10 April 2012


When medical students do their clinical rotations, an important ritual is the presentation of a new patient case to the medical team. The student tries to orient the team to all relevant aspects of the case, including (among other things) the patient's age, gender, and background; the patient's "chief complaint"; the history of the illness; the relevant lab findings and imaging studies; the differential diagnosis; and the presenter's recommended plan of action.

Presenting is a real art. The presenter needs to condense all they have learned about the patient (how many grandchildren they have, what they ate for lunch) into only a digest of the most relevant details. But who can know just what details are most relevant? A patient's broken arm might have an underlying cause, like a genetic defect in bone formation, a tumor that has invaded the bone, or a history of trauma from an abusive spouse. Different diagnoses center around different aspects of a case history: a history of prior broken bones for a genetic defect; a history of unexpected weight loss for cancer; a history of marital strife for domestic abuse.

The problem is that the diagnosis is usually uncertain. If the presenter has a good idea of what the diagnosis will be, he focuses his presentation around that hypothesis. But at the same time, he needs to include enough details so that even if his hunch was wrong, the listener could arrive at the correct diagnosis nonetheless. Medical students must tread especially carefully, because they are not as experienced as attending physicians at assembling the constellation of symptoms, history, and physical findings into a unifying diagnosis.

Emphasis matters. While shadowing, I heard a presentation that emphasized minor details but buried a worrisome lab finding that suggested urgent life-threatening disease.

The presentation objectively informs and subjectively argues; the presenter draws upon what he knows yet is mindful of what he does not. From the outside, the practice of medicine might seem formulaic and almost robotic. But the presentation is not. It hinges upon one's unique ability to observe, investigate, reason, and communicate.