Hi, I’m Dave Pierce. I’m an emergency medicine attendant in Buffalo, New York. I’m going to share with you how to present a case. This applies to residents, PAs and nurse practitioners.
In the past I’ve had residents and students present a case to me, saying, “Hey doc, I have a great case.” Then they share 40 minutes of information and 15 layers of family history. As they’re doing this, I’m starting to have chest pain myself. At this point, I want to check myself into the ER.
It’s not that you have to do anything differently in terms of your history and physical. It’s how you roll it to an attending that I think is important. What I want you to focus on is:
- Being committed to the case.
- Making sure you don’t miss anything.
- Pushing further into your differential diagnosis.
I want you to look like a rock star when you present the case. This is all about good patient care and looking competent. Looking competent is pretty important when you’re going through your provider, and when you become an attending. When the patient asks, “What do you think it could be?” You don’t say, “I don’t know. I’m just ruling out your MI, I don’t care about anything else.” Patients don’t find that endearing.
Strive for Five
Here’s the deal. I want to tell you right up front that I stole this from Wegmans, a supermarket in upstate New York. One of the best things Wegmans came up with is “Strive for Five.” What that means is that you want to aim for five servings of vegetables and five servings of fruits every day. Now, we’re going to use Strive for Five in terms of five differentials.
When a resident comes up and presents a case to me, I tell them up front this is how I want to hear it. I want to hear, when you present the case, “I have a 75-year-old guy with chest pain, history of peripheral vascular disease, GERD, that I think has…” And tell me what your diagnosis is.
Don’t give me a rule out; tell me what it is. “I think he has musculoskeletal chest pain.” With a 75-year-old with chest pain, you better have some good things in your history and physical to narrow your diagnosis down to musculoskeletal.
Then, give me four differentials. “I think it’s chest pain due to musculoskeletal. I also considered dissection, GERD, pulmonary embolism, whatever it happens to be.” You want to focus on telling me the whole story.
Commit to Your Case
I have one resident who used to come up to me while I was attending and say, “Yeah, you know, I got this case and, you know, I got this guy. He’s got some belly pain and…” I ask, “Okay, well, what do you think is going on?” He goes, “Well, you know, I want to get some CTs, some belly labs and we’ll see what’s up.” So, I ask again, “What do you think is up?” He says, “Well, I don’t know. We’ll see what the CT shows.”
After I resist the urge to wrap my fingers around his neck and shake, it’s all about you committing to the case. If you commit to the case, it’s a lot more satisfying. It helps focus your diagnostic test. When you say, “Listen, I have someone with chest pain. I’m going to rule out an MI.” And when you really think it’s GERD, you shouldn’t have given him the aspirin. Or you think it’s anxiety, so you probably should have treated that, instead of saying, “They’re really anxious in the room. I’m ruling out the MI.”
Look Like a Rock Star
You want to focus on what you think is really going on. I’m not saying you can’t rule out other things but narrow down your case presentation. Hit it up front, telling your doc, “This is I think they have and these are the other things I considered.” Then tell the whole story.
- Number One: Presenting your case up front makes you look like a rock star.
- Number Two: You’re less likely to miss things when you present the cases this way.
- Number Three: You’re doing your patients a service by sitting down and thinking about what the case could potentially be. The patients that go up to the floor and die from a pulmonary embolism are because you failed to think about pulmonary embolism.
Hopefully, this will help you. Be committed to your case, push your differentials further and strive for five.