Deliberate Practice: Deliberate Patient Presentation

by Chris Keefer (@Dr_Keefer)

After every single patient encounter learners present to their staff.  This is frequently a painful process for both learner and preceptor.  Too often the learner fails to paint a clear picture of what they think is going on and the preceptor is left picking up the pieces and doing the problem solving.  Educators infrequently focus on teaching the art of presentation and as a result the learner will often make this presentation style habitual and little progress is made in their clinical judgement and ability to communicate.

Einstein is famously quoted as saying “The definition of insanity is doing the same thing over and over again and expecting different results.”

What if patient presentation was taught and practiced in a deliberate manner so that it became the keystone for learners to develop expertise and unlock their full clinical potential?  What if we can teach our students the art of “Deliberate Presentation”?

The acquisition of expertise has long puzzled us.  Are experts born with innate talent?  Does practice make perfect?  How can we make sense of the enormous variation in performance within a given field?  How can we bring everyone within a field towards the performance of the top 5%?

Cognitive psychologist and preeminent expert on the science of expertise Anders Erricson has spent his career trying to answer the mysteries of talent through rigorous study.  In so doing he has described a framework for the development of peak performance that he calls deliberate practice.

Deliberate practice involves the following:

• Choosing a specific skill for improvement
• Identifying what expert performance looks like
• Consistently going beyond the comfort zone to achieve it
• Developing excellent mental representations
• Receiving and implementing timely feedback
• Having a coach to guide your training

Erricson’s research demonstrates that experts perform better because they have well developed mental representations relevant to their field.  A mental representation is a construct of the mind that is not actually present to the senses.  Think of a chess master. Through years of study and practice she can look at the pieces on the chess board and identify a recognizable pattern (a mental representation) and figure out the next most advantageous moves and their consequences.

Medicine is no different.  A good physician is able to analyze the signs and symptoms of the patient in front of her and create a concise and accurate mental representation.  This representation allows her to plan decisively for diagnostic and therapeutic intervention and anticipate possible complications.

The following is an example of a mental representation: “Blunt polytrauma requiring decompression of tension pneumothorax and hemodynamic resuscitation prior to neuroprotective intubation.”

So what is deliberate presentation and how does it help learners to improve so quickly?  Deliberate presentation emphasizes hypothesis generation and efficient communication of a mental representation.  It demands early commitment to a diagnosis and management plan and intelligent organization of supporting evidence.

Efficiency is achieved by ruthlessly editing out extraneous information. It involves prioritizing supporting evidence by leading with the most relevant information.  A good way to think about this is building a case by starting with clinical signs and symptoms that have high +ve likelihood ratios. Similarly treatment plans should emphasize interventions in order of their clinical importance.

Think of Deliberate Presentation as an expository essay:

• Thesis: Most likely diagnosis, differential diagnosis and treatment plan
• Paragraph 1: Supporting evidence for the most likely diagnosis
• Paragraph 2: Refuting evidence for the differential diagnosis
• Conclusion: A succinct mental representation of the clinical entity and plan

A sample Presentation Template is included for download.  It is based on my clinical environment as an emergency physician and is intended only as a possible starting point for learners and faculty.  It is expected that learners will use this as a tool to build their own presentation style.  Other clinical environments may require adaptation.  In addition this succinct presentation template should not be thought of as the be all and end all of deliberate presentation but rather a tool to encourage learners to improve and reveal their mental representations.  This gives faculty a better opportunity to identify knowledge and perception gaps and ask clarifying questions to correct errors in clinical judgement.

Here is how I go about explaining deliberate presentation to my learners:

• Example
• Goal and motivation
  • “Our specific learning goal today is to improve your patient presentation skills. This is going to be useful for you in two ways.  First, it will give you the opportunity to rehearse your judgement as if you were out in independent practice.  Second, it will help you develop better mental representations of common clinical problems. This approach is going to allow you to squeeze out all of the learning possible from your shift today and and improve your clinical acumen much faster.”
• Demonstrate Expert Performance
  • “Here is a copy of the presentation template I’d like you to use today.”
    • (download Presentation Template)
  • “I’m going to start off by demonstrating what I am looking for in a patient presentation.”
  • Give sample presentation
    • (download Presentation Template)
• Explain comfort zone
  • “This change in your style of patient presentation is going to make you feel uncomfortable. You are likely going to be afraid of making mistakes and looking bad in front of me.  I am not concerned about whether you are right or wrong in fact I welcome mistakes as a learning opportunity and a chance for you to grow your clinical judgement.  All I care about today is that you commit to your diagnosis and treatment plan and learn to communicate with greater efficiency.”
• Explain mental representations
  • “I’m going to encourage you to develop mental representations of the patient’s illness. A mental representation is a clinical snapshot such as the following.”
  • “New onset stable atrial fibrillation with rapid ventricular rate in a low CHADS score patient amenable to electric cardioversion”

• Feedback
  • “I’m going to give you feedback on each of your presentations. We will be focusing on committing to the diagnosis and treatment plan,  We will also be focusing on becoming as efficient as possible at organizing relevant clinical information and editing out extraneous information.”

• Coaching
  • “I am going to coach you by playing a game of catch. You will present to me and then I will take the information you provided me, edit it down and present back to you.  We will pass the information back and forth in this manner until we are satisfied that this presentation and your mental representation is as good and efficient as it can be.”

• Consolidation
  • “At the end of our shift you will present your mental representation of each patient that you saw to me in one sentence. For example:
    • Pneumo-sepsis secondary to aspiration requiring early antibiotics, fluid and vasopressor resuscitation prior to intubation for anticipated decline
    • Unstable upper GI bleed requiring reversal of anticoagulation, blood product resuscitation and urgent endoscopy for definitive control of hemorrhage.”

This approach takes considerable effort on behalf of the clinical preceptor but comes with substantial rewards.  My hope is that clinical educators can go the extra mile and take advantage of the opportunity that patient presentation offers us.  I believe that we can apply the latest principles from the science of expertise towards helping our learners to extract the most benefit from their clinical encounters and achieve their full clinical potential. Let me know how it goes.

Download the Presentation Template.

Chris Keefer is a an assistant clinical professor at McMaster University and a staff emergency physician at Credit Valley and St Joseph’s Hospitals in Toronto Canada.  His passions lie in high fidelity medical simulation and pedagogy.  He is the founder and former medical director of the Brantford Medical Simulation Laboratory and a simulation facilitator at Trillium Health Partners.  He is also a medical consultant at the Canadian Centre for Victims of Torture and the Refugee Law Office.  He can be contacted at chris.keefer@medportal.ca and on twitter @Dr_Keefer

References:

Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Boston, MA, : Houghton Mifflin Harcourt.

Senninger (2000). The Learning Zone Model – ThemPra Social Pedagogy. [online] ThemPra Social Pedagogy. Available at: http://www.thempra.org.uk/social-pedagogy/key-concepts-in-social-pedagogy/the-learning-zone-model/ Accessed 21 Mar. 2017].

Image courtesy of Nick Youngson on Alpha Stock Images