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Mercy Catholic Medical Center Drexel University College of Medicine

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1 Mercy Catholic Medical Center Drexel University College of Medicine
Making SOAPS SAFER A model for Teaching and Evaluating Oral Case Presentations Eric Green, MD, MSc, FACP Mercy Catholic Medical Center Drexel University College of Medicine

2 Contributors Eric H. Green Mark Fagan Warren Hershman Brad Sharpe
Linda DeCherrie Rich Simon (for the 4C’s mnemonic) With thanks to… Jeffrey Wiese Jeffrey Greenwald Sandhya Wahi-Gururaj Nancy Torres-Finnerty

3 Increasing emphasis on patient-doctor communication.
Context Increasing emphasis on patient-doctor communication. ACGME competencies. USMLE Clinical Skills Assessment. Premium on accurate, pertinent and cogent MD to MD communication. Dizzying pace of clinical care. Frequent patient ‘handoffs’---RRC Work Hours Regulations, Night Float Systems. Important observed “performance” for evaluation and feedback Oral case presentation skills are implicitly (although not explicitly) a part of medical educations goals and assessments. They are also clearly vital given the hectic pace and frequent handoffs involved in modern medicine.

4 Presentation skills are a complex synthesis:
“This is not easy.” Presentation skills are a complex synthesis: Knowledge and experience. Clinical reasoning. Speaking skills. Expectations. Oral case presentations is a complex task, requiring an integration of basic “medical knowledge” (history taking skills, etc), higher skills (clinical reasoning), speaking/elocution skills, and an understanding of what is expected.

5 Important skill but execution often suboptimal
Try to set high standards—present like Lincoln at Gettysburg. Access to colleagues. Can open the door or… Bad breath

6 Observations of student presentations1,2
What do we know? Observations of student presentations1,2 Students believe presentations are driven by formula while attendings see them as driven by context and content Surveys of teachers and clerkship leaders3,4 Concordance that ideal presentations both report HPI and interpret other elements in context of assessment and plan There is limited research into oral case presentations. One line of investigation involved observation of students (at UCSF) presenting to clinical attendings. The students and attendings were also interviewed. Students believed that oral case presentations followed (or should follow) a set formula and felt frustrated because they had difficulty understanding what was “relevant” to the presentation. The attendings, on the other hand, believed that presentations should be flexible according to the content and context of the presentation. The second line of evidence, drawn from standardized questionnaires of clinical attendings and clerkship directors, revealed that most attendings value a full and complete HPI (telling the story of the patients illness), a selected (pertinent) selection of other history, physical exam, and labs, and a prioritized problem list. 1.Haber RJ. JGIM Lingard LA, Acad Med 3. Green EH, JGIM Green EH. Teaching & Learning in Medicine. In press

7 Our Model: Making SOAPS SAFER

8 Teaching & evaluating oral presentations is complex.
Bad presentations are obvious to teachers “I know it when I see it” Feedback is often specific to presentation Little formal instruction on performing or evaluating oral case presentation Challenging for learners to generalize feedback Ideal feedback should include generalizable points Key is identifying core qualities of an oral case presentation and framing feedback around those

9 Schematic Model: What Usually Occurs
Many teachers approach a poor presentation with immediate suggestions of how to improve it. Unfortunately, this does not allow the learner to abstract these lessons to other presentations How can it be fixed? Recommend changes

10 Schematic Model: Proposal
What is good and bad? Cite specific examples What caused this? Clarifying Questions We suggest breaking up the process explicitly by first citing errors, including both general categories and specific examples. This will allow the learners to better understand what they did wrong in general. Next, the teacher needs to explore WHY the learner made the error, understanding that often teachers “jump to conclusions” about the origin of a problem. The final step involves a suggested remediation for the general problem that caused the problem (general and specific) in the presentation. How can it be fixed? Recommend changes

11 Identifying Strengths and Weaknesses
5 basic qualities of an oral presentation SOAPS Provide a basis for didactic instruction Frame evaluation and feedback The first step here involves identifying strengths and weaknesses. This is hard because there is no gold standard for this. We propose using a model we call “SOAPS” (explained in subsequent slides) to both guide instruction and evaluation/feedback of oral case presentations.

12 5 Basic Qualities of an Effective Presentation: SOAPS
Story: Identify and describe complaints Organization: Facts are where the listener expects. Argument: “Makes the Case” for assessment and plan Pertinence: Only includes information relevant to the assessment and plan Speech: Fluent, well spoken This slide describes the SOAPS model.

13 Story: 3Cs Chronology Start with “chief complaint” – reason the patient is “here” Present the “facts” chronologically and in appropriate detail. Core attributes e.g. “OPQRST” – onset, palliate/provoke, quality, region/radiation, severity/associated symptoms, temporal aspects Context of illness- the rest of the history needed to understand the most important problems in the A/P Level of detail determined by the context of presentation The story has 3 elements, the 3 C’s, described here.

14 Context: 3 Key Elements Audience -- Purpose.
Who are they What do they need to know Purpose. For clinical care typically “build a case” In conferences, etc may want to “create a mystery” to generate differential diagnosis Time- Occasion (setting and circumstances) 1-2 line bullet. 1 paragraph synthesis. 3-5 min. targeted, formal presentation on work rounds Context (1 of the 3 “Cs”) also has 3 key elements, described here. There are clearly interrelated. The key is that the presentation is designed for the purpose of the listener – so understanding what information the listener needs (based on context of presentation) is key to deciding the level of detail, etc.

15 Context Drives Content
Hypothetical 60 year old with NSTEMI Presentation to hospitalist – detailed, comprehensive, “builds a case” Presentation to urology consultant - limited, focused, “builds a case” Presentation to “night float” – limited, broad, “builds a case” Presentation at morning report – detailed, comprehensive, “mystery” This slides describe how context drives content – imagine the same patient presented multiple times to multiple audiences. How should the presentation be modified? What should be included? For whom?

16 Presentations are organized in a standardized format
Organization Presentations are organized in a standardized format A defined schema helps listener process large amounts of data efficiently Key elements Standardized: history before physical, etc. One of the reasons oral presentations are used is to allow rapid transmission of data. In order to facilitate this presentations need to be organized. By organizing the data – pre-digesting and classifying it so to speak – it is easier for the listener to incorporate and retain that data in their “clinical data base.” Deviating from this standardized organization confuses and distracts the listener.

17 Argument Key elements Presentation should include
Commits to a patient-specific assessment/plan Structures rest of presentation to make a coherent case for this Presentation should include a synthesis problem by problem A/P The argument reflects a learners clinical reasoning. It (along with pertinence) allows the learner to demonstrate clinical reasoning. A relatively untrained person can take a patients history and regurgitate to a learner in a standardized way (story and argument); an argument demonstrates reasoning. An argument does not need to be a single diagnosis – it can be a limited differential diagnosis (e.g. PE vs. pneumonia) or even a syndrome (chest pain). Once the learner has decided on an argument, the presentation (story, etc) should be constructed to systematically to lead the listener to the chosen diagnosis. For example, when presenting an HPI pertinent details can be structured to support the diagnosis and demonstrate a differential diagnosis – e.g. “she describes crushing sub-sternal chest pain worse with exertion and better with rest. It radiates to the arm and jaw, and is associated with lightheadedness and dizziness. She denies lower extremity swelling, pain worse with inspiration, or recent long travel/immobility. She denies acid reflux or hypersalivation” supports a cardiac cause of chest pain while excluding PE and GERD.

18 Pertinence Key elements Relevant facts Relevant facts included
Irrelevant facts excluded Relevant facts helps explain/support differential diagnosis Characterize the severity of illness Helps understand and address key issues in evaluation and management The key to pertinence is that presentation is a highly edited version of the patient’s history. Only facts needed to support the chosen argument, or refute alternative arguments (e.g. the differential diagnosis) should be included. Included within this idea of pertinence are facts that may influence diagnosis or management (e.g. homelessness) even if they are not directly related to the disease pathophysiology. As with argument, the learner demonstrates skill in clinical reasoning with their selection of only “pertinent” facts. When evaluating an oral presentation it is important to remember that an argument may be wrong, but the selection of facts pertinent to that incorrect argument may be correct (e.g. learners designs an argument to support pulmonary embolus in a patient who has constrictive pericarditis). When this happens, it is important to emphasize that although they got the presentation “wrong” they have demonstrated competency is choosing what is pertinent.

19 Speech Recognizes that this is spoken art form Key elements
Speed and tone Spoken, not read Presentations are spoken, not read like the H&P. As such, rhetorical technique is important. A perfectly constructed presentation that is monotonal, whispered, or unintelligible is useless in patient care. The emphasis on “spoken, not read” reflects the tendency of some to read their written H&P rather then “script out” an separate oral case presentation. The written H&P can and should have more detail (including details of borderline pertinence) that the oral case presentation.

20 Schematic Model: Proposal
SOAPS What is good and bad? Cite specific examples What caused this? Clarifying Questions This slides shows that SOAPS can be used to help classify strengths/deficiencies of an oral presentation. Once this is done, we need to reflect this back to the learner with concrete examples and ideally labels so the learner can track their progress from presentation to presentation. For example, I really understood the this patients story, and the rich detail you have about the patient’s 48 hours leading to admission was particularly helpful. And I appreciated how well you articulated your argument that he had a possible acute coronary syndrome, and noted the how you used this to limit your presentation to only pertinent data and therefore make it succinct. It was well spoken, with few “umms,” but I found your organization quite confusing. You kept jumping between history, physical exam, and labs and I had trouble keeping focused. How can it be fixed? Recommend changes

21 What deficit caused this?
Most problems in presentation can have multiple etiologies 5 potentially correctable deficits (SAFER) It is important not to jump to any conclusions regarding WHY a learner made the error they did, as an error can have multiple possible causes. It can be helpful to have a systematic way to think about these errors. SAFER is a system we use although it is not perfect. This slide, and the slides after, are designed to illustrate how to apply SAFER or another schema to this problem

22 Possible Correctable Deficit: SAFER
Speaking: Poor elocution skills Intrinsic or situational Acquisition of Data: H&P, review of records Fund of knowledge Expectations: Unaware of needs of listener or standards Reasoning: Omits or incorrectly applies clinical reasoning SAFER represents one potential list, although it is probably not all-inclusive. Speaking refers to the act of oral rhetoric, which can be done poorly because of poor English language skills, anxiety (stage fright), or a distraction (e.g. a page). The first is clearly intrinsic to the learner, the last situational, and the middle could be either (do they just get nervous in front of the program director). Acquisition of knowledge refers to the art of developing/recording the clinical data base. Failures here could be because the learner has poor skills in DOING with H&P, poor skills in RECORDING the H&P, or (if presenting a patient admitted by someone else) in REVIEWING the H&P. Fund of knowledge refers to knowledge of medicine – it is impossible to diagnosis that which is not known. Expectations refers to a learner’s understanding of what does into an oral case presentation, which could either be in UNDERSTANDING basic standards/expectation or APPLYING the wrong standard (e.g. given a detailed presentation to a consultant). Finally, reasoning looks at the ability of the leaner to APPLY clinical reasoning. Consider for example a learner who neglects to mention nausea/vomiting in an oral case presentation of a patient suspected to have an acute coronary syndrome. This could be because they got nervous and skipped it (speaking), forgot them in the flurry of admissions from the night before (Acquisition of knowledge), didn’t know that ACS could cause GI symptoms (fund of knowledge), didn’t realize that the listener wanted to hear all details, positive or negative, that would help determine if the patient has ACS (Expectations) or didn’t “process” the history to form a ranked differential (reasoning).

23 What deficit caused this?
Most problems in presentation can have multiple etiologies 5 potentially correctable deficits (SAFER) Use iterative questions Once forming a differential diagnosis for the presentation error, we need to ask the learner (in a non-judgmental way) a series of questions to “diagnose” the presentation error. For example Did the patient have nausea or vomiting (Acquisition of data) What did it mean to you to find out the patient had nausea? (reasoning) - how does ACS cause nausea? (Fund of knowledge) - why is it important for me to know whether the patient had nausea (expectations) Speaking one usually gathers from the answers to the other questions

24 Schematic Model: Proposal
SOAPS What is good and bad? Cite specific examples +/- SAFER What caused this? Clarifying Questions Remediating errors once correctly identified could be 10, 20, or 50 lectures! If you can narrow down to a single error with a single cause, you and the learner can identify a remediation strategy. How can it be fixed? Recommend changes

25 Pearls for Learners Story
Think of the oral case presentation as building a case as an attorney would in a court of law.  You are providing information to allow others to come to the assessment and plan you did.  You are also providing enough information to have them help you care for your patient. This slide, and those that follow, give pearls you can relay to learners regarding the key components of the oral case presentation.

26 Pearls for Learners Organization
Starting with the chief complaint orients your listeners and prepares them for what follows. “Don’t eat the dessert before the salad” – never change the basic format of the presentation – it is always the same. (ID, HPI, PMH, MEDS, ALL, SH, etc.). Use standard headings to keep your listeners oriented. The relevant past medical history is... On physical exam I found… In summary... If you put family history, social history, or parts of the review of systems into the history of present illness, there is no need to repeat it later in presentation

27 Pearls for Learners Argument
An oral presentation is supposed to be a bedtime story not a suspense thriller. Everything is designed to support an assessment and plan that should never be a surprise. Pertinence If you’re not sure if a detail is relevant leave it out of the oral presentation. Your listener can always ask for more. Think of the oral presentation as the “Cliff’s notes” version of the written H&P – it includes all the details you need to understand the plot but not much more.

28 Pearls for Learners Speech
Practice your presentation before giving it. General: If you lose people's attention, think about what part of the presentation lost them. If preceptors keep asking for the same types of information after your presentation then include it! The assessment and plan is a wonderful opportunity for you to demonstrate your clinical reasoning and medical knowledge. Don't miss this chance to shine! Always know what your listener is expecting to hear – 2 minutes or 7 minutes? All or some of the labs? Never “act out” the physical exam while you are presenting. Use your words, not your hands.

29 Remember the 4 C’s: A Mnemonic for Effective Oral Presentations
COHERENT CONCISE COMPLETE COMPELLING Not to be confused with the 3C’s of the “Story” in SOAPS, this is a catchy summary of some key pearls developed by Rich Simons, Sr. Assoc. Dean of Education at Penn St. He also created a corresponding 4C pocket card mnemonic (available in a separate link in this module) which can be given to students and house officers.

30 COHERENT Introduction (one sentence!) Subjective Vital signs I/O’s
Physical Exam (pertinent) Drug list New study results Review of chart (nurses notes, etc) Assessment and Plan:

31 CONCISE ( 1-2 minutes) Essential Pertinent Uncluttered The student should be brief and lucid The student should speak crisply and clearly without notes

32 COMPLETE Symptom complex fully defined Pertinent findings ( e.g. funduscopic exam, mental status) Significant laboratory abnormalities (new trends!)

33 To be COMPELLING the student must . . .
Know the patient Have a firm grasp on the differential diagnosis Identify the specific problems Make an ASSESSMENT Outline the interventions in the PLAN

34 Pearls for Teachers Teaching
Remind learners this is a standard of the medical profession that they will be using throughout their careers. This is not the teacher’s personal style or just another requirement to pass a rotation. Try to avoid teaching solely by example (“you could say it like this “). Instead, identify the deficit and have the learner try again.

35 Pearls for Teachers Evaluation Feedback
Use your interactions with the learner outside of the presentation to help inform you as to which deficit they have. Allow the learner to identify their weaknesses before you comment Concentrate on identifying the biggest problem in the presentation and start to intervene there. Feedback Take notes during a presentation. When providing feedback, refer to specific things the learner said. Decide when is the best time to give feedback

36 References Green et al The Oral Presentation: What Internal Medicine Clinician-Teachers Expect from Clinical Clerks. Teach Learn Med. 2011;in press. Green et al Using a Structured approach to Teaching and Evaluating Oral Case Presentations: the SOAPS method. Acad Int Med Insights. 2010;in press. Green et al Expectations for Oral Case Presentations for Clinical Clerks: Opinions of Internal Medicine Clerkship Directors. JGIM. 2009;24(3):370-3. Green et al. Developing and implementing universal guidelines for oral patient presentation skills. Teach Learn Med. 2005;17(3):263-7. Kim et al. A Randomized-Controlled Study of Encounter Cards to Improve Oral Case Presentation Skills of Medical Students. JGIM. 2005;20(8):743-7. Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered model for outpatient education. Acad Med. 2003;78(9):893-8. 

37 References Wiese J, Varosy P, Tierney L. Improving Oral Presentation Skills with a Clinical Reasoning Curriculum: A Prospective Controlled Study. Am J Med. 2002;112:212-8. Wiese J, Saint S, Tierney LM. Using Clinical Reasoning to Improve Skills in Oral Case Presentation. Sem Med Pract 2002;5(3): Haber RJ, Lingard LA. Learning Oral Presentation Skills: A Rhetorical Analysis with Pedagogical and Professional Implications. JGIM. 2001;16: Lingard LA, Haber RJ. What Do We Mean by "Relevance?" A Clinical and Rhetorical Definition with Implications for Teaching and Learning the Case-presentation Format. Acad Med. 1999;74 (Supp)(10):S124 - S7. Kroenke K. The Case Presentation: Stumbling Blocks and Stepping Stones. Am J Med. 1985;79:605.

38 or
Contact Information Contact Information Eric Green, MD, MSc, FACP or Warren Hershman, MD, MPH For 4C’s mnemonic: Richard Simons, MD

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