Here are some (unorganized) thoughts about my experience at the Society of Hospital Medicine (SHM) 2011 conference in Dallas, TX.

Opening Plenary

The initial presentation dissected the SHM Annual Compensation survey, discussing regional variations in pay and work effort over time. I understand the importance of that stuff, but ever since I got my first $638.36 paycheck as an intern, money hasn’t been an issue for me.

The second talk was by Bob Kocher, an Obama insider during the recent healthcare reformd. Gerry would have loved this one. He briefly described how a bill becomes a law… it apparently doesn’t follow the Schoolhouse Rock model anymore. At one point, reform looked dead, when the Catholic Nuns came out in favor of the legislation allowing multiple congress members to change their vote to “Yes”. As Kocher put it (paraphrasing), “When the Nuns broke with the Bishops, healthcare reform could move forward.” Doesn’t that seem like a statement that should be in a history book about medieval times, rather than a statement about 2010 United States politics? Maybe it’s just me…

Neurologic emergencies

The Neurologic emergencies talk was entertaining, though maybe more useful to an intensivist. David Likosky is hilarious in a geeky kind of way. A few things I learned:

Always maintain a good differential diagnosis and don’t jump to a conclusion too quickly. He described a case of an alcoholic who presented in coma and had dynamic pupils making a brainstem stroke the most likely diagnosis. A lot of time was spent to rule that out, and then his labs came back with a sugar of 13, indicating that the diagnosis of hypoglycemia was missed. He described some of the reasons that happened and I can see them happening to me. Never get fixated on a diagnosis, especially before you’ve made the proper initial evaluaation. A fingerstick glucose should always be done in a coma workup.

A few points on status epilepticus (SE)

• Convulsive SE is a seizure that lasts more than 5 minutes, and is a medical emergency.
• Lorazepam is probably better than Diazepam and don’t be afraid to use high doses (Start at 4 IV). We commonly underdose and underdosing hurts.
• Nonconvulsive SE is considered as a medical urgency. A lot of patients have SE on EEG after convulsions have stopped and many have persistent subclinical seizures after SE is controlled. So, repeat the EEG, and consider transfer to a center that can do continuous EEG monitoring.
• Absence seizures is really a diagnosis of children. (Not really about SE, but interesting)

Things to make you think that a CVA may be posterior circulation: Loss of consciousness, pupillary abnormalities, superhigh BP. Allow it to stay superhigh and keep the patient flat. Because posterior circulation strokes have such bad outcomes, it’s OK to intervene after the normal time window if there doesn’t seem to be any other hope.

Dermatology images (Paul Aronowitz)

When approaching a rash, ask 3 questions: Did the patient cause this rash? Did we do that to the patient? (Ask this twice). Is this rash a manifestation of some other disease? We often jump to the third question, but should consider the first two.

The snake bite risk factors are pretty interesting: - Male - Age 17-27 - Deliberate attempt to handle, harm or kill snake - Summer months - Alcohol intoxication - Tattoos

DRESS (Drug reaction with eosinophilia and systemic symptoms) usually occurs 2-6 weeks after the drug is started, but occurs quicker after rechallenge with the drug.

Reactive arthritis can be seen after Clostridium difficile infections.

20% of cases of Neisseria meningitidis do not have meningitis.

Poster presentations

The poster presentations are always fun to read, though if I see one more poster about the readmission problem, I will vomit.

Research Abstract Awards

The winning research abstracts were very interesting.

• UCSF described changes that they made to meet new ACGME requirements while decreasing costs and improving certain quality measures.

• Johns Hopkins hospitalists modified their CPOE system to show the costs of specific lab tests, hoping to change provider behavior. They were able to show that providers ordered less tests when they saw the cost. Duh, you say, but there is so little cost information available to providers, so this is innovative if only for that reason.

• Hospitalists (in Colorado, I think?) used the Toyota Production System to model problems with current intern work schedules. They then reworked the schedule to minimize waste of resident resources, while improving continuity and resident satisfaction. They were able to basically eliminate moonlighter and jeopardy use. I didn’t understand the schedule because it was presented quickly, but I like the idea of taking a nonmedical thought approach and applying it to medicine. I also like that they optimized for continuity of care, so that after the intervention there was a huge increase in the amount of patients that were seen only by 1 intern during their stay. Very interesting!

SHM promotion

My attention faded during the award presentations and SHM motivational speeches, but Joseph Li, the incoming SHM president, did come clean and acknowledge that he was born outside the U.S., despite his lack of an accent. The birthers were right!

Geographic rounding

Emory Hospitalists then presented a talk which was titled ‘Utilizing Technology to Improve Clinical and Operational Performance of Hospitalists’ but it should really have been titled “Geographic Bedside Rounds: Just Do It!”. They did mention the IT improvements they’ve made to support geographic rounding, but the value of the talk was in describing how they implemented geographic rounding and how it has been received by the involved parties. Moving to geographic rounding helps providers the least. It’s basically an addition to our workload. On the other hand, patients, nurses, and social workers get a lot of benefit and obviously, the patients are the most important factor here. We will have to see the patient more than once and our workflow will have to change, but it seems that the benefits outweigh the extra costs to the individual provider. Paraphrased, “Nurses and social workers would riot if we stopped this system, but even hospitalists wouldn’t want to go back to the old way, if put to a referendum.” Something that only came out in the post-talk questions was how this has improved overall teamwork. They used to have a complicated system about how new admissions were assigned, taking into account census numbers, discharge numbers, and other factors. Now, with the new system, there are days that one hospitalist will have completely unequal numbers or new patients than another hospitalist, but it is understood that things will even out over time. That has encouraged hospitalists to stop focusing on numbers and instead to focus on making things run better, so hospitalists who were previously “anti-teamwork” are now offering to help out when they’re done with their work. Anecdotal, but I like stories like that.

They also mentioned that they created a video dramatization of their bedside rounds. If I can find it, I will link to it.

Updates in Hospital Medicine

• Oral prednisone 60 mg daily as good as 600 mg IV for COPD exacerbation (Presented at DRH Journal club)
• OK to extend peripheral IVs rather than change routinely (Emailed to me by DRH Hospitalist)
• Getting appts for COPD exacerbation pts within 30 days may decrease rehospitalization (duh!)
• Benefit for tPA in stroke up to 4.5 hours, but earlier is better (DRH Journal club)
• Gurgling sounds predict pneumonia and ICU transfer (duh)
• Routine ID consultation in Staph aureus bacteremia significantly improves mortality (HR 0.44) (NEW TO ME)
• Coagulopathy in liver disease doesn’t protect against VTE (duh)
• Metformin does not cause lactic acidosis (old news, but nice to be data-supported now)
• Enteral nutrition better than TPN in pancreatitis (DRH email/conversations)
• In ICU palliative care situations, only 47% of family members based their survival estimates on MD’s prognosis advice.

I skipped the ICU stuff. Only one of these updates was new to me (listed as NEW in the list above). I attribute that to my colleagues at Durham Regional who have been sharing the knowledge that they’ve been collecting from various meetings and readings this year.

Careers in Academic Medicine

This was a workshop on how to pursue your ideal life in academic medicine. I loved the energy and enthusiasm of the instructors. This probably would’ve benefited from being a longer course with fewer, more involved participants. The basic premise was to document what exactly you are doing now, what you’re getting paid to do, and what you enjoy doing. Reconcile the differences in those 3 lists and try to identify how to make them match.

No wireless

This would have been posted a lot earlier if I could ever get on the SHM wireless network at the Gaylord Convention Center. “Please wait. You will be redirected to the authentication page in 5 seconds.” You lie!

I recently finished reading Learning Android. I have a Droid X, Mala has a Droid Eris, and I just bought a Viewsonic g-tablet, so I have plenty of Android devices. While I still have trouble with the idea of typing on a touchscreen, I know that we are moving towards a future where mobile devices are our primary computers. This is not earth shattering. Philip Greenspun mentioned it 5 years ago. Android will be one of the more prominent mobile OS’s along with iOS, so I want to learn how to program it.

I came into this book having browsed some of the example code on the developer.android.com website. It is great for an overview, and there is a lot of in-depth information on APIs, etc., but I still didn’t quite understand how to go about starting an app.

In March, O’Reilly had a sale on e-books, so I bought Learning Android. It is a reasonable introduction to Android programming. It’s beings gently, explaining the history of Android and providing a general overview of how the Android stack works. It’s explains how to use the Eclipse IDE, but as a fervent emacs fan, I was easily able to adjust to using emacs (with android-mode.el) for all of my development. There were typos and minor errors, but fortunately O’Reilly has an errata page where people can post fixes and suggestions. Keep that page open while you’re reading this book. There were a couple areas where the ordering of the discussion could have been improved. If I didn’t have that errata page at hand, I would have been completely frustrated. Especially at the beginning, the instructions were not detailed enough. For example, we are instructed on how to create a program and how to start the emulator, but there is no clear explanation on how to run the program on the emulator. A little more step-by-step hand-holding would have been nice.

In case you ignored my advice to check out that errata page, at least make sure that you have the updated version of the jTwitter library, or else you’ll never get the sample programs to run without errors.

I haven’t used Java in a while, so I forgot how verbose Java is. Writing Tcl, Ruby and Python has spoiled me. It takes so long to do something simple in Java. I know that this is usually offset by code generators and IDEs, but it still just seems so clunky to read and write. There is a scripting language project for Android (SL4A). I haven’t tried it, but it involves bundling the scripting environment with your app if you want to distribute it to others. I’m also not certain that it provides access to all of the functionality provided in the Java SDK. Someday, I hope that a scripting language SDK is provided. It seems like a natural progression.

All in all, I think Learning Android is perfect for someone who wants to get started in Android programming. It gives a nice gentle introduction to all of the basics of how the platform works. Most of this information is available on the web in various places, but it’s nice to have it all in one place, and I still think there’s value to having one book that takes you from step zero to a working app. I think I’ll now be able to use the online docs to get me moving. I was often frustrated by the typos, minor technical errors and inconsistencies, but I suspect the book was under a lot of time pressure, given how hot mobile programming is these days. It just felt like it was written on a rushed deadline. It’s also not the most entertaining book in the world, which is OK for a technical book. I’d always rather have a boring technical book, than an attempt at an entertaining one.

I ran the 15K Philosopher’s Way Trail Run today. It’s on the eastern end of Carolina North Forest. I’ve been running a lot on the western end of these trails so I had never seen any of these trails before. The weather was perfect - sunny and mid 50’s - and the trails were in good shape. I only got a little muddy. The race was very well organized for such a small race. The only minor annoyance was the beginning of the race where a couple hundred runners turned from a 20 foot wide course onto a single track bike course. Everyone came to a halt and we all walked for about a quarter mile. I didn’t really start running smoothly until about a mile in and the next 3 miles were spent passing and waiting, passing and waiting. That in itself is ok … it’s part of trail running. I would’ve just extended the time that we were on the wide track to give time for people to string out a bit more. Like I said … minor annoyance.

Once we got moving, I had a blast. I just love running in the woods. I felt unstoppable until about mile 7 and then I lost my gumption and my thighs started to complain. I held on to the people in front of me as much as I could, but one person did pass me at the end, the only person to pass me in the last 5 miles. I think I saw 1:33 as I finished, but my GPS time was 1:29:09. I think it stops the clock whenever it thinks I have stopped and it got really confused on the trails. It recorded my final distance as 6.0 miles which is 3.3 miles too short. I had suspicions that my earlier trail runs were underestimated, but never thought it was this inaccurate. My B goal was 1:30 so I was close and I definitely hit my C goal.

I’ll definitely be doing this run again next year, if I’m free. I’m currently posting my runs at dailymile (a cool site built by two UW grads), so follow me there!

There’s something about photography that seems to attract programmers. So many of the really good programmers that I know are also into photography. I, on the other hand, am just happy if my latest photo of the kids doesn’t include massive red eye. I’m always happy when a shot looks nice, but I know I’m not interested enough to be an exceptional photographer. I’ve never wanted a fancy SLR camera because I know I’d leave it on the shelf collecting dust. I’d rather have a camera that I will actually carry with me.

On that note, I’m really happy with the Canon Powershot S95 that Mala bought me. It’s even tinier than my previous pocket cameras but it takes really good photos. It’s no SLR, but I’m pretty impressed with the quality so far. I learned from David Pogue’s Digital Photography: The Missing Manual that image sensor size is, by far, the most important criteria by which to compare cameras and the S95’s image sensor is huge. It’s only 10 megapixels, but that is mostly a meaningless statistics. Ignore megapixels and pay attention to the image sensor size. I also love that it has no noticeable shutter lag. I’ve been chasing running kids around the past couple days and have yet to miss a shot.

If you’re not a photography buff, David Pogue’s Missing Manual has a lot of straightforward, simple advice that will make your pics better.

Here’s a few photos from this weekend:

Tim Bray posted the links that his browser displays when he types each letter of the alphabet. Here’s mine:

[A]dSense. I spend too much time watching the zero’s pile up.

[B]orkware. Always good for a quickie. Wait… that didn’t sound right.

[C]ite-U-Like. I’ve started to use this site to keep track of journal articles that I read.

[D]ocs (Google). I store my Habits spreadsheet, my weight spreadsheet, our address book spreadsheet (because Google contacts aren’t shareable) and other random documents.

[E]vernote. I’ve been trying to use this more to keep a central repository of notes, but it hasn’t stuck yet.

[F]acebook. I don’t know why this is there. I never use facebook.

[G]queues. I’m surprised that Google lost this one. I’m using Gqueues to keep track of my todos. It’s pretty nice. My main complaint is that it’s a little slow and there’s no Android client.

[H]ttp://facebook.com. Oh, how embarrassing. OK, my name is Vinod Kurup and I’m a facebook addict.

[I]nstapaper. I store longer articles here for later reading. I use the Instafetch client on Android to read them.

[J]ournal Watch. Phew! At least one site relevant to my day job!

[K]urup.org. The most amazing site on the internet.

[L]loogg. tail -f access.log for the web

[M]yfitnesspal. We’re using this to track our diet and exercise. We used to use Fitday, but this is so much easier and there’s a social component that is motivating. It’s amazing how comprehensive their food database is.

[N]ewegg.com. Mostly for printer cartridges, but occasionally for toys.

Duke [O]utlook. My new work webmail. Outlook 2010 == HIT’s idea of modern.

[P]icasaweb. Pictures of the cutest kids in the world.

[Q]. This space for rent.

[R]uby-doc.org. I’m trying to learn ruby (the right way)

[S]ports.yahoo.com. My University of Wisconsin, Green Bay Packer and Milwaukee Bucks/Brewers addiction is slow to die.

[T]witter. Yup, I still use twitter.com.

[U]. bUeller… bUeller…

[V]ictory Village. Kid’s daycare. Lots of snow this winter meant lots of checks to see if daycare was open.

Old Duke [W]ebmail. Lotus Notes, then Outlook 2007, now defunct.

[X]KCD. The best comic strip in the world.

[Y]outube. Videos of the cutest kids in the world. Plus I think there are some other videos there…

[Z]. This space left intentionally blank.

And had to add (because it’s so heavily used):

[1]27.0.0.1:4000. My local Jekyll server.

Written a few weeks ago

I came home late today, so Anika and Kavi had already eaten dinner and taken their baths. As I drove down the driveway, I could see Kavi’s excited little head poking over the upstairs windowsill. I parked the car and opened the door into the house. I was immediately met a voice screaming, “Daddy, Daddy!” with pure joy in his voice. He ran down the stairs and gave me a huge hug. I just love that. There is nothing better than coming home to such a loving family. It makes all the stress and BS at work melt away.

Then I followed him upstairs and Anika ran over and gave me a big hug and then started “Dancing on the diaper pad!” (Will have to upload a video of that someday). I watched for a few moments and then got up to go change my clothes. She started to get upset, so I held her hand and walked her down the hallway with me. That’s another thing I love. Seeing this sweet little girl with her arm extended as high as she can possibly reach to hold my hand, walking with me, like I’m the most important person in the world, just makes my heart melt. I don’t know what I’ve done to deserve such love and admiration. I just hope that I can live up to their expectations.

Kavi had a scary episode on Superbowl Sunday. We were just getting ready to go next door for the Superbowl party. I was upstairs with Anika and she had just been getting upset about how she wanted to go downstairs. Kavi and Mommy were downstairs, but they were coming upstairs, so I wanted Anika to stay up here, rather than go down and then come up again. I picked her up and held her in my arms to keep her happy. I heard Kavi start coming up the stairs, and normally I would have opened the baby-gate for him, but this time I didn’t want Anika to see me opening the gate, because I thought she’d start getting upset again, wanting to go downstairs. Instead, I just stood a few feet away from the gate, telling Anika, “See, Kavi’s coming upstairs.” He’s opened the gate hundreds of times and has never had any trouble doing it. This time, however, he opened the gate, lost his balance and the gate started swinging open over the stairs. He held on to the gate and swung with it. He was hanging on tightly and I could see his feet dangling, trying to find a foothold on a step, but since the gate had swung open over the stairs, he was too high to reach the stairs. I vividly saw the fear in his huge eyes and ran to the gate, but by the time I got there, the gate had given way and he was tumbling down the stairs.

Time stopped.

He screamed with the most terrified scream that I’ve ever heard. He initially landed on his feet in the middle of the staircase, but the momentum made him fly down the stairs and his head banged against the far wall. The gate followed close behind and landed on top of him. Anika started screaming in my arms. She instinctively knew that something bad had happened. I initially bent over to put her down at the top of the stairs and then quickly reconsidered, knowing that she would want to come down with me and might fall in the process. I picked her back up and headed down the stairs as Mala raced up from the kitchen. I gave Anika to Mala as I grabbed Kavi and looked him over. He had a tiny scrape on his head, but no bleeding. He seemed to be complaining most about pain in his left arm and shoulder. It reassured me a bit, because I was worried about his head, but then I got worried that maybe he had broken his arm or something. We held him for a while and put ice on his head and shoulders. Anika was tearful watching all of this but calmed down quickly. Then I went upstairs to fix the gate.

Within a few minutes he was bouncing around without any sign that he had fallen. I was so relieved, but I still have visions of his eyes being full of fear as he was hanging from that swinging gate. I know how lucky I am and how lucky we have been, in general. I also know that there will be other scary moments in the future - it’s a part of life. Weathering this admittedly minor mishap took all the strength and fortitude that I could muster. How do people do it? How do people withstand bad things happening to their kids? I just don’t know how people can take so much potential pain.

Thanks to Mala’s inspiration, I’ve been running a lot more over the past month. Whenever I get into a good running rhythm, my mind starts to relax and I occasionally get bright ideas (believe it or not!). While I am running, these always seem Nobel Prize-worthy, but they seem to lose some of their glitter when the endorphins wear off. I still believe we could solve all the world’s problems if everyone was a runner.

On a recent run, I was thinking about how Einstein said that compound interest is the most powerful force in the universe. (Turns out he probably didn’t say that, but let’s pretend someone did.) It occurred to me that really, it’s time that is the most powerful force. Compound interest is a function of time and possibly may be the most efficient way to turn time into money, but time is what makes compound interest powerful. Compound interest over the course of 10 days isn’t very powerful. Any activity repeated over a long period of time can be a powerful force, even if each individual activity doesn’t accomplish much.

Spending a few minutes a day over the past few weeks has made a significant difference in my life. I’ve started a Habit spreadsheet to track some habits, specifically, brushing my teeth at night (wanted to start with something easy), writing, pushups, running and meditation. Each day’s activity is miniscule, sometimes to the point of seeming pointless, but over just a few weeks, I’ve seen tangible benefits. I’m writing more and therefore learning more about myself. Sure, I’ve also written some really bad stuff, but I know if I continue these sessions, my life will improve because I will know more about what I really want out of life. That small amount of time, compounded over days, weeks and years will make such a huge difference. The kind of difference where, in a year from now, I’ll be able to describe it better than “such a huge difference”.

I am probably in better shape than I’ve been in since college because I’m running, doing push-ups and playing more with the kids. I ran 40 miles last week, which I haven’t done since my marathon training days. It felt easy and most importantly it’s been giving my mind some time to relax (and generate blog posts like this!) Finally, I’m meditating daily and while that has felt like the least useful of the new habits I’m forming, it is the habit that I think has the most overall potential to improve my life. Having more control over my thoughts and my mind will have positive implications for all parts of my life. My mind has just been very hard to settle down during my sessions so far. (Any tips for a beginning meditator would be appreciated!)

I also started working on my website again and I found that I was able to pick up commands and bits of knowledge that I thought I had forgotten. Little pieces of web scripting and SQL just seemed to come back to me even though I haven’t actively used them in a couple years. Since I had put in so much time learning them before, I picked them up with much less effort now. Same with running. I find it impossible to run on days that I am working, so I have to wait for my “stretches off” to run. It used to be really hard to get to a decent level when I had taken time off, but now I can take a week off and still run 5 miles without feeling bad. Maybe that’s because I run so slow.

When I think about the huge benefit I’ve gotten in a few weeks with such a small amount of daily commitments, I just can’t wait to see what will happen in a few years! Thinking that far in the future used to seem ridiculous because I always wanted results now, but the older I get, the more I’m willing to wait. Paradoxically, stretching out my time-frame for results makes it more likely that I will see results sooner. When I was always trying to make things happen now, I would ignore the little self-improvement things in the name of efficiency. Now that I take the time to do those things, the benefits compound with time and I may end up seeing results even on the things that have nothing directly to do with the habits I’m performing daily.

I also thought about how I’ve been trying to simplify my life and I wonder whether it was worth it. As a general rule, simplifying is a great idea. Try to drive less, spend less, eat less. Those are all good things. But I also found that I limited the time that I spent developing my website. I moved it from OpenACS to a static template solution. There were steps in between, but each step since leaving OpenACS has been in the name of simplification. OpenACS (like all active free-software projects) was changing and I couldn’t keep up with it while also being a dad and a doctor, so I thought it would be better to outsource (Wordpress) or simplify (Jekyll/Blogofile). While that seems to make sense, it also means that I’ve spent less time on my website and one of the joys of my life became smaller. So, I am going to take a more active role in improving my website because I love doing it. I’m not going back to OpenACS, because I do think it was more complex than I needed. I’ve reimplemented google analytics and adsense because watching those numbers gave me some satisfaction.

Final thought for the day. I’ve gotten so much accomplished over the past few weeks because I’ve become more physically and mentally active. I used fatherhood as an excuse to avoid running and self improvement. I said I didn’t have time for it. That lack of activity just reflects poorly on everything else in life. I know that’s too dramatic, because life truly has been good for all of us. But, I guess my lesson to new parents would be to make time for exercise and self-improvement. It will make you a better parent.

Lessons from this run:

1. Time is the most powerful force in the universe; using it to do meaningful things is never a waste.
2. Don’t simplify things that you enjoy doing!
3. Take care of yourself first.

The time comes in every man’s life where he eventually has to break down and buy a minivan. That time has come. The Altima is on it’s last legs and we really need a vehicle which can seat our whole family plus a couple visitors plus luggage. Only a minivan fits those requirements.

I’ll probably wait until the spring to buy. That’s when the annual Consumer Reports auto issue comes out. In the meantime, I’m doing some preliminary research. The Honda Odyssey seems to get the best reviews, but it’s also the most expensive. The Toyota Sienna isn’t far behind on reviews (or on price) and is the only one that comes with AWD. If the controls on the Sienna are similar to our current RAV4, then that would simplify life. On the other hand, I’m not happy that our RAV4 alternator died just a month out of it’s warranty. The Kia Sedona gets decent reviews and is much cheaper, but at the expense of questionable reliability and poor resale value (which might make it worthwhile to buy gently used). Finally, the dark horse is the Mazda5. It was the top rated minivan by Consumer Reports last year though I hardly ever see one on the roads. It is significantly smaller than the others, but it’s cheaper and gets much better mileage. Reviews claim it can seat 7 adults without too much squeezing. We’ll have to test drive each of them, but I would love it if the Mazda5 fit our requirements.

Philip Greenspun recently posted an entertaining review of the 2011 Honda Odyssey. It’s a favorable review, but includes quite a few bits of Greenspun’s biting humor. My favorite was this comment about the lack of progress in automotive technology:

Suppose that you’re a sleep-deprived mother. Your infant is sleeping in the middle row of seats and you’ve forgotten all about him. You go into a store and leave him to bake in the Odyssey’s greenhouse of glass. The child starts to cry. The Odyssey has a sensitive microphone as part of its telephone Bluetooth interface. The Odyssey’s computer system is always on, waiting for a radio signal from the remote control. The Odyssey has multiple interior temperature sensors for the automatic climate control system. Does the Odyssey’s always-on computer have enough logic to say

    IF child crying in interior 
       AND car is parked and off 
       AND interior temperature is above 100 degrees
    THEN
       roll windows down
       send text message to owners

? No. In fact, the Odyssey’s computer will happily sit there, with all of its sensors telling it “a child is being roasted to death”, and do nothing.

Maybe someday our cars will be as smart as our phones. Anyone else have advice on a great minivan?

I enjoyed @FutureDocs’ guide to medical student oral presentations, so I thought I’d share the cheat sheet that I give to the medical students and PA students when I start each teaching block. As she mentioned, presentations always have to be tailored to the listener, and each attending is different, so you’ll see minor differences in what I recommend.

To me, the most important aspects are organization and preparation. I don’t like to have the sense that the student is “winging it”. Prepare for each presentation like you are preparing to give a talk to a roomful of people. For me, that meant practicing the presentation at home and with the residents before I presented to an attending.

I also give each student a printed copy of the guidelines posted at the University of Washington’s medical education site. It goes into more detail about all of these issues. My favorite portion is the graph that they present, which I’ll reproduce here:

Here’s a printable copy of my cheat sheet.

Initial Presentation:

CC/ID

Be Brief. Gets the listener primed for what type of case is going to be presented.

This is a 33 year old male with a history of asthma who presents with a chief complaint of dyspnea.

HPI

This is the meat of the presentation. Pretend that you’re telling the patient’s story to a friend. How much information would they need to really understand what the patient is going through? Think about it from the patient’s perspective. What was the tipping point that made them seek medical attention? What have they tried to make things better? Stay consistent in your timeline. I like to start at the last point that the patient was completely well. In patients with chronic illness, that is hard, so you may have to start at the last time that they were “relatively” well.

He was completely well (or “in his usual state of health” for chronically ill patients) until 5 days ago, when he noticed feeling short of breath after walking 300 feet to his mailbox. Over the course of the next 5 days, his dyspnea worsened to the point that he was short of breath at rest. He tried taking his albuterol inhaler, but felt no relief. Etc…

It’s also useful to split the HPI into 2 distinct sections. The first part is the patient’s story, as described above. In the second part, you take that story and decide what a reasonable differential diagnosis list would be after listening to the first part. Then provide the listener with appropriate ROS and PMH items to help them rule those other diagnoses out.

PMH

You may have mentioned a few of these in the CC, but repeat them here. For most conditions, just list the diagnosis, but if it has particular pertinence to the HPI, then provide more detail. Also, try to give some indication of the severity of the condition for certain conditions: CHF (EF), DM (A1C), COPD (FEV1).

Past medical history includes Asthma. He has been hospitalized twice in the past year, and required mechanical ventilation in April. He also has hypertension and allergic rhinitis.

Meds

List meds like a robot :-) Include doses if they are important. You’ll learn the importance of doses with experience. In general, if the med is related to the HPI, I want to know the dose. You can’t go wrong by just giving me the dose on each med. Just run through them quickly

FH/SH/ROS

You should obviously have done these portions of the interview, but if they were important, I would have wanted to hear about it in the HPI. (Pt lives in a nursing home… Pt smokes… etc.) It’s OK to go over it quickly, but probably better to say:

FH/SH/ROS is unremarkable aside from what was presented in HPI

Exam

List the VS: Temp/HR/BP/RR/O2 sat. Then provide an overall impression:

In general, the patient appears tired and seemed to be in mild respiratory distress.

Pertinent negatives and significant positives only:

Lung exam was remarkable for diffuse expiratory wheezes with accessory muscle use. Cardiac exam confirmed tachycardia. There was no lower extremity edema and the remainder of the complete physical exam was normal.

Be completely objective. Avoid downplaying your exam skills. It’s OK to get things wrong – it’s often the best way to learn. Avoid patient interpretations here.

Labs/Xray/EKG/Procedures

If it’s all normal, OK to say it’s all normal, but if any are abnormal, I like to hear each value in that group.

ER course

Brief sentence on what happened in the ER before you saw the patient.

Assessment/Plan

Second juicy part of the presentation. Identify each problem and go one by one. Put the most pressing issue first. If the diagnosis is in question, give me a differential diagnosis and let me know what we’re doing to rule out items on the differential. If the diagnosis is relatively certain, present me with various therapeutic options and the reason why you chose the one you did.

Think about “goals of care”, if appropriate

Always mention disposition. What are we looking for before the patient can be discharged? In some cases, this will be nebulous, but at least mention it. “Disposition is unclear at this point because of X”

Overnight course

What happened after you put your plan in place? Brief status report on how patient is doing today.

Subsequent Day Presentations:

1 line about patient:

Ms Jones is our 87 year old woman here with an aspiration pneumonia

Overnight course:

Since yesterday’s rounds, she has had a speech evaluation and they recommended a video swallow study. She had one temperature spike to 38.5 degrees and blood cultures were drawn. She appears to more comfortable this morning, though she is still confused.

Exam: Vitals, superquick exam describing pertinents only

Labs: Any new labs that came back since we met for rounds yesterday.

Plan for today: Go by problem again.

Problem 1: aspiration pneumonia, she’s on D3 of Zosyn and we will continue to followup cultures. Overall she seems improved, but we’ll have to continue to monitor her mental status and oxygenation for further improvement. Problem 2: Altered mental status: This is almost certainly due to her pneumonia, but if it does not improve by tomorrow, we may consider other etiologies. At that point, repeat labs, EKG, and head CT may be indicated. … Problem 53: Disposition …

Be prepared to answer questions if you have been appropiately brief!

All I could think of while watching the news about the supercomputer Watson beating humans at Jeopardy was how this could be used in medicine. Looks like I’m not alone.

Time to start looking for a new job?