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Abstract & Commentary
Source: Maddow CL, et al. Efficient communication: Assessment-oriented oral case presentation. Acad Emerg Med 2003; 10:842-847.
What is the best way for one physician to present data to another? The authors of this study have made a detailed analysis of two methods of presentation—traditional and assessment-oriented formats. In the traditional format, the presentation starts with the chief complaint, continues with selected data from history of present illness, past medical history, social and family history, review of systems, physical examination, and laboratory data. After this, the presenter concludes with diagnosis or assessment and plan. In the assessment-oriented format, the presenter begins with diagnosis or assessment and plan, continues with data in variable order, including pertinent positives and negatives from history and physical as deemed important.
The study was conducted using 25 first- to third-year emergency medicine residents. The residents had a one-hour conference and 30-minute workshop in both styles of presentations, as well as practice sessions on the two styles. The residents were asked to then use the traditional format while working in the ED for the first month and then switch to the assessment-oriented format in the ED for the second month. A research assistant recorded the length of presentation and then surveyed the faculty member and resident for satisfaction with organization, content, and expression of decision making. The bottom line: without diminishing the quality of the presentation, the assessment-oriented format took a little more than a minute on average, whereas the traditional format took almost two minutes. Both styles of presentation were viewed as satisfactory, although the residents expressed slightly greater satisfaction with the organization of the assessment-oriented approach.
Commentary by Richard J. Hamilton, MD, FAAEM, ABMT
When I was working in a small community hospital, I had some practice-shaping experiences, one of which was dealing with a notoriously brusque but competent orthopedic surgeon. When he was contacted by telephone about a fracture, instead of patiently waiting to listen to the entire case presentation (however abbreviated or accelerated) he would cut the caller off and bellow, "What’s the fracture?" I finally reached the point that, one day when he called back, I picked up the phone and said, "Bimalleolar fracture left ankle," without even introducing myself. There was a pause, and he said, "I’ll be there in 10 minutes."
Since then, I have been keenly interested in presentation styles and how they influence the efficiency of information transfer. While we insist on teaching students the classic format that starts with chief complaint and methodically goes through history of present illness, we are impressed when residents and colleagues are able to encapsulate the case quickly, focusing on the chief complaint, diagnosis, treatment, and disposition. The presentation style I teach to all my students and house officers is what I call a journalistic style, or the "Headlines in the Times" approach. As in a news story, the key information is presented at the beginning; amplifying information and details are found later. In that form of presentation, the case might be summarized along the lines of "Man dying of MI in Room 5: Cath lab needed quickly," which probably says it all. In fact, a sleepy cardiologist, when awakened by the ED staff in the wee hours of the morning, truly appreciates that introduction to the case, and quickly will ask questions that probe for the needed amplifying detail to obtain action-oriented information in an efficient manner.
The ED is a point in the patient’s care where enormous quantities of new information are collected, organized, and transmitted to a great number of health care providers. It is important to communicate all this data in an efficient manner without losing fidelity. The assessment-oriented technique is an excellent approach to this challenge.
Dr. Hamilton, Associate Professor of Emergency Medicine, Program Director, Emergency Medicine, MCP Hahnemann University, Philadelphia, PA, is on the Editorial Board of Emergency Medicine Alert.