Prática de Shadowing: How to Present a Patient Case: The Signpost Method - Aprenda a falar inglês com o YouTube

Hi, my name is David Keegan.

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Hi, my name is David Keegan.

I'm an academic family doctor here at the University of Calgary.

We're here today to talk about how to present a patient case to one of your preceptors.

So in medical training we're doing this all the time.

I don't know how many hundreds or thousands of patients over the years in my medical school training,

my residency, and so on,

I ended up having to present to somebody above me,

one of my preceptors.

We're doing this all the time.

And as a preceptor, I hear all the time from medical students how they find it's hard to negotiate

and figure out what kind of preceptor, what kind of presentation.

Sometimes they want it short and sweet,

sometimes they want it long.

And they find it really confusing to negotiate that.

And sometimes it actually causes problems in even their relationship with their preceptor.

And we'll see it on summaries at the end

when a preceptor talks about a trainee who's presenting cases in a certain way,

and then you talk to that trainee and nobody ever talked to them and they never negotiated this upfront,

what's the right way, what's the most helpful way that people need to hear a case presentation.

So this is all about how to do that.

This is sort of like level one,

sort of like a good foundational approach.

And then there's a sort of more fancy one,

Level 2, which we'll get into in another video.

So when you're presenting a case to a preceptor,

the trick is a preceptor is a human too.

And I've probably just been dealing with something else and now I suddenly,

you suddenly have my attention as a preceptor.

And so, but I'm only a human.

And that means that I didn't see the patient because you've seen the patient first.

And it's going to be hard for me to process everything all at once.

And so a mistake that some trainees will do is actually just give me tons

and tons and tons of information to the point that I get kind of lost.

Now why are you presenting a case?

You're presenting a case so that I,

as the primary or the most responsible physician,

know kind of what's going on with the patient so that I know it'll help me in their patient care.

Number two, it's also so that I know where your knowledge ends and where your gaps begin

so that I know what I have to do to fill in things,

and I can also then know when I can stop relying upon you and all that kind of stuff.

It's also important for you to be able to show me that,

because then you're going to demonstrate who you are as a clinical thinker.

You don't want, as an outcome,

presenting a case presentation, and then you're going into the past medical history,

and you're seeing that I'm getting all fidgety and agitated.

You don't want me to suddenly say, you know what?

That's great.

Thanks very much.

Let's go in and talk to the patient.

Because what I've done then is I've just basically stopped you at some of the history details.

You might have in your head really good thinking about the likely diagnosis or the likely problem going on with this patient.

You might have a good plan that you've kind of put together.

Or at the very least,

you've got a plan put together.

It might not be perfect.

But I don't get to even know

that you've even been thinking about a plan if we are only ever stuck on past medical history.

so this method is a way to make it clear to Your your preceptors where you are.

It's called the signpost method

So the signpost method starts

and I'm gonna be playing both roles with the trainee telling the preceptor a little bit of a heads up

So when I'm over there,

I'm the trainee when I'm over here.

I'm the preceptor.

So Excuse me, Dr. Keegan,

can I talk to you about this patient that I just saw?

Sure.

Great.

So overall, she's a clinically stable 29-year-old,

but I'm worried she could be seriously ill with an ectopic pregnancy.

Whoa, okay, tell me more.

Tell me kind of quickly what's going on.

Okay, so just so you know,

I've seen her, I've done a history,

a physical exam, I've checked some investigations,

and I have a proposed plan of management.

Do you want me to get started?

with the history.

So what the student is doing then is making it clear to the preceptor

that he or she has already thought about this patient in detail.

So they've got history, they've got physical,

they've done investigations, they've got a provisional diagnosis,

and they've already had some thinking about a plan.

So at this point what you've done is you've planted signposts about where the preceptor can drive this conversation.

And these signposts are critical.

So the preceptor might say,

you know what, just tell me what are the key things in history

and the key things on physical that make you think it's an ectopic pregnancy that this patient has.

Or the preceptor might say,

okay, you said she's stable,

tell me more about that and how I know she's stable or how do you know she's stable.

Or the preceptor might say,

because the situation is a bit urgent,

say, you know what, okay,

let's just go straight to the bedside.

Regardless, you got the key message across.

You've seen a patient who actually has a serious medical condition,

or a potentially serious medical condition.

You got that message clearly across in your first sentence by giving the overview.

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And then you put out some signposts about where the preceptor could bring the discussion next.

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Now for a different patient,

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when there's a bit more time to think about things,

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it can still the same flavor.

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So let's say you're in an outpatient clinic,

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maybe a family medicine office,

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and the story goes like this.

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The preceptor says, sorry, the student says,

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hi, I've just seen a 10 year old boy accompanied by his parents who's here because of continuing nighttime cough,

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which I think might be asthma.

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Can, can, do you want me to go into,

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sorry, can I present this patient to you now?

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Or do you want me to go into more detail?

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Or, or you can even be explicit at this point and say I've done a history,

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a physical, I've got a provisional diagnosis and a differential diagnosis,

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and I've got a plan for where we should move forward.

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So again the preceptor knows you've given a one sentence encapsulation of this patient.

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Great.

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That's then that's pretty an impressive skill to begin with.

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You've now situated the preceptor to understand the story a little bit

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so that now they can start thinking and understanding where you're going with

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and you've told him or her what are the potential options,

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like it's like a buffet menu from which they can pick and hear about you're thinking about this patient.

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So with that signposting the preceptor might say,

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okay well sure give me more of the history.

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And then you'll proceed to tell the preceptor about the history.

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Say well this 10 year old fellow,

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he's got this nighttime cough,

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it's been there pretty much every night over the last several years.

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The family notices that he,

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whenever he gets a chest infection of any type of flu or a virus,

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it always seems to affect him far more than everybody else that they know.

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And then he has like a prolonged cough afterwards.

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He's though fully active in sports and doesn't seem to appear restrained in any way,

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he's a very active little fellow and has been previously medically well up until now.

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In terms of review of systems,

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he's got no other cough during the daytime,

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he's got no sputum, there's no exposure to secondhand smoke,

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and the rest of his past history is is completely clear,

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no surgeries, he's on no medications,

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no drug allergies, and everything else seems pretty clean.

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Do you want me to go into detail on any more of the history elements,

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or do you want me to move to the physical?

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So again, you've put up a signpost showing that this is branching.

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You're almost giving your preceptor a chance to choose their own adventure.

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Some preceptors will want more detail on the history,

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and that's great, and hopefully you've done it.

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You've gotten into any dust precautions they've talked about,

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or any recent construction or renovations or any other respiratory triggers and you've already got all that detail and so on.

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You've got the family history about whether or not there's allergic entities like allergic rhinitis,

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eczema or other family members with asthma,

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all that sort of stuff.

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Or maybe this preceptor now say,

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you know what, why don't you just actually tell me what you found on a physical exam?

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Say, great.

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So he's in no distress,

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he's sitting comfortably reading his book when I walked into the room.

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When I look at him,

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he seems to be physically mature,

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his height and weight are appropriate for his age at the 50th percentile.

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When I listen to his lungs though,

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I don't hear any wheezes,

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but I do notice that his expiratory phase is prolonged compared to his inspiratory phase,

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which that sounds like a reverse.

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It should actually be a shorter time period to hear the expiratory phase.

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I took a peak flow and today it was a 175 liters per minute.

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And, and, oh, forgive me,

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viewer, I don't have the exact age-appropriate peak flow.

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But let's say for this case,

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say, and that's, that's about 90% of what he would have had for his height and weight,

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for his height and age, rather.

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Great.

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And then the preceptor would say,

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okay, so what do you think is going on?

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You said earlier you were thinking of asthma.

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And then again, the, now the student,

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because they've signposted that they've had some diagnostic thinking and even have a planned thinking.

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You can say, yes, I'm seeing it as asthma.

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I guess some other possibilities that there's some reflux going on,

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or maybe it's primarily only allergic rhinitis,

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and he's got some post-nasal drip,

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which is triggering some cough late at night.

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And that's why he's getting nighttime cough and not daytime cough.

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But I still think actually most likely it is asthma.

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So it gives you a chance to kind of think through your differential diagnosis in real time,

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and then the preceptor can say,

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and what were you thinking about doing?

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saying, well, he's not distressed now,

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so we could certainly send him for peak flow,

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sorry, pulmonary function testing right now,

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since he's not like sick.

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But if there's any delay in getting that,

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we could actually just start a therapeutic trial of inhaled steroids and PRN or as needed beta agonists.

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And then, you know, see how he does with that and get him back and check his peak flows throughout.

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And then if there's greater than a 20% variation,

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then that's diagnostic for asthma as well.

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So what's incredible about that is

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that you've been able to show the preceptor you had this the number one the encapsulating overview sentence

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or maybe two sentences at most and then you told the preceptor I've done these different elements.

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That and that's great and and then you'll get used to

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that this one preceptor preceptor a might always want more history

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and so pretty soon you'll know to not keep signposting every single time

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but you'll have learned their preference and you'll give them more data on the history.

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And there's other people who you'll learn,

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oh, they really just want you to consistently,

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you know, describe what you think is the diagnosis and your plan

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and then work backwards and tell them the history and physical.

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Which is a completely other appropriate way to do things too.

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And there's a whole bunch of other ways that preceptors can have these conversations.

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But the key thing is,

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you've made clear the summary sentence.

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You've made clear in that if there's any major problem,

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like the ectopic pregnancy patient earlier.

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You've made clear about the overview picture, about what's going on.

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And then by signposting what you've done,

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you've made it clear that whether or not you get into it,

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that you've thought about those things.

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And then your preceptor will feel now confident and comfortable going into that.

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Now be prepared.

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They're going to challenge you on that.

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And that's OK.

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That's part of good medicine training,

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is that they might ask you to give evidence.

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Well, you say it's asthma,

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but tell me why you think it's asthma.

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Why is it asthma more than reflux disease?

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Or why is it asthma not allergic rhinitis?

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And so they might challenge you for sure, but that's okay.

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This means that you're being challenged on clinical reasoning,

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you know, therapeutic care plans and so on.

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Not on the basics of did you correctly report that there's nighttime cough on so many nights out of the year,

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which is an important fact,

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but you're probably at a higher level than just a conversation that focuses on some grainy details of the history.

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So that's how you do it.

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In the signpost method, you just one,

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give a quick overview and two,

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tell the preceptor that I've done the history,

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the physical, I've looked into old charts,

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I've got differential diagnosis and a preferred diagnosis and I've got a possible plan of management for moving forward on this patient.

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And then they'll know that you're on it,

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that you're on the ball,

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Plus they know

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that they can ask about all these different sorts of things

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to help them figure out how to provide good care for the patient

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And then also how to actually get a good sense of where you are with your clinical reasoning

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and understanding and To also find out where you're wrong and

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if you make a terribly big mistake You know what there's all there's good research that says that's fine,

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too You will learn better because at least you're talking about the gaps the errors you make

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Instead of the basics of a history element that you've done a hundred times before Thanks very much.

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I hope your case presentations go awesomely.

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