How To Present to an EM Attending

The major challenge as a trainee presenting to a supervising attending is that every attending is different, wants different things, has a different approach, which makes your job impossible. You will do better to have a system. Here’s one system.

Before presenting the case at hand,  provide an update on what’s going on with your other patients. How are they doing? What are they waiting on? Now you’re ready to start in with the present case.

Frame First. Open up with a very brief one-sentence summary of the case, with your conclusion. This frames everything else you’re about to say.

“I think Ms. Jones has pneumonia.”

“I think Mr. Smith will need a CT scan for rule out appendicitis.”

“I think Mr. Lee will need a workup for chest pain, but if negative can be managed as an outpatient.”

Next is the chief complaint.

“Mr. Jones is a 34 year old male with abdominal pain.”

Past medical history follows, most important first. 

“He had a kidney transplant in 2004 for polycystic kidney disease. He is also known for diabetes and hypertension.” 

Notable medications, especially important are recent changes in medications or noncompliance, and relevant allergies to medications.

“He’s on cyclosporin and mycophenolate, as well as glyburide, amlodipine, and hydrochlorothiazide. His amlodipine dose was recently doubled. He reports a penicillin allergy, which gives him a rash.”

Pertinent social situation follows, as it pertains to the situation. This is often omitted, but social situation plays an important role in admit/discharge decisions;  how can you discharge a patient without knowing the environment you are discharging to?

Who does the patient live with? (alone / with family / with spouse, who also has advanced dementia)

What sort of living environment does the patient reside in? (apartment / group home / nursing home / homeless)

What does the patient do during the day? (works as an administrator / is a left-handed pianist / is unemployed / is a student)

What is the patient’s level of function? (fully functional / able to do some but not all ADLs / fully dependent) 

How much help does the patient have at home? (24/7 home health aide / home health aide twice per week for 6 hours / visiting nursing every day)

Bad habits? (drugs, alcohol, cigarettes. history of withdrawal)

Does he have physicians looking after him? If the patient was referred to the ED by a physician, this is particularly important. If there are clinicians who play a particularly relevant role in the present concern, report this. Taking care of patients is a team sport.

Does the patient have any advanced directives? What are the goals of care?

“He lives with wife, works as a bus driver. Denies bad habits. Is supposed to follow with Dr. Green in the renal transplant service at Heartbreak Hospital, but hasn’t seen Dr. Green in six months.” 

Next is a good place to comment on prior visits to the ED.

“He’s never been to this department.”

“He has 48 similar visits to this department, has been extensively worked up dozens of times.”

Next is the history of present illness. This should start with “[The patient] was in his usual state of health until…” and then provide a chronological sequence of events that led up to the present visit; the first part of the HPI should report all the patients complaints, which were elicited with open ended questions, and end with the complaints that led to his coming to the ED, and then what complaints he has at this moment. The next part of the HPI is the focused review of systems, which you can delineate from what the patient offers up without prompting by using phrases like, ‘on questioning,” ‘endorses,’ and ‘denies.’ This is not a complete review of systems, but a focused review of systems with pertinent positives followed by pertinent negatives. A good way to end the HPI is to comment on prior episodes.

“Mr. Jones was in his usual state of health until 3 days ago, when he developed dull periumbilical pain that was intermittent but progressive until this morning, when he developed vomiting and the pain became constant, sharper, and moved to the right lower quadrant. He went to see his family physician, who referred him to the emergency department. At the moment he complains of severe right lower quadrant pain and nausea. On questioning, he endorses diarrhea and chills, but denies mucus or blood in the stool, recent travel or antibiotics, urinary or testicular complaints, shortness of breath, and rash. He had a similar, much less severe episode a few months ago that resolved in one day by itself.”

After the HPI comes the physical exam, which should always start with general appearance and vital signs, and then proceed from head to toe, with a level of detail appropriate for your level of training. I think it is best to leave the area of interest for last. 

“Mr Jones is well appearing, calm, and mildly uncomfortable in abdominal pain. His vitals are normal except for a heart rate of 106. His head to toe exam demonstrates no findings about the head, neck, heart, lungs, and extremities. His abdomen is moderately tender in the right lower quadrant, without signs of peritonitis. His GU exam is normal.”

Now you’ve finished the H&P, and the next question is what has been done for the patient already, if anything, and results

“He was treated with 4 mg of IV morphine and 4 mg of IV ondansetron, and a CBC, chemistry, LFTs and lipase were sent, as well as a urine analysis, according to the abdominal pain nursing protocol. He was uncomfortable when I saw him, so I ordered another 4 mg of IV morphine. The UA has been resulted and shows trace blood, all other studies are pending.”

And now your assessment and plan. I think the best way to provide a summary of the key features of the case, and then answer these questions:

  1. What do you think the patient has?
  2. What dangerous conditions or complications could be causing or associated with this patient’s symptoms?
  3. What tests are indicated to rule out or rule in these dangerous conditions?
  4. What therapies or symptom relief measures are needed?
  5. If the tests that you order are negative, what is the plan for the patient?

“Mr. Jones is a healthy young man with abdominal pain, diarrhea, and fever for 36 hours, his exam is reassuring but he has mild lower abdominal tenderness. Most likely, Mr. Jones has a self-limited GI illness, but I’m concerned about appendicitis. Bowel obstruction and perforated ulcer are unlikely given the relatively benign abdomen. Given a normal GU exam, I don’t think we need to further pursue a lesion there; his abdominal tenderness makes thoracic causes of abdominal pain like pneumonia or cardiac etiologies very unlikely. If his labs show no diagnostic abnormalities, I think he needs a CT scan of the abdomen with IV contrast to rule out appendicitis. If that’s negative, I think he’s safe to be discharged with a nonspecific diagnosis and followup. He’s comfortable right now but I’ll continue to treat for symptoms as needed, and I’ll also give him a liter of fluid.”

The most important way that this system differs from the most common presenting style is that the HPI is presented after the patient’s background information is presented. Most attendings will want to hear the HPI first; I believe that in a stable patient, the HPI can only be properly interpreted in the larger context of the patient’s medical history, social history, etc.

How much detail you present depends on the complexity of the case and how senior you are as a trainee. If you’re about to graduate your residency, your attending may not want to hear anything else than, “Mr. Jones is a healthy 34 year old with a flu-like syndrome, I discharged him with follow up.”

Send thoughts, comments, suggestions, objections, additions to emupdates@gmail.com

 

Related:

Trainee worksheet, with specific guidance on how to succeed during an EM shift. Designed to fit on one page, front and back.

List of ways that I might practice differently than other attendings, to save residents some trouble.

Older, detailed guide to patient assessment.

Rehearse on a sheet of newspaper: An acting coach critiques my SMACC keynote and tells me how I can do better

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I thought there was nothing more excruciating than listening to myself in audiocasts, but then I was video-recorded at SMACCDub, and discovered that watching myself on video is even worse. So I sought the advice of a professional acting coach to improve my presenting mojo. I sent her the video of my presentation and she responded with these notes, which were so useful that I felt they were worth sharing.

 

Overall this is a strong talk, and you’re an engaging speaker. I enjoyed watching it. I have some thoughts on how you can fine-tune a few things, presented here in roughly chronological order.

One thing that stands out to me is that you tend to speak with your brows up, which makes your forehead get wrinkly and “hard.” This is a response to mild nervousness on your part which causes mild anxiety in your audience. If you can relax your forehead a bit, that would be great. To wean the habit, either get a gentle round of botox, or put a piece of scotch tape vertically on your forehead (from top of nose to hairline) while you rehearse the presentation. It will give you biofeedback when you wrinkle your brow. It will be distracting as hell, but it will help you gain awareness of the habit.

You tend to shift your weight a bit, which is probably not as distracting in person but on camera it’s too much movement; stillness would be better. This also comes from nerves–you don’t do it at all at 17:00, but you do it quite a bit around 2:20. When you’re comfortable, your body will reflect that state with increased stillness and more purposeful movements; you will shift your weight when you shift tone or subject, rather than doing it compulsively at unmotivated moments.  Again, biofeedback will help–my advice to young actors is to rehearse the talk while standing, wearing shoes, on a sheet of newspaper, so you can hear when your weight shifts. Wearing different shoes for your talks might help, too–the foam soles on those sneakers are going to make your entire stance more bouncy. Springy soles are good to help “lift” performers who tend to be overly rooted- but in your case that’s not a problem; harder soles would help ground you.

Weight shifting and tense forehead are very common reactions to the stress of presenting (other people nod their heads weirdly, or pace, or clear their throats, wring their hands, or any number of other tics). It will likely take months to wean these habits, don’t stress, you’re pretty good on these fronts already–working on them is just that last little bit of polish.

Around 12-13 mins in, when you talk about thrashing delirious people, you’ve really warmed into it–your delivery is smoother and more natural, and it feels like you’re speaking more in your own native turn of phrase to people you know, rather than giving a speech. That’s a sweet spot for you. You might be able to reverse-engineer this level of comfort; try to remember how you felt at that part of the presentation, dissect the reasons, and then recreate that feeling elsewhere in the presentation. Ideas for how to get that warmed up feeling at the top of the presentation:

– Give yourself a calm, private, focused atmosphere before starting the presentation. For instance, hide in a restroom far from the crowd, or duck into an empty room or stairwell, and rehearse the easiest, smoothest part of the script right before you start the presentation. This will help you tap into the emotional state of calm confidence. For rehearsal, try to create physical conditions that are as much like your performance as possible–stand up and look out at a large open space, focusing your gaze on at an imaginary audience, rather than looking down, looking into a corner, or letting your gaze turn inwards into memory land. Muscle memory works–harness it by rehearsing your stance and eyelines accurately (more on eyelines below).

Imagine a specific person in the audience and speak just to them. Pick a person who likes you, who’s interested in this subject and roughly as knowledgeable as the rest of the audience, and who you are NOT nervous about. Usually I find my nerves come from one or two specific imaginary or real people whom I catastrophize are peering at me from the audience and judging me. If I shift my imagined audience to just ONE person who I know is the perfect target for this talk, my tone will be right for the whole room. So never imagine “ladies and gentlemen,” instead imagine “talking to Greg” or whatever it takes. Who are you talking to? is question #1 for all acting, and public speaking is a form of acting. If the ideal target person is someone you’re close with and the talk is really important or intimidating, you could even go so far as to call them up and ask if you can deliver the talk to them privately as a form of intensive rehearsal.

– Alter the writing so the beginning of the presentation is more colloquial and less technical, which will help it sound more natural even if you feel a bit stressed.

– Add more jokes off the top. Jokes are great as you know, because they (a) engage the audience, (b) get the audience’s buy-in so they will cut you slack if you make errors or annoy them later, and (c) give you feedback – their laugh is authentic proof they like you and are listening, so you can relax.

As you’re rehearsing, pay attention to any parts of the presentation that consistently make you nervous or uncomfortable. Spend extra time on them and rewrite those parts if necessary–try not to have any sections that you dread, even a little bit. If you find a specific part of the talk is particularly hard to memorize, it’s a clue that the writing is weaker – perhaps you’ve inadvertently created non-sequiturs or used awkward phrasing. Rewrite those parts until they flow smoothly and are easy to memorize. This is a classic playwrights’ rule of thumb: good writing is easy to memorize.

Around 19:00 (ketamine) and again around 22:00 (CT/LP) you get a bit…intense. Intense for you is kind of a relative term, as you’re pretty mellow/consistent, but in these sections your pace accelerates and your tonal range flattens. Can you identify why? Is it because you’ve spoken about K so much that you’re going a bit by rote? Are you worried about time? Identify and address the cause so the tone through this segment can be a little calmer and more gracefully shaped–the ketamine part feels a bit like a bullet train. Maybe add some more jokes.

Are you reading a prompter? Your eyeline to the prompter is too low; can you raise the physical location of the prompter so your eyes are higher when reading it? Eyeline is important and often overlooked. I think you’re doing this pretty well already, but it bears mentioning: be sure your eye contact includes the whole audience. Eye contact is the net you use to draw the audience in–make sure to cast it out wide enough to get them all. Look at both sides right out to the edges, the front row, the back row, and right up to balcony.

I think it’s best to make true eye contact with specific people for about 3 seconds each, but if that freaks you out, you can cheat by looking at the spaces between their heads, and you can have a few default gaze targets that are along the back of the room, about a foot above the heads of the people in the back row. Angling your gaze upwards in this way helps your words to travel “up and out” to the audience, which draws them in–the amateur opposite is to look only at the front couple of rows, which creates a low, downwards eyeline, shoots your ideas into the floor, and shuts the back of the audience out. When you look slightly upwards, we can see you and connect with you better.

Answer this question out loud: What color is your bedspread? Your eyes probably darted up and to the right–but sort of blindly–as you remembered the answer. We tend to “look at nothing” for a second when we’re concentrating–for instance, carefully delivering a memorized speech–and those glazed, spaced-out eyes are a hindrance to connecting with the audience. So, as my favorite acting teacher used to holler at us mid-monologue, keep your gaze in the room. Work on being able to really look at people during your talk, rather than, say, hyperfocusing on the exit sign or sweeping your eyes around blindly. You want to actually see the people. You can practice at home by sticking little faces cut from magazines all over the wall (or use sticky notes with little faces drawn on), and actually look at each face for a few seconds as you speak. Or just look at actual objects in the room: the doorknob, the teapot, the rice cooker. Make sure your eyes are alive enough to really notice what you’re looking at, which will ensure that your eyes–like your feet, in an ideal world–are moving deliberately and with purpose.

The goal here is to keep your eyes, and by extension your awareness, alive, present in this room at this moment–to keep your eyes receiving, not just sending. A talk needs to send a message OUT, yes, but great speakers are great because they are simultaneously taking the audience IN. In most normal conversations, you probably achieve this state of simultaneous broadcast-and-reception without really trying; but when the pressure of the speech hits, we tend to shut down our receiving capabilities and become little automaton radios spitting pre-programmed words at the audience, so the listener may feel talked-at and tune out to some extent. During a speech, your ideal state of being is present and aware enough that if someone sneezed, you’d hear them and be able to say gesundheit without skipping a beat. Achieving this kind of awareness is super-advanced and takes a lot of time and practice- but it is truly the tipping point from good to great. As a bonus, it will also help ease your forehead tension and improve your posture–we tend to raise our brows and push our faces forward when we’re emphatically projecting, as though our ideas are a unicorn horn we’re stabbing at the audience–but when we are empathetically listening without judgement, our foreheads relax and our eyes soften, which lets the audience relax and allows them to hear you better.

Your little microphone cord loop at the back of your neck keeps distracting me. Look in a mirror and tuck that shit in.

Your tiny smiles when you’re about to make, or have just completed, a joke are delightful. It’s always fun to see someone enjoying themselves. This is why we love Saturday Night Live the most when the actors break character and giggle.

Try to wean out the phrase “you guys” (it comes up in the Q&A at 25:00), and replace with “you” or “you all”, etc.  “You guys” is gendered and lacks gravitas.

You also mentioned, and I agree, that in general your posture could use a bit of an adjustment. As a diagnostic, try this: stand up, open your arms wide into a T and then drop them back down. Your hands will probably end up in front of your thighs naturally (here is an exaggerated version). Now do it again, but this time slowly and deliberately lower your hands beside you, so your thumbs end up resting along the side-seams of your pants. As you lower your arms, try to initiate that final hand position long before you get there, and from your back rather than from your arms or chest–it should not feel like holding your arms back or puffing your chest out, it should feel more like you are pulling your shoulder blades gently together–that’s the posture you want.

You can do exercises to enhance this:  try things that open your arms wide against resistance, like bent dumbbell flies where you try to get hands higher than shoulders, to strengthen / tighten your trapezius and latissimus dorsi muscles, or do incline dumbbell flies with low weight, but relax your arms outwards and let gravity and the weights stretch your pecs and biceps. And try to place your head over your spine rather than out in front of your spine. You can also add in some pec stretches in doorways and against walls and on balls. Yoga would be a good challenge for you.

Improving your posture is a very long term thing- it would be hard and distracting and probably a bad idea to think about it during presentations so I suggest working on it during workouts and in your regular life- once you have it as a normal habit, it will happen automatically onstage. I spent YEARS fixing my posture in acting classes, singing classes, yoga, and even flute lessons, before it became second nature.

Strengths overall: You have strong content to offer, your voice is pleasant, well-articulated, comfortable and easy to listen to–you’re breathing well and using your vocal instrument in an easy, natural way. The talk is well-written, strikes a good balance between natural and formal, and it’s interesting, even to a non-clinician, which I think is saying a lot. It’s obviously a great talk, and you deliver it very well. Would love to see the next iteration of it.

Nicole Stamp is a toronto-based director, actor, and acting coach.