October 28, 2008

5 Tips for Telling Better Stories

And how to apply it to your case presentations. The majority of these pearls are things I've gleaned from simply writing FIVE History and Physicals on some of my patients in the Inpatient Medicine block... my preceptor is very particular. She was very thorough in with her criticism, but as a result, I really felt the difference in my thinking. I'd like to send these tips along to you.

1. Keep it simple.
* A strong assessment needs to occur in your head FIRST, in order to frame a simple story, simply. I've made a lot of short stories much longer with my med-student induced compulsion for all details regardless of relevance.

2. Openings and closings are very important.
* Like an abstract for a research article, the first sentence should be the last thing you write. This sentence should give away your entire story and make the listeners feel smart for figuring it out so swiftly.
* Similarly, for the listeners that zoned out the whole time, you need to piece the whole thing back together at the end.

3. Be mindful of your story’s spine.
Keep in mind that EVERYTHING you say must come from the Patient-First Perspective. What does that mean? You need to pay attention to everything they say!
* Don’t interrupt the patient! There have been studies that show doctors interrupt the pt after only 18-22 sec (on average) after asking "so tell me what brought you here to the ED/hospital/clinic." However, given the opportunity, patients will only talk for 90 sec (on average) and no more than 2 min uninterrupted... much shorter than it feels I'm sure with the most verbose patients.
* Giving patients the opportunity to frame their OWN story before you stuff them into a boxed diagnosis gives you the chance to uncover something brilliant. I always make a few good observations on my team's behalf whenever I remember this particular rule and give the patient some freedom at the beginning of the interview.

4. Make sure not to alienate your audience.
* Residents, attendings and consultants are very busy people, I've learned. It's best to figure out EVERYTHING that's important before you dive in and present your case. The whole reason why med students are required to ask everything in the history, perform everything in the physical exam and present everything in a systematic order is NOT to bore people to death, though that's a major side effect. It's because we're dumb. We don't know what is important yet.
* Basically, as a med student, you should revisit this fact and remember who you're talking to. Sure, for the purposes of displaying your full understanding and adherence to procedure you can recite a HUGE laundry list in your review of systems... but the attendings will cut you off. Cater your speech to them.

5. Tell the truth.
* In rounds, I've frequently joked and said "oh, just make something up, they won't know the difference" whenever someone asks a solid question that wasn't investigated further as a query to the patient, lab data not collected or study left unperformed. But really, this negates the whole point of the rounding exercise. A patient's wellbeing is at stake.

Hat tip to A Storied Career
Gordon, GH. Defining the Skills Underlying Communication Competence. Seminars in Medical Practice. Vol 5, No 3. Sept 2002.

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