In medical school, case presentations bridge the gap between the didactic phase of the first and second years, and the clinical rotations that make up the third and fourth years.
Developing a differential diagnosis and presenting to an attending physician are critically important components of medical training, and they can take practice to learn to do well, says Saroj Misra, DO, a family physician and the program director of the family medicine residency program at Michigan State University College of Osteopathic Medicine.
To help students fully master the many moving parts that make up an effective case presentation, Brianna Marzolf, DO, a family medicine resident at the University of Michigan, Ryan Smith, DO, a family medicine resident at Ascension Macomb-Oakland Hospital in Madison Heights, Michigan, and Dr. Misra offer the following three tips.
1. Stick to a formula.
Dr. Misra said the most common mnemonic to structure presentations with is known as a “SOAP note,” or Subjective-Objective-Assessment-Plan. For students interested in what that system entails, he provided this document.
Dr. Marzolf said that if a presentation becomes stressful early on, having a structure like SOAP to fall back on can get you back on track.
“If you’re panicked and lost, just go back to the formula,” Dr. Marzolf said. “That’s what makes the best presentation, something that an attending physician can follow. I try to think, ‘if I’m an attending, what do I want to hear? How would I want this presented?’ And that comes with practice.”
Nonetheless, Dr. Misra stressed that the mnemonic you use to organize your thoughts matters less than making sure you are consistently presenting all of the pertinent facts about a patient in a way an attending physician can understand.
2. Err on the side of more information
The most useful skill developed in case presentations is the ability to give a differential diagnosis, Dr. Misra said. While he said most cases can usually be attributed to typical causes, not exploring every possibility might eventually lead you to misdiagnose.
“Our job is not just to teach the student to hone in on what they think is going on, but rather to be able to explore all possibilities, common and uncommon, as a mental exercise, and then determine the best course of action,” Dr. Misra said.
In the midst of listing diagnoses, Dr. Marzolf cautioned students not to overlook basic patient information.
“I was always told, vital signs are vital,” she said. “When you get to the objective portion of a SOAP note, it’s essential to list the vitals first. Attendings really want to know the objective values right away. That’s easy to forget sometimes when you’re bogged down in all the details.”
If you found something intriguing about a particular case, there’s a good chance your colleagues and attending physicians will find it intriguing, too, Dr. Smith added. In general, he said, it’s better to err on the side of giving more information when formulating your initial differential diagnosis.
“As you hone your skills, you’ll learn from the questions the attendings ask you what should have been included in the presentation from the get-go,” Dr. Smith said.
3. Practice beforehand, and don’t be afraid to ask for help.
Case presentations may not come easily to students who are less comfortable speaking publicly, Dr. Misra said. To try to overcome performance anxiety, he suggested writing out a script and practicing with someone else beforehand.
Dr. Marzolf said that as a third-year starting clinical rotations, the residents she worked with were willing to listen to her and give her feedback.
“If you ask for help, people want to help you,” she said. “Everybody’s been a third-year before and knows how it feels to be very overwhelmed and need a little direction. There’s always going to be people in the hospital who know more than you. That’s OK, and that’s the stage you’re at.”
Interns and residents are most likely to give you specific feedback about what an attending they’re working with prefers to hear, Dr. Misra said. For instance, they might be able to tell you that an attending physician doesn’t tend to ask about a patient’s immunization history. In that case, he said, they might suggest you say you have the immunization history, and let them make the decision if they want to hear it.
It’s all part of establishing a good rapport with people who can mentor and guide you, Dr. Smith said.
“I would always encourage students to find a resident or physician who they connect with to guide them along this process. Students are always running cases by me and asking how they can make their presentations more engaging. That’s something they should all be trying to do.”