Every aspiring physician knows the importance of memorization, especially in the basic science years. As you advance in your career, however, communication skills come to the forefront. Physicians with poor communication skills are more likely to be sued. (Virshup) They are more likely to be disciplined by the medical board. They may not receive as many professional referrals from colleagues or word-of-mouth referrals from patients.
Successful communication requires establishing a connection and imparting a message. Successful patient care does not end with gathering data from your patient. It revolves around imparting that information to the entire team that is involved in patient care: your team members, the consulting physicians, the nurses, the patient and family members, and even the cafeteria, among others. (“The patient’s allergies include a history of anaphylaxis to shrimp.”)
Third year students, in the midst of early clinical rotations, quickly recognize the importance of communication. Memorization may be a crucial skill for those taking exams and receiving grades based on an objective test score. However, when receiving a subjective grade based on your ability to take care of patients, one’s ability to communicate with patients, to establish rapport with colleagues, and to impart medical information, become important indicators of communication skills.
How exactly do medical schools determine a student’s ability to provide excellent patient care? A student’s grade in core clinical rotations is determined by several factors, including subjective ratings and objective test scores. One study examined the evaluation techniques of 97 US medical schools. (Kassebaum) Faculty and resident ratings accounted for 50-70% of a student’s grade in core clinical rotations.
How do faculty and residents arrive at their subjective rating of a student’s abilities? Clerkship evaluation forms ask faculty to rate students on specific skills, such as a student’s ability to take a history and perform a physical examination. However, attending physicians rarely or infrequently observe students in these areas. In fact, in a survey of 322 University of Virginia medical students at the end of their third year, 51% reported never having a faculty member observe them while taking a history; 81% had never been observed performing a complete physical exam. (Howley) Therefore, many faculty draw conclusions about a student’s ability in these areas from the quality of the oral case presentation.
In a study of surgical faculty, Pulito found that it was rare for faculty members to directly observe a student taking a history or doing a physical examination. (Pulito) In fact, only one of nine faculty members surveyed had done so. Despite this, five of the nine faculty participants rated students in this area. They inferred the rating of this characteristic from other factors, particularly the oral case presentation. Pulito wrote that “in the clinic setting, for example, if a student presents a patient to an attending and is verbally facile, succinctly describing a focused history and physical examination, the inference may be drawn that the student expeditiously obtained the relevant history and performed an appropriate examination.”
In one study focusing on communication apprehension among medical students starting a surgery rotation, Lang wrote that “much of a student or resident’s evaluation is based on oral presentations.” (Lang) In another study assessing student performance on a pediatrics clerkship, Greenberg found “a highly significant relationship between students receiving a final grade of honors and an ‘A’ on their case grade.” (Greenberg)
In oral case presentations, students aim to effectively transfer important clinical information between team members. When done well, these presentations facilitate patient care, improve team efficiency, and become a valuable learning experience. Since they also serve an evaluative function, students hope to deliver high-quality presentations to prove their competence. While some students are inherently gifted in the area of making presentations, all would benefit from practice and the following suggestions:
- Expectations for the oral case presentation vary from clerkship to clerkship, attending to attending, and resident to resident. For this reason, always meet with your attending and resident on the first day or two of the clerkship to ascertain their expectations.
- Your goal is to leave this discussion knowing the attending or resident’s personal preferences (preferably before your first presentation). Ask specific questions about time limits, the order in which to present information, and so on. “Do you want me to report the entire physical exam or just pertinent positives?” “Which labs would you like to hear, or would you prefer to hear all of them?”
- What worked well with one attending or resident may not work well with another. You may have internalized a certain set of “presentation rules.” With the start of a new clerkship or arrival of a new attending, recognize that these rules may not meet their needs.
- Be aware of the context in which you are presenting. Your presentation to a resident with whom you evaluated the patient should be different than the presentation given to an attending who is hearing about the patient for the first time.
- Make your presentation flow like a story. Your goal, many times, is to make an argument for a particular condition. Put the details of the case together in such a way as to lead the listener to a diagnosis.
- As a novice clinician, your inexperience makes it difficult to decide what to include and what to leave out. The easy way out, and the route that many students take, is to simply read the written H & P word for word. However, the oral case presentation should be a carefully edited version of the written record. The key is to communicate only what’s relevant. For a new clerk, that can be very difficult. Don’t be afraid to ask for help in this area.
- Use residents as a resource. Residents are often familiar with attending preferences and can help polish your presentation before you have to deliver it to the attending.
- Seek feedback after each and every one of your presentations. The best feedback is that which is explicit and timely. Many attendings won’t automatically provide feedback; you may have to specifically ask for it. “Dr. So, do you have any suggestions on how I can improve my presentation?”
- Uncertainty is normal with oral case presentations. Because of the evaluative function of these presentations, it can be tempting to bluff or lie in an effort to look good. As hard as it can be to say “I don’t know,” honesty and accuracy in the transfer of clinical information is vital to patient care. In a survey of Johns Hopkins medical students, 13% to 24% admitted to cheating during the clinical years of medical school. (Dans) Examples included “recording tasks not performed” and “lying about having ordered tests.”
- Projecting confidence is important. Your choice of words, the manner in which you speak, and your body language are all factors that will be used to judge the quality of your presentation.
- It is rare to present a patient without any interruptions. In one study of emergency medicine faculty and students, the mean number of interruptions was 2.49 per oral case presentation. (Yang) Although students often view interruptions as a sign that their presentation is lacking, this is often not the case. Attendings find it difficult to balance the need to teach with the need to care for a service full of sick patients. In addition to interruptions due to time constraints, you may be asked to repeat information or clarify a certain point. Unfortunately, many students let interruptions derail their presentation, and find they can’t recover.
- Many students stop short of offering an assessment and plan, especially novice clinicians who don’t feel qualified to do so. Always offer your own assessment and plan. Attending physicians are impressed with students who take the initiative to do so.
- Read extensively about your patients’ problems using a variety of resources, including handbooks, specialty textbooks, and the recent literature. As you read, make it a habit to ask “why?” Why did we order this test? Why did we choose this particular antibiotic? Such questions further your understanding of the disease – not to mention prepare you for the attending questions that are sure to come during or following your presentation.
Because of the complexity of the oral case presentation and the varied needs and expectations of residents and attendings, delivering high-quality presentations can be difficult. Is it worth the effort? Absolutely. First, presentation quality is a major factor used in the evaluation of students. Second, the development and acquisition of communication skills is important for your future career as a physician. That’s precisely why, in recent years, organizations such as the Association of American Medical Colleges (AAMC), Clerkship Directors of Internal Medicine (CDIM), and the Accreditation Council for Graduate Medical Education (ACGME) have emphasized its importance. In fact, the AAMC considers the development and acquisition of communication skills a core learning objective for medical students.
Communication skills remain important at every stage of your career. For fourth year students, currently in the process of submitting applications and awaiting invitations to interview, communication skills take on renewed importance. A successful interview requires establishing a connection with the interviewer and imparting a message about your strengths and abilities, a topic we will review in our next column.
About the Authors
Dr. Rajani Katta, a dermatologist and Dr. Sami Desai, an internist, are the co-authors of The Successful Match. They have recently released an updated version for the 2017 Match.
Virshup BB, Oppenberg AA, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Qual 1999; 14(4): 153-9.
Kassebaum DG, Eaglen RH. Shortcomings in the evaluation of students’ clinical skills and behaviors in medical school. Acad Med 1999; 74(7): 942-9.
Howley LD, Wilson LG. Direct observation of students during clerkship rotations: a multiyear descriptive study. Acad Med 2004; 79 (3): 276-280.
Pulito AR, Donnelly MB, Plymale M, Mentzer RM Jr. What do faculty observe of medical students’ clinical performance. Teach Learn Med 2006; 18(2): 99-104.
Lang NP, Rowland-Morin PA, Coe N. Identification of communication apprehension in medical students starting a surgery rotation. Am J Surg 1998; 176 (1): 41-45.
Greenberg LW, Getson PR. Assessing student performance on a pediatric clerkship. Arch Pediatr Adolesc Med 1996; 150 (11): 1209-1212.
Dans P. Self-reported cheating by students at one medical school. Acad Med 1996; 71 (1 Suppl): 70-72.
Yang G, Chin R. Assessment of teacher interruptions on learners during oral case presentations. Acad Emerg Med 2007; 14 (6): 521-525.