Thread by @jeremyfaust

I love this time of year.

An influx of newly minted physicians ready to learn and make a difference!

#TipsForNewDocs has become a tradition.

Well, I've got something that'll make your year(s) smoother.

A little thread on PRESENTING CASES to your supervising doc! 1/

It all comes down to the SIX T's

(Four of these I made up, and someone on twitter added two at some point).

1. Tale (History)
2. Touch (Physical exam)
3. Threats (differential diagnosis)
4. Tests
5. Treatments
6. Turf

Let's get into what I mean.

(btw, if you always cover the 6 T's in every presentation, and in order, you'll almost never be misunderstood. And that's the point here. You're communicating what you know and think to your supervising physicians).

1. Tale. This is the history.

Some patients provide minimal history.

Despite snooty attendings who will tell you otherwise, there really ARE poor historians.

But never SAY the patient is a poor historian because that particular attending might be (lamely) annoyed by this.

Sidebar: I can't stand attendings who make this a point of contention and harangue residents for this.

I'm sorry but I had a practicing white collar professional last year crisply tell me he was prescribed no medications and had no surgical history.

Turns out, he had a recent surgery and was supposed to be taking 5 meds

Became clear he had some progressive memory loss. Sad situation. Was still going to work. Shouldn't have been. He had a perfectly good reason to be a TERRIBLE historian!

Sorry for noticing.

But I digress.

Back on topic: "The tale."

How to give a good history is an art unto itself, needs 5 threads.

I'll just say: don't forget to include recent hospitalizations/procedures, recent interactions with healthcare system, medications (old and new), and past medical history relevant to situation.

2. Touch.

This is the physical exam.

ALWAYS ALWAYS ALWAYS start with a comment on general appearance and VITAL SIGNS.

You'd be shocked how much impending SHOCK I've seen an intern miss because they forgot to notice the vital signs.

Does not need to be every number (at least not for me).

"Looks uncomfortable, but not gravely ill. Vitals notable for mild tachycardia only."

I'm telling you.

Make this a DO-NOT-PASS-GO habit.

You'll thank me later :)

From there, focus on the problem at hand.

If it's a DVT rule-out, I don't need a description of all 12 cranial nerves in the presentation.

(Sure, chart at of that, for the bean counters and the Federales...)

Instead, home in on the area of interest: "Exam head to toe largely non-contributory. Heart and lungs normal. The Right leg has swelling and tenderness in the proximal calf; distally there is full range of motion, sensory and motor intact, good circulation."

3. Threats.

This is the crux of the assessment and plan.

A good one-liner is, like history, its own art. Needs its own thread.

What we care about, especially the emergency department, is the MUST-NOT-MISS DIFFERENTIAL DIAGNOSIS.

There are two ways to present this:
A) In order of likelihood.
B) In order of what can't be missed.

I actually like a modified version of #2.

Let's imagine a chest pain that you think is benign. Rather than say "I think it's GERD or costocondritis...."

Show me you thought of the scary stuff too but WITHOUT making it seem like you really think it is that.

Here's how:

"While I think this is likely ultimately a benign cause, there are some dangerous entities on the differential diagnosis we need to consider...

...I don't think it's an aortic dissection because [xyz]. A pulmonary embolism seems highly unlikely because [xyz]. Could this be a mild acute coronary syndrome? Maybe."

You get my drift.

But residents skipping the DIFFERENTIAL DIAGNOSIS (and going right into tests and other orders) is so common, you wouldn't believe it.

Don't :)

4. Tests.

If you know the differential diagnosis, then you probably know the tests. Biggest error we will pick apart is when you are testing for stuff you didn't identify on the differential diagnosis. Limit your testing to what is REALLY on the differential diagnosis.

Free tip: If you're getting a CBC, it's far better to say "to check for anemia" than "to check for infection."

CBC's are *terrible* at picking up infections. If you're relying on a leukocytosis for diagnosing acute infections, we won't be impressed.

Free pearl. Couldn't resist.

5. Treatment. Patients came to feel better.

Of the 6 T's this one among the most often missed.

Pain control counts!

And of course, like...curative interventions. Always good to mention those :)

Finally:

6. Turf!

Where the patient is going.

If everything is positive, they STILL might be going home. But verbalize this. "If the work-up goes as expected, I think they'll need admission, but not the ICU."

That's it!

Go forth with the 6 T's!

Good luck!