Oral Case Presentation Research Articles

Interrater Reliability of an Oral Case Presentation Rating Tool in a Pediatric Clerkship

Background: Composing and delivering effective oral case presentations is an important skill for medical students to learn, but the large variety of patients and presenting problems makes teaching and evaluating this skill complex. Few published tools are available for educators to use, and those that are described are not well studied. Purpose: The authors describe the development of the Patient Presentation Rating tool and the study to establish its interrater reliability. Methods: Three raters reviewed 15 recorded new patient presentations delivered by 3rd-year medical students on their pediatrics clerkship. Intraclass correlation coefficients were used to determine the interrater reliability of the tool as a whole, its subsections, and each individual item. Results: The tool was found to reliably rate the technical aspects of presenting patients as well as several aspects of clinical reasoning embedded in that process. Conclusions: The Patient Presentation Rating tool is a reliable instrument for evaluating medical students’ oral patient presentations.

A qualitative study of pediatric residents' developmental oral case presentations

Objectives: To explore how pediatric residents apply their knowledge of relevance in their oral case presentations to the unfamiliar context of a chronic care setting, that of developmental pediatrics. Methods: Pediatric resident oral case presentations were observed and semi-structured interviews were conducted with residents and staff developmental pediatricians. A total of 13 residents and 5 developmental pediatricians were observed and 13/18 participants were interviewed and audiorecorded. Qualitative transcript data were analyzed for emergent themes using an inductive thematic analysis approach. Results: Pediatric residents identified challenges with determining relevance in their oral case presentations in this context. They had difficulty generating succinct case presentations and integrating patient information into an overall clinical impression. Residents conflated the strict organization of information with relevance, and demonstrated presentation formats akin to those used by more novice medical trainees. Staff members viewed the oral case presentation as a flexible vehicle to integrate patient information; however, this perspective was not always explicitly shared during teaching exchanges. Conclusions: Results of this study draw attention to the possible contextual nature of residents’ understanding and use of relevance principles in their oral case presentations. Clinicians responsible for teaching in outpatient chronic care settings need to be aware of the possible challenges residents may have with their case presentation, so that teaching strategies can be implemented to ensure residents’ acquisition and appropriate adaptation of this essential communication skill.

E-learning and deliberate practice for oral case presentation skills: A randomized trial

Background: Oral case presentations are critical for patient care and student assessment. The best method to prepare early medical students for oral presentations is unknown.Aim: We aimed to develop and evaluate a curriculum of on-line learning and deliberate practice to improve pre-clinical students’ case presentation skills.Methods: We developed a web-based, interactive curriculum emphasizing conciseness and clinical reasoning. Using a waitlist control design, we randomly assigned groups of second-year students to receive the curriculum in December 2010 or in April 2011. We evaluated their presentations at three time points. We also examined the performance of an untrained class of students as a historical comparison.Results: We evaluated 132 second-year medical students at three time points. After the curriculum, mean scores of the intervention students improved from 60.2% to 70.1%, while scores of the waitlist control students improved less, from 61.8% to 64.5% (p < 0.01 for between-group difference in improvement). Once all students had received the curriculum, mean scores for the intervention and waitlist control students rose to 77.8% and 78.4%, respectively, compared to 68.1% for the untrained comparison students (p < 0.0001 compared to all curriculum students).Conclusion: An on-line curriculum followed by deliberate practice improved students’ oral presentation skills.

What’s the Story? Expectations for Oral Case Presentations

This article focuses on teaching and evaluating oral presentation skills as part of the ongoing Council on Medical Student Education in Pediatrics (COMSEP) series on skills and strategies used by superb clinical teachers. While oral presentations by students can be used to enhance diagnostic reasoning,1 we will focus this article on the characteristics of high-quality oral presentations by medical students, highlight several common pitfalls, and reinforce the connection between effective oral presentations and clinical reasoning. A model for evaluating student clinical performance, the RIME model, will be reviewed. Students often struggle with what is expected of them when asked to give an oral presentation of a patient encounter. Many preceptors have asked a student to present a case, only to be answered with the question, “What would you like to hear?” Students frequently perceive the oral presentation as “a rule-based, data-storage activity governed by order and structure.”2 Clinicians, however, view the oral presentation as a flexible form of communication, with content determined by the clinical context and audience. The first step in bridging this gap is to set explicit expectations. Students should be told early in the clinical experience the commonly accepted and expected style for oral presentations and the rationale for the organization. The ultimate goal of the presentation is to provide the justification for diagnostic and therapeutic decisions. Table 1 summarizes the elements of an effective oral presentation.3 View this table: TABLE 1 Oral Presentation Expectations Checklist3 ### Chief Complaint: Who Are We Talking About? Presenting information in an expected order makes it easier for listeners to process information. This begins with the chief complaint. Either a direct quote (eg, “My tummy hurts”) or an identifying statement (“A 6-year-old girl with fever and abdominal pain”) sets the context for this patient’s story from the first line (a different context than that … Address correspondence to Michael Dell, MD, Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Children’s Hospital, 11100 Euclid Ave, Cleveland, OH 44122. E-mail: michael.dell{at}uhhospitals.org

The art of presenting

The oral case presentation is a time-honoured tradition whereby a trainee presents a new admission to the attending physician. We describe the presentation styles of students, residents and staff physicians and offer pointers on how to present like stereotypical members of each group. Although the

45 Assessment of Clinical Teaching During Oral Case Presentations in a Busy Academic Emergency Department

Significant impediments to effective emergency department (ED) teaching compromise what could otherwise be an excellent learning environment. Attending physicians must balance the need to quickly devise patient assessments and plans with their responsibility to devote time toward teaching students. There is little literature to guide faculty development around specific emergency medicine teaching techniques. The purpose of this study was: 1) describe the frequency and nature of various teaching styles used by attending physicians; 2) determine if there is an inverse relationship between effective teaching and clinical demands; and 3) quantify the frequency of interruptions by the training physician that occur when students and residents do oral case presentations (OCPs) in the ED.

The Oral Case Presentation: What Internal Medicine Clinician–Teachers Expect From Clinical Clerks

Background: The oral case presentation (OCP) is a fundamental communication skill that frequently is taught as part of internal medicine clerkships. However, little is known about the optimal content for an OCP. Purpose: We hypothesized that internal medicine clinician–teachers have common expectations regarding OCPs by 3rd-year medical students. Methods: We administered a 42-item survey to 136 internal medicine faculty members at 5 U.S. medical schools who spent at least 8 weeks as “ward attending” in the 2005–6 academic year, or spent at least 4 weeks as a “ward attending” and had an administrative role in medical education. We asked about the relative importance of 14 potential attributes in a 3rd-year medical student OCP using a 6-point Likert scale. We also asked about their expectations for the length of a new patient presentation. Mean responses from the 5 schools were compared using chi-squared, analysis of variance (ANOVA), and t testing, as appropriate. Results: We received 106 responses (78% response rate). Of our respondents, 45% were hospitalists and 80% self-identified as “clinician–educators.” Some aspects of the OCP were rated as more important than others (p< .001) Six items, including aspects of the history of present illness, organization, and structuring the presentation to “make a case” were rated as important or very important by more than 70% of respondents. Fewer than 10% of respondents believed that inclusion of a complete review of systems or detailed family history were important. Few differences were seen between institutions. Faculty expected that OCPs should take 9.9 ± 5.4 min, with faculty at one institution having significantly different expectations than all others (15.9 ± 6.4 min vs. 7.8 ± 2.8, p< .001). Conclusions: Internal medicine clinician teachers from 5 U.S. medical schools share common expectations for OCPs.

Case presentations: A key method for evaluating core competencies in professional psychology?

The clinical psychology training literature highlights the need to evaluate student competency in core competencies (e.g., assessment, intervention, interpersonal relationships, research, ethics, supervision). One such evaluation method that allows for a broad-based examination of core competencies is the oral case presentation. The oral case presentation is not new to clinical psychology, but the use of this method to evaluate core competencies has not been extensively discussed. We conducted a Web-based survey on the use of case presentations to evaluate students in professional psychology programmes in Canada. Responses were obtained from 20 of 28 Canadian Psychological Association (CPA)-accredited programmes. Respondents reported on the use of the oral case presentations in the evaluation of students and the perceived value of case presentations. The majority of respondents (N = 14) reported that students gave an oral case presentation during the course of training. Most of these programmes required the case presentation in the fourth year (N = 8), a point in time when competency might be best assessed. Only very few programmes (N = 3) reported that the case presentation was evaluated by a committee, with formal guidelines to assess the case presentation. The case presentation was viewed as being helpful for evaluating several different abilities (e.g., case conceptualisation, awareness of metaknowledge, use of research in practice, reflective skills). Overall, the case presentation was positively evaluated, but appears underutilised in Canadian professional psychology programmes to evaluate clinical competency. To encourage further use of this method for formal evaluation, guidelines for presentations and evaluation are provided. Future directions for research are also outlined. Keywords: core competencies, case presentation, evaluation, training Graduate training is a subject of intense interest in professional psychology. Decisions about training directly affect students and faculty, as well as clients, practicing professionals, employers, and regulatory bodies that rely on graduate training programmes to produce competent practitioners. The need for comprehensive and diffuse competency in several areas of professional psychology, and the assessment of multiple competencies, has been emphasised in recent literature (e.g., Fouad et al., 2009; Kaslow et al., 2009). In particular, a Cube of core competency has been articulated (Rodolfa et al., 2005). This model delineates the importance of professional psychologists having numerous foundational competencies (i.e., professionalism, reflective practice/selfassessment/self-care, scientific knowledge and methods, relationships, individual and cultural diversity, ethical legal standards and policy, and interdisciplinary systems) and functional competencies (i.e., assessment, intervention, consultation, research/evaluation, supervision, teaching, and management-administration; Rodolfa et al, 2005). Specific to Canada, the Mutual Recognition Agreement (MRA) of the Regulatory Bodies for Professional Psychologists in Canada (2004) recommends that regulatory bodies for professional psychology in Canada evaluate applicants seeking entry into the profession on six core competencies, including competency in interpersonal relationships, assessment, interventions, research, ethics and supervision. In response to current attention to competency, CPA recently released a revised draft of accreditation standards and procedures for doctoral programmes and internships in professional psychology (Canadian Psychological Association, 2009). The revised standards and procedures place increased attention on these core competencies and require Canadian students to be systematically trained and evaluated in the six core areas of competency identified in the MRA. Given the diversity of core competencies in psychology, the need for a variety of competency evaluation methods is required. …

286: Clinical Teaching In a Busy Emergency Department: Interruptions During Case Presentations

In the emergency department (ED) of a teaching hospital, attending physicians are challenged to instruct medical students and residents while simultaneously caring for critically ill patients. Thus, they must balance the need to quickly devise patient assessments and plans with their responsibility to devote time toward teaching students. Studies have only recently begun to quantify and characterize interruptions occurring in the ED. Our objectives were to determine the frequency and nature of interruptions by the training physician that occur when medical trainees perform oral case presentations (OCPs). This was a prospective observational study which took place from June 2009 through August 2009 in the ED of a large academic medical center. A convenience sample of house officers and fourth-year medical students were observed during OCPs with attending physicians. None of these physicians or students were aware of the purpose of the study. They were informed only that a second-year medical student was observing case presentations as part of his/her summer elective. As many different attending physicians as possible were sampled while maintaining equal hours of observation for each daily shift. The student completed a simple data sheet after each case presentation and recorded OCP duration, interruption frequencies, and interruption types. An “interruption” was defined as any event that caused the learner to stop the OCP for longer than 2 seconds, and only interruptions initiated by the teaching physician were recorded. Effects of learner level or time of day on frequency of interruption were evaluated using analysis of variance, with statistical significance at the p < 0.05 level. A total of 570 case presentations were observed during the study period; involving 53 EM faculty, 52 house staff and 11 medical students. The mean duration of presentation was 3.4 + 2.2 minutes (range 0.5 to 14 minutes). There were a total of 1739 interruptions during case presentations; mean 3.0 (+ 2.4) interruptions per presentation or 0.94 (+ 0.70) interruptions per minute. At least one interruption occurred in 94% of OCPs, with a maximum of 16. The interruptions were categorized as follows: interruptions by faculty (88%), phone calls (4%), questions by nursing staff (7%), ECG interpretation (1%), and orders on other patients (1%). The majority of faculty interruptions (55%) involved questions about history or exam findings or injection of teaching points. In 37% of OCPs, attending physicians interrupted to give an assessment and/or a treatment plan before the learner had done so. The number of interruptions (per OCP) and duration of OCP varied by learner level of training (p < 0.01), with more experienced learners giving shorter presentations and being interrupted less often. Neither frequency nor number (per OCP) of interruptions was statistically different by time of day. The education of students and residents occurs primarily during case presentations to ED faculty, an environment in which interruptions frequently occur. The majority of these interruptions are driven by the faculty themselves and vary by the learner level of training. These interruptions can be potentially beneficial, such as the injection of timely teaching points or clarification of clinical findings.

Pilot of Direct Observation of Clinical Skills (DOCS) in a Medicine Clerkship: Feasibility and Relationship to Clinical Performance Measures

Purpose: To assess the feasibility of Direct Observation of Clinical Skills (DOCS), a program for formative assessment of students’ clinical skills during a medicine clerkship and to determine relationships between DOCS measures and other clinical performance measures.Method: From August, 2004 through June, 2005, Medicine Clerks assigned to the primary on-campus clinical site were asked to participate in the pilot phase of the DOCS program. Students were asked to complete at least one DOCS exercise focused on interviewing, physical examination, or oral case presentation.Results: Of the 79 students who rotated on the Medicine Clerkship during the pilot period, 79% (n=62) participated in DOCS, and 163 forms were submitted for evaluation. Seventy-seven percent (77%) of the clinical observations occurred while on-call or during daily rounds. Seventy-three (73%) of observations were completed in 30 minutes or less. In 89% of encounters students received at least 5 minutes of verbal feedback. Satisfaction ratings from both students and observers were ’’moderately satisfied’’ or better. Global ratings from DOCS physical exam and case presentation sections were strongly correlated with both faculty ratings of clinical performance and final clerkship grade. DOCS measures were not statistically related to clerkship written examination scores.Conclusions: These data support the feasibility of the DOCS session for formative assessment of student interviewing, physical examination, and oral case presentation skills during a medicine clerkship. Observer ratings from DOCS physical examination and case presentation sections were found to be predictors of final clerkship grade.

Pilot of Direct Observation of Clinical Skills (DOCS) in a Medicine Clerkship:Feasibility and Relationship to Clinical Performance Measures

Purpose:To assess the feasibility of Direct Observation of Clinical Skills (DOCS), a program for formative assessment of students’ clinical skills during a medicine clerkship and to determine relationships between DOCS measures and other clinical performance measures.Method:From August, 2004 through June, 2005, Medicine Clerks assigned to the primary on-campus clinical site were asked to participate in the pilot phase of the DOCS program. Students were asked to complete at least one DOCS exercise focused on interviewing, physical examination, or oral case presentation.Results:Of the 79 students who rotated on the Medicine Clerkship during the pilot period, 79% (n = 62) participated in DOCS, and 163 forms were submitted for evaluation. Seventy-seven percent (77%) of the clinical observations occurred while on-call or during daily rounds. Seventy-three (73%) of observations were completed in 30 minutes or less. In 89% of encounters students received at least 5 minutes of verbal feedback. Satisfaction ratings from both students and observers were “moderately satisfied” or better. Global ratings from DOCS physical exam and case presentation sections were strongly correlated with both faculty ratings of clinical performance and final clerkship grade. DOCS measures were not statistically related to clerkship written examination scores.Conclusions:These data support the feasibility of the DOCS session for formative assessment of student interviewing, physical examination, and oral case presentation skills during a medicine clerkship. Observer ratings from DOCS physical examination and case presentation sections were found to be predictors of final clerkship grade.

Expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors.

Little is known about the expectations of undergraduate internal medicine educators for oral case presentations (OCPs). We surveyed undergraduate internal medicine educational leaders to determine the degree to which they share the same expectations for oral case presentations. Participants were institutional members of the Clerkship Directors of Internal Medicine (CDIM). We included 20 questions relating to the OCP within the CDIM annual survey of its institutional members. We asked about the relative importance of specific attributes in a third-year medical student OCP of a new patient as well as its expected length. Percentage of respondents rating attributes as "very important" were compared using chi-squared analysis. Survey response rate was 82/110 (75%). Some attributes were more often considered very important than others (p < .001). Eight items, including aspects of the history of present illness, organization, a directed physical exam, and a prioritized assessment and plan focused on the most important problems, were rated as very important by >50% of respondents. Respondents expected the OCP to last a median of 7 minutes. Undergraduate internal medicine education leaders from a geographically diverse group of North American medical schools share common expectations for OCPs which can guide instruction and evaluation of this skill.

Assessment of Teacher Interruptions on Learners during Oral Case Presentations

Assessment of Teacher Interruptions on Learners during Oral Case Presentations

Assessment of Teacher Interruptions on Learners during Oral Case Presentations

Studies have only recently begun to investigate the effects of interruptions on physicians in the emergency department (ED). To determine the frequency and nature of interruptions by the training physician that occur when medical trainees do oral case presentations (OCPs) in the ED. This was an observational study. Learner OCPs to attending emergency physicians were observed in the ED of an urban Level 1 trauma center at a major teaching hospital. A single investigator followed attending physicians blinded to the study objective in a nonrandomized convenience sampling of all ED shifts, recording information regarding teacher interruptions during new patient presentations. Learners completed a brief questionnaire after each OCP. A total of 196 OCPs were observed. The mean (+/-SD) duration of OCPs was 3.30 (+/-1.85) minutes, and the mean (+/-SD) number of interruptions was 0.75 (+/-0.60) per minute and 2.49 (+/-1.95) per OCP. The number of interruptions (per OCP) and duration of OCP varied by learner level of training, with more experienced learners giving shorter presentations and being interrupted less often. Frequency (per minute) of interruptions did not vary by learner level. In 40.3% of OCPs, attending physicians interrupted to give an assessment and/or a plan before the learner had done so, but 8.3% of interrupted learners believed that teacher interruptions were "disruptive" to their OCP. Attending emergency physicians frequently interrupt learners during new patient OCPs, with the number of interruptions varying by learner level of training. Teacher interruptions appear to have minimal, if any, detrimental effect on the perceived effectiveness of OCPs as a learning experience.

Evaluation of Checklist and Inter-Rater Agreement in Oral Case Presentation of Undergraduate Medical Students

Evaluation of Checklist and Inter-Rater Agreement in Oral Case Presentation of Undergraduate Medical Students

Learning Activities and Third-Year Medical Student Ratings of High Quality Teaching Across Different Clerkships

Objective: To identify and compare learning activities that students associate with high quality teaching across clerkships.Methods: For six months, 110 third year medical students recorded data on learning activities and teaching quality using personal digital assistants (PDAs) during five different required clinical clerkships. Univariate and multivariate analyses were performed to assess the association between learning activities and student ratings of high teaching quality.Results: 11,450 teaching interactions were recorded. Univariate analysis revealed that feedback was associated with perceptions of high quality teaching in all clerkships. Proposing a plan, formulating an assessment and giving an oral case presentation were associated with high quality teaching in 80% of the clerkships (p < 0.01). Multivariate analysis demonstrated that receiving high quality feedback was an independent predictor of student ratings of high quality teaching for all clerkships.Conclusion: Receiving high quality feedback is the learning activity most strongly associated with students’ ratings of high quality teaching across four different clerkships

Who is the Silverman of Caffey-Silverman disease?

Sir, I read with interest the letter of Walter Berdon in the July issue of Pediatric Radiology [1]. I must say that I do not share his opinion concerning the confusion in Europe between William Silverman and Fred Silverman. The term “le syndrome de Silverman” is used in Europe and Africa only in the French-language medical literature and only as a synonym of the abused child syndrome. This term was coined in the early 1950s by a group of paediatricians in the Enfants-Malades Hospital in Paris. During the same period, in the same hospital, the paediatric radiologists, under Jacques Lefebvre, were fighting to convince their clinical colleagues of the reality of unrecognized bone injuries, of the battered child syndrome as initially described by Caffey and later by Kempe. When we proposed such a diagnosis we were told we were wrong, having mistaken lesions due to scurvy, rickets or congenital syphilis. For years I wondered why this entity was suddenly accepted and under the name of Silverman. I found the explanation some 20 years ago from a paediatrician colleague who was present when the name of Silverman was adopted for this situation. It was the result of an oral case presentation by Fred Silverman. I have given full details of the story in the foreword I wrote for the second edition of Paul Kleinman’s textbook [2]. Fred Silverman knew that in France his name was used to refer to the radiographic features of unrecognized bone injury. It is probably the reason why in a lecture [3] presented in October 1971 he said, “If an eponymic term is to be considered, I should like to offer that of ‘the syndrome of Ambroise Tardieu’.” I discovered the existence ofAmbroise Tardieu when Fred asked me, in early 1971, to provide him with photographs of the man himself and of the first page of his article on child abuse. Ambroise Tardieu, born in Paris in 1818, was professor of legal medicine in the University of Paris, and in an article published in 1860 [4], reprinted in a book published in the year of his death, 1879, Ambroise Tardieu described all the lesions he had discovered in maltreated children. He introduced the concept of the abused child with not only medical but also demographic, social and psychiatric features. Since Fred’s proposal, each time I have to deliver a lecture, or even a discussion in a case presentation on this topic, to medical students or residents in France I use the term ‘syndrome d’Ambroise Tardieu’ explaining who the man was and why I use his name, but always without result. In the French medical literature, this entity will remain linked to the name of Fred.

Developing and Implementing Universal Guidelines for Oral Patient Presentation Skills

Background: Oral case presentations are important for patient care and clinical education. Previously published attempts to improve oral presentation skills have been labor intensive and have focused primarily on medical students.Description: We created a multifaceted intervention to improve oral case presentations of medical students and internal medicine residents. Our intervention included a written handout with detailed instructions, pocket cards, model presentations, and multiple teaching sessions. The intervention was developed by consensus, supported by the department of medicine and endorsed by key faculty within the department. In addition to soliciting feedback from students and residents, we evaluated our intervention with prospectively acquired ratings of student oral case presentation skills recorded on a standardized evaluation for the internal medicine clerkship.Evaluation: Students, residents, and faculty gave positive feedback, although they noted some practical obstacles to effective oral case presentations. After dissemination of the guidelines, 44% of students (42/96) were rated as "excellent" in oral presentation skills on standardized evaluations of the internal medicine clerkship, compared to 30% in the previous academic year (33/111; odds ratio [OR] = 1.8, 95% confidence interval = 1.04-3.3; p =. 036).Conclusion: A multifaceted intervention improved medical student oral case presentation skills. Although participants noted barriers that need further attention, we demonstrated modest improvement in student performance.

A randomized-controlled study of encounter cards to improve oral case presentation skills of medical students

To determine the feasibility of oral case presentation (OCP) encounter cards as a tool for formative evaluation, to estimate the reliability and validity of the ratings when used in a medicine clerkship, and to examine whether the use of OCP encounter cards improves students' OCP skills. Randomized controlled study. Medicine core clerkship at a U.S. medical school. Students enrolled in the medicine core clerkship (n=164) from January to December of 2003 were randomly assigned to receive weekly feedback using OCP encounter cards rating nine presentation compentencies or receive usual feedback. Mean OCP ratings were correlated with multiple summative assessments. Performance on an end-of-clerkship OCP was compared between intervention and control groups. Eighty percent of cards were completed. The mean OCP rating averaged over 9 competencies was 7.7 (SD=0.8) on a 9-point scale. Standard error of ratings was 0.3. OCP ratings were correlated with inpatient evaluations (r=.58), inpatient ratings of presentation skills (r=.43), and final grades (r=.40). Final OCP performance was similar for the intervention and control groups (7.0 vs 7.2, P=.09). OCP encounter cards are a novel and feasible tool to assess clerkship students' oral case presentation skills. OCP card ratings are reproducible, and validity is suggested by their correlation with multiple markers of performance. However, encounter cards did not improve performance on summative oral presentations.

Interruptions during Oral Case Presentations in the Academic Emergency Department: Benign Or Problematic?

Interruptions during Oral Case Presentations in the Academic Emergency Department: Benign Or Problematic?