For this episode, we are joined by guests Brian Barbas, George Willis, and Casey McGillicuddy to discuss one of the most important parts of any EM rotation; patient presentations.
Emergency medicine is very different from alot of other rotations. It can be tricky for students to get used to the different style of presentations that are preferred by most EM physicians. In this episode our guests break down the EM presentation and give their tips on how to shine as a student in the emergency department.
Setting expectations
When you start your shift introduce yourself, figure out who you should be presenting your patients to, and ask how they prefer their presentations. Every attending or resident is going to give you a different answer. Be open to different presentation styles and accept feedback on how you can improve. If you are presenting directly to the attending often times the residents will be able to help guide you. No matter how concise your presentation may be it is important to always be ready to answer any follow up questions about the patient. Realize that over the course of your rotation you will learn a bunch of different presentation styles – there is no one-size fits all approach!
Before you see the patient
Start formulating your differential based on the chief complaint so that you have an idea of what questions you want to ask. Don’t forget to review the patient’s vital signs and any relevant nursing notes. If you have access to old records, you may want to avoid reviewing them till after you meet the patient to avoid biases. As a student you do not have the clinical gestalt to label patients as “frequent fliers” or “chronic complaints”. Do not make any bias statements about patients.
Seeing your Patient
Always start by introducing yourself and asking what brought them to the Emergency Department today. This allows you to confirm their chief complaint. As you get your history and physical exam you should be whittling away at your differential diagnoses. Don’t forget to ask questions relevant to any clinical decision tools you might want to apply to the patient. Your goal is to use your history and physical exam to come up with an appropriate EM differential.
If you go to see a patient and they have unstable vitals or you are concerned they are critically ill stop and go get your attending. It is more important to recognize a sick unstable patient then to get a detailed history and physical exam.
Presentation
After you finish your history and physical take a few minutes to organize your presentation in your head and come up with your differential and plan. Remember to stay relevant and only include things in your presentation that are important to the patient’s chief complaint today. You should still gather a detailed history and know as much as you can about the patient but only present what is relevant! Your goal should be to tell the patient’s story while highlighting your thought process.
Alot of students take notes while interviewing patients. If you do, I would recommend only writing down pertinent things not every detail the patient says. Many preceptors will challenge you to present without looking at your notes. You may be shocked to find out your presentation is much better that way because you are telling the patient’s story and only hitting on what you remember as important instead of reading every detail they told you off of your notepad.
Try to push yourself to not just be a reporter of information but also an interpreter. Being able to give an interpretation of what you are reporting shows your progression from a student to someone who is actually understanding the concepts. You’re learning these skills. What is your differential for this patient? Then taking it a step further, what would you like to do about it now?
Commit to your differential. It is ok to be wrong as a student but it’s not okay to avoid the thought process. By coming up with a differential for each presentation it helps us as educators understand your thought process and then indentify potential learning opportunities. Always include the emergencies for each chief complaint in your differential even if you have “ruled them out” based on your history and physical exam. Instead show that you know what dangerous diagnoses you should be thinking about and then explain briefly why you don’t think it is those things. This gives your preceptor an idea of your thought process.
Patient Reassessment
Don’t forget to reassess your patients. Take ownership of them! Be sure to follow up on any labs and imaging results. Keep the patient updated and if you provided a treatment circle back to see if it was effective. If they are being discharged, prove that that is a safe option. That might mean PO challenging the patient, ambulating them, or rechecking vital signs. It is important to reassess your patients without prompting!
Patient Disposition
Be sure to take the time to sit down with the patient and discuss their final diagnosis. Make sure they understand any medications they will be prescribed, follow up appointments, and ED return precautions.
Another way to shine is to consider how the patient’s non-medical needs or social aspects are going to affect the plan. If a patient can’t afford their medications or doesn’t have transportation for follow up appointments this is important to know. Often times this gets looked over in the hustle of the ED. If you can be a medical student who starts thinking about the social aspect of their care, this can be a gold star moment for you.
Take home points
- Understand what is expected of you from the beginning of your shift
- Stay relevant
- Tell a story
- Show your thought process when presenting your differential
Listen to the Episode
Presentation resources you should check out:
- ALiEM’s 8 Tips on how to succeed on your EM sub-internship
- The 3 minute EM medical student presentation article
- EM in 5 Patient Presentations
- ALiEM’s Rapid Infographic
Medical Student Resources you should check out:
- The American College of Osteopathic Emergency Physicians- Resident and Student Organization: https://acoep-rso.org/
- CORD’s Osteopathic Emergency Medicine Applying Guide: https://www.cordem.org/globalassets/files/student-resources/applying-guide—osteo.pdf
- ALiEM’s EMBound Student Newsletter: https://www.aliem.com/em-bound/
- EMRA’s Medical Student Newsletter: https://www.emra.org/students/newsletter-articles/
- EM Over Easy’s other Med Students Over Easy content: https://emovereasy.com/med-students-over-easy/
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