Communication Breakdown: Presentable Presentations

If you want to be a better clinician the most important area to improve your skills is communication.

Really.

Of course you need medical knowledge, but that takes a while to build.  And you need procedural proficiency but that also takes time and opportunities.  And you need to learn to function in different clinical environments, each with it's own set of processes, rules, and traditions.  That also takes time and  you start over with each new place.

But communication.  That is something you already have experience with and does not require a prolonged investment of time.  What it takes is the desire to actually communicate better.  With patients, with staff, with other services, and with your supervisors.

Not coincidentally, communication is also the skill that can most dramatically improve your evaluations during your EM rotations.  We will tackle the other areas of communication later.  Today we are diving into the art of presentations.

A really good, focussed, well organized presentation to your supervisor is the most effective way to convince them of your skills.  You will be evaluated in many areas.  Knowledge base, focussed history taking and exam skills, ability to form a differential, and ability to make a plan all being fairly typical of what your supervisors will be assessing you on.  To know exactly what they are asked to assess you on in writing you a "letter" take a look at the SLOE.

You will sometimes be directly observed to see how well you relate to patients and gather info from them.  However, in most rotations these skills will more often be assessed when you present to your supervisor.  More direct observation would be better, and as we will discuss below, more fair.  The pace of most ED's and a common belief that watching you will change your behavior (The Hawthorne Effect) prevents direct observation from happening more often.

If your presentations are going to be this important to the perception of your abilities then it is critically important that you make them good.  Relay only the pertinent HPI details and exam findings and you will appear able to distill information and focus.  Describe an appropriate DDx, giving weight to life threats and common problems, and they will believe you have a strong and well-organized knowledge base.  Share a plan that includes tests and treatment, and that is practical in the ED setting, and they will believe you understand EM practice.

Let's take two hypothetical students:  Student A and Student B, and put them on a hypothetical rotation together.  Student A is well read, with great board scores, and spends a lot of time with his patients getting their history and explaining their care.  Student A gives long, very detailed presentations, and does not suggest a DDX or plan because he does not feel confident that he knows enough to create a good one.  Student B prefers to learn by doing, has mediocre scores, and moves fast, talks fast, and is all over the department.  Student B gives short, focussed presentations and is willing to throw out a DDx and plan even though they are often wrong and get changed.  Student A may turn out to be the better physician but Student B is usually going to do much better on her ED rotation.  If you empathize with Student A this should seem patently unfair.  And that is because it is unfair.  Most emergency physicians are high energy, decisive, and direct people and they usually value those attributes in others.

This is not to say that the ideal is Student B.  Those who incorporate the best qualities of both Student A and Student B are those most likely to experience long term success.  Student B is just going to have an easier time getting in to EM.

If you believe your presentations need work, a good road map to get you started is The 3 Minute EM Presentation.

Good luck!

The New SLOE is Revealed

The SLOR has been revamped to emphasize its true utility as a letter of evaluation. The new SLOE, retains many of the previous features to define each candidates fit, commitment and abilities in EM, while striving to be both standardized and accurate. 

Departmental SLOEs are often composed by the clerkship director, with input from the program director, and faculty that worked with you. Personal SLOEs can be written by any faculty member with whom you have had extended clinical contact. You should strive to have two departmental SLOEs done by October.  A personal SLOE can act as an additional letter of evaluation.

The SLOE continues to relate the author's credentials, provides a global assessment of each candidate, allows for peer to peer comparison, and for personal written comments about each student. 

The SLOE begins with background information including the type of SLOE, author, length of your and the author’s relationship, nature of your contact, the grade during your rotation, how many EM rotations you’ve completed, and last years grade distribution for the clerkship. In the new SLOE there is an added space to distinguish required and elective rotations. This will allow programs to view the grade scale in context of the rotators, and continue to discourage grade inflation.

The new SLOE also defines the author's relationship to the residency program. Since SLOE's are not solely used by the program administrators, this better defines how closely the author influences and understands the ranking process.

Next the SLOE establishes the students qualifications for EM, in comparison to other applicants. Your commitment to EM, work ethic, differentials and treatment plans are each compared with your peers, and categorized as “Above Peers,” “At level of peers,” and “Below Peers.” In the new SLOE the descriptors of candidates now emphasizes team work, and ability to communicate a caring nature to patients. These two essential characteristics of the EM candidate have replaced the personality questions on the previous SLOR, to shift focus from personality traits to skills.

The predicted amount of guidance each student will need is now defined in comparison to peers.  Students are ranked as needing, “Less than peers,” “The same amount as peers,” or “More than peers.” Given this guidance the author predicts your success as “Outstanding,” “Excellent,” or “Good.” 

Next the Global Assessment of each candidate with ranking compared to other EM candidates recommended in the last academic year, as “Top 10%,” “Top 1/3,” “Middle 1/3,” and “Lower 1/3.” The number of applicants recommended in each category last year, and the number of letters written last year are listed, to allow for both context and comparison. Finally the expected placement of each student on the programs rank list as “Top 10%,” “Top 1/3,” “Middle 1/3,” and “Lower 1/3,”  or “Unlikely to be on our rank list.” 

After each applicant is compared to peers there is a comments section with the emphasis clearly on addressing areas of concern and strength. Detailed information about the rotation itself, the residency program and grading system, are now separated onto the program demographics form easily accessed at the cord website, or it can be attached to each letter. This allows all programs to define their theory and unique approach, without adding bulk to the evaluation itself.

This new streamlined SLOE's name may be quirky but it's aim is true: to create concise accurate and useful evaluations, to maximize students matching at the program best suited to their abilities and needs.

Communication Breakdown: Get 'em booked

One of the most intimidating tasks for a student in the ED is getting patients admitted.  You want the responsibility.  You want the sense of ownership.  You want to prove that you can be persuasive and get things done.  Successfully booking an admission accomplishes all of these things. I am more impressed with a student who can complete a tough admission than if they can close a complex laceration.  

Conversely, should the admitting conversation not go well, you may feel embarrassed or inadequate.  If your supervisor has to take over, their evaluation of your performance may go down.  

There is no surefire, guaranteed, approach that will sell even the obstructionist medicine resident.  But there are some things you can do to keep your admission call from going down in flames.

Walk a mile in their clogs

Understand the perspective of the person on the other end of the phone.  This may be easier as a student, having recently been on these other services,  than a couple years from now when you are firmly entrenched in the ways of the ED.  

Dig up those detailed IM presentation skills and give them a deluge of data.  Often times they do not want you to tell them what you think is wrong with the patient, they want you to give them the information so that they arrive at the same conclusion you did.  This is, of course, the exact opposite of what we are looking for in the ED - for you to make an assessment and come up with a plan.  

But if you are talking to a surgeon, you need to give them a very specific reason for why the patient should be admitted to them.  Not, “because they have belly pain”, instead, “we believe they have appendicitis”.  

Use the hammer

The hammer is the point that cannot be argued, that no physician behaving in a remotely professional manner can ignore:  “the best interest of the patient”.  This is a powerful tool.  You will encounter many objections from people you have contacted asking them to do work.  You have added to their task list.  They may be thinking in terms of what your request means for their day/night/weekend.  By judiciously using “the best interest of the patient” you can wear down almost anyone.  

In the same vein, you will often encounter pushback on “social admits”.  These are patients who cannot go home, but not for a strictly medical reason.  These patients are very frustrating for in-patient doctors and so they will often work hard to convince you that they do not need to take them in the first place.  But if a patient is unsafe, or can’t walk, or can’t control their pain at home, going back to “the best interest of the patient” is a hard thing to argue effectively.  

Practice makes perfect

If possible, run your admitting presentation by one of your supervisors.  If that is not time practical, at least make sure that the reasons for the admission are clear.  Make sure that you understand why the patient will benefit from being in the hospital.  If you do not know or if you are struggling to put the rationale into words, this is probably not a good admit for you to attempt because you are likely to fail.  

It is important to remember that even if you do everything right, sometimes you will have to call in your supervisor because the person on the other end of the phone is not being reasonable.  This has happened to everyone.  Making your calls within earshot of your supervisor helps them realize when it is not you that is the problem.  

If you want additional tools for getting others in medicine to do what you want, have a listen to an EMRAP Educators Edition podcast with Dr. Chad Kessler on communicating with consultants.  

Good luck!