background and then follow with a focus on the patient’s current presentation. For example:


image For the complicated patient with diabetes mellitus, atherosclerotic cardiovascular disease, congestive heart failure, and end-stage renal disease (ESRD) who presents with appendicitis, start: “On a background of medical disorders including, diabetes mellitus, atherosclerotic cardiovascular disease, congestive heart failure, and ESRD, this 73-year-old male presents with RLQ pain.”

image For a patient with small bowel obstruction (SBO) due to adhesions, who has had previous colon resection, and two previous lyses of adhesions, start: “On a background of multiple previous operations, this patient presents with distention consistent with SBO due to adhesions.”


DISTILLATION


This is particularly difficult in the complicated patient. One technique is to include only parts of the past medical history that will influence your decision making, such as coronary artery disease (the patient may need invasive monitoring) or ESRD (the patient may have an electrolyte imbalance or may have recently had dialysis).



SYNTHESIS


Provide a clear, concise chronological history that includes positive findings and pertinent negatives. Bring together the essential elements of the history, examination, laboratory data, and radiographic data into a unified diagnosis and remember to propose a treatment plan.


In the example on the next few pages, aspects of a typical history and physical have been highlighted. High-priority findings and buzz words appear in red type. Important but lower-priority details are in blue type. Review the differences between three working situations: the 1 AM call to wake your attending, the 7 AM report to your chief resident, and 3 PM teaching rounds. Notice how these high- and lower-priority elements are incorporated into different types of presentations.




Typical Written History and Physical


NOTE THE HISTORY AND PHYSICAL BELOW AND THE THREE DIFFERENT ORAL PRESENTATIONS ON THE FACING PAGE USING THE SAME DATA POINTS.


Chief Complaint: 53-year-old male with hx of peptic ulcer disease (PUD) presents with abdominal pain


HPI: The patient is a 53-year-old male with a history of a duodenal ulcer who underwent endoscopy 3 weeks ago and was found to have an ulcer in the anterior wall of the first portion of the duodenum. He was placed on H2 blockers and antibiotics and scheduled for follow-up in 2 weeks. He has been having intermittent epigastric pain for 2 weeks, somewhat relieved by milk and antacids, but noted the acute onset of severe pain about 12 hours ago. He admits to drinking a six-pack of beer almost every evening and admits noncompliance with medication. He increased his drinking to alleviate the pain. He was found on the floor writhing in pain by his son and brought to the ER at midnight. He denies any nausea, vomiting, or fevers. Pertinent positive and negatives include a colonoscopy 3 years ago that was reportedly normal, no hx of weight loss or carcinoma.









PMH: hypertension, PUD; denies DM, CAD PSH: none

Meds: HCTZ, Maalox, Zantac (noncompliant)

Allergies: NKDA

Family History: smokes 1½ PPD × 25 years; drinks 6 beers daily; denies recreational drugs; divorced father of 2; lives alone; works in construction

ROS: CV, GU, NEURO unremarkable; GI as in HPI

PE: VS: T =100.8, P =120, R =20, BP =110/60

Gen: WDWN male in moderate distress; ETOH on breath

HEENT: unremarkable

Neck: supple; no JVD
CV: RRR no M/R/G

Chest: BS clear bilaterally

Abd: distended, rigid with involuntary guarding; rebound; BS hypoactive, no masses/scars appreciated

Rectal: nl tone, no masses, prostate nl, no nodules, stool: hemocult trace+

Genitalia: penis and testes WNL

EXT: no clubbing, cyanosis or edema. Fem, DP, PT pulses all 2+

Neurological exam: alert, oriented; cranial nerve exam wnl; no gross motor or sensory deficit

Labs: WBC = 18, Na = 135, K = 3.2, CL = 110, CO2 = 19

AXR/CXR: free air under the diaphragm

Assessment: 53-year-old male with an acute abdomen and free air under the diaphragm with probable perforated duodenal ulcer; doubt diverticulitis or other reasons for free air


Plan:


1. Aggressive fluid resuscitation with LR; prophylactic antibiotics; K+ supplementation; to OR for immediate exploration.

2. Monitor post-op for hypertension and place back on HCTZ when appropriate.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on The Art of Oral Presentation

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