The Art of the Oral Presentation: An Intern’s Guide

Author: Joshua Lowe, MD (EM Attending Physician, San Antonio, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Manpreet Singh, MD (@MPrizzleER); Brit Long, MD (@long_brit)

The fluorescent lights above cast a clinical pallor over the bustling ED. A cacophony of sounds envelops you. The relentless beeping and chirping of monitors created a dissonant symphony. Each beep, a reminder of a patient’s heartbeat or oxygen saturation, seemed to echo the fragility of life. The distant wailing of ambulance sirens grew louder and then abruptly cut off as they arrived at the ED entrance. From behind closed curtains, the occasional muffled cries of pain and distress. The symphony of sounds in the Emergency Department can be overwhelming. It serves as a constant reminder of the high-stakes nature of the work being done here, where lives hang in the balance, and where the ability to navigate the chaos with skill and compassion will define your journey as an emergency physician.

The clock on the wall seemed to mock you, ticking away precious seconds as you stand before your colleagues, your voice the only lifeline connecting the complex web of symptoms, diagnoses, and decisions.

Mastering the art of delivering an effective oral presentation in the ED is a crucial skill that can mean the difference between clarity and chaos, life-saving interventions, and costly delays. The way you present a patient case often leaves the most lasting impression on the attending physician, far more than the number of patients you saw. At the end of a busy shift, what stands out is whether your presentations were clear, provided a solid plan, and were delivered with the confidence that indicates you know what you are doing. Let’s explore the foundational principles and practical techniques that will help you excel in this critical aspect of emergency medicine.

The Foundation of Effective Presentations

Before we dive into the specifics of ED presentations, it’s crucial to grasp the core principles of effective communication in any medical setting. No matter your level, these fundamentals remain timeless:

Know Your Audience: Effective presentations begin with an awareness of your audience. Who are you speaking to? What is their level of expertise? What are their expectations? Tailoring your message to your audience ensures it resonates and is understood.

Organize Your Thoughts: In the fast-paced ED, there’s no time for rambling or disorganized information. Structure your presentation logically, following a format that makes sense for your case. A common approach is the Situation, Background, Assessment, Recommendation (SBAR) framework.

Clarity is Key: Use simple, concise language. Avoid jargon when possible, and explain any medical terminology you must use. Your goal is to ensure everyone in the room understands your message.

Engage Your Audience: Maintain eye contact, use appropriate gestures, and project your voice. Engaging your audience not only keeps their attention but also conveys confidence.

Stay Calm Under Pressure: The ED can be chaotic, and emotions can run high. Maintain your composure, even in stressful situations. Confidence in your presentation will inspire trust in your abilities.

The Anatomy of an ED Presentation

Now that we’ve established the foundational principles, let’s dissect an ED presentation to understand its essential components:

Patient Introduction: Begin with a concise introduction of the patient, including their name, age, gender, and chief complaint. This sets the stage for your presentation.

Presenting Complaint: Clearly articulate why the patient has sought medical attention. Include the onset, duration, and any aggravating or relieving factors.

History of Present Illness (HPI): Provide a focused history of the current problem, highlighting key elements such as associated symptoms, past medical history, medications, and recent events. Remember, this isn’t Internal Medicine rounds; focus on what’s pertinent to the patient’s chief complaint.

Vital Signs and Physical Examination: Share relevant or abnormal vital signs and summarize your physical examination findings, emphasizing pertinent positives and negatives.

Laboratory and Imaging Results: If available prior to the patient being roomed, present essential lab results and imaging findings, interpreting them concisely and explaining their relevance to the case.

Assessment and Plan: Offer your assessment of the patient’s condition and outline the plan of action. This should be based on the patient’s chief complaint, the most likely diagnosis, and can’t-miss diagnoses.

Tips for Success

Delivering effective oral presentations in the ED is an acquired skill that improves with practice. Here are some additional tips to keep in mind:

Practice, Practice, Practice: Rehearse your presentations before delivering them. This will help you refine your delivery and boost your confidence.

Seek Feedback: Don’t shy away from constructive criticism. Seek feedback from colleagues and mentors to continuously improve your presentation skills.

Stay Humble: The ED is a dynamic environment where cases can challenge even the most experienced clinicians. It’s okay not to have all the answers, but it’s crucial to demonstrate a willingness to learn and adapt.

Stay Current: Medicine is an ever-evolving field. Stay up-to-date with the latest guidelines and research to enhance the credibility of your presentations.

Unfortunately, too often the presentations delivered by medical students or new residents are rambling and incoherent, no doubt influenced by ward rounds which take half a day. The following is a very real presentation from a couple of years ago.

Consider the following example. I exaggerated for effect some of the issues, which we will iron out.

Intern: “Uh, good morning, everyone. So, I have this patient, a 34-year-old woman, who…um, has chest pain. Yeah, chest pain.”

Attending: “Go on.”

Intern: “So, she’s 34, and, um, she came in with… chest pain. I mean, it’s in her chest, you know? She said it hurts. Sometimes. I think she said it started like… yesterday? Or maybe the day before? I’m not exactly sure.”

Attending: “Ok. Is there anything else?”

Intern: “So she was born premature at 36 weeks, but didn’t require a stay in the NICU. She had her appendix out when she was 7 and has a scar on her left knee that required 4 stitches from when she fell off of her bike when she was 10. Otherwise she had a healthy childhood. She’s fully vaccinated. She’s sexually active, mainly with men but she did experiment in college. Has never had an STI. Last menstrual period ended yesterday. She’s married with one child. A boy named Thomas. Her grandfather died of a heart attack last year at the age of 92.

Attending: “Does she have any other symptoms related to her chest pain?”

Intern: “I didn’t really ask her about her medical history or any other symptoms. I mean, it’s just chest pain, right? Should I have asked about other stuff?

Attending: “Right…what are her vitals?”

Intern:  “Oh, her vital signs? Yeah, they’re… normal, I guess. Nothing really stood out. Blood pressure was okay, I think.”

Attending: “Ok. Well what do you want to do with her?”

Intern: “Yeah. I don’t know., I think we should probably do some tests or something, like an ECG, maybe? Or, uh, blood work? I just thought I’d, you know, start with the basics.”

Obviously, there is room for improvement here. It lacked essential details, failed to address key questions, and left the medical team with more questions than answers. Effective communication and thorough data collection are crucial in the ED, and this presentation demonstrated a severe deficiency in those skills.

Your interview guides your workup. A good history and physical is the bases for every patient interaction.

You: Good afternoon, my name is Dr. Smith. I’m one of the ED resident physicians. How can we help you?

Patient: Hi, Dr. Smith. I’m Sarah, and I’ve been having some chest pain that started today. It feels like a pressure or tightness in the center of my chest. It’s really uncomfortable, and I’m worried it might be something serious.

You: I’m sorry to hear that, Sarah. Can you tell me more about the pain? Is it constant, or does it come and go?

Patient: It’s been kind of coming and going for the last few days, but it’s been there consistently for the past hour. It’s not extremely severe, but it’s definitely uncomfortable.

You: Does anything make your pain better or worse? Does it stay in the same place, or does it radiate or move anywhere?

Patient: It gets worse when I take a deep breath, but it doesn’t move anywhere. It just stays right here (points to her sternum).

You: Are there any other symptoms you’ve noticed? For example, have you felt short of breath, lightheaded, or had any abdominal pain, nausea, or diarrhea?

Patient: Yes, I’ve felt a bit short of breath, especially when I walk around. I also felt a bit lightheaded when the pain started, but nothing else.

You: Have you had any recent illness? Cough, fever, runny nose, or anything like that?

Patient: No, none of those.

You: Any headaches or neck pain? Any numbness or weakness anywhere?

Patient: Nope.

You: When was your last menstrual period?

Patient: It ended yesterday.

You: Have you ever been diagnosed with any medical conditions? Are there any medications that you take regularly?

Patient: I have anxiety, and I take birth control pills regularly, but otherwise, I’m healthy.

You: Have you ever experienced anything like this before? Does this feel like your anxiety?

Patient: No, this feels different. That’s why I’m worried.

You: Have you ever had any surgeries?

Patient: Yes, I had my appendix removed when I was a kid.

You: Does anything run in your family? Any history of heart disease?

Patient: Yes, my dad had a heart attack when he was in his 40s.

You: Have you traveled recently?

Patient: No.

You: Do you use alcohol, tobacco, or recreational drugs?

Patient: I vape sometimes.

You: Is there anything else that is concerning you today?

Patient: Just this chest pain.

Her vitals are as follows:

Heart Rate: 104 BPM

Blood Pressure:114/68

Respiratory Rate: 14

Oxygen Saturation: 98%

Temperature: 98.3 F

A focused physical exam was unremarkable.

What is your leading diagnosis? What are your can’t-miss diagnoses?

Take a moment to think about how you would present this patient.

Here is an example of a well-composed and thought-out presentation:

Sarah is a 22-year-old female, past medical history significant for anxiety, family history significant for early cardiac disease as her father had a heart attack in his 40s, who presents today for intermittent substernal chest pressure and exertional dyspnea, worse with deep breaths, that started today and has been constant for the last hour. She denies any trauma, recent illnesses, nausea, or radiation of the pain. Given the fact that she is tachycardic and on birth control I have concern for a possible pulmonary embolism. We cannot use the PERC criteria to rule her out because she is tachycardic but she is still low risk according to the Well’s criteria so I would like to start with a D-dimer to rule that out. If it’s positive, we will have to get a CT-PE to further evaluate. I would also like to get an EKG to look for any arrhythmias or ST elevations or depressions. Additionally, I would like to get a chest XR to look for any evidence of pneumonia, pneumothorax, pericardial or pleural effusion, widened mediastinum, or fracture. Given her family history of early cardiac disease I would like to get a troponin. I don’t think that she is having an aortic dissection as she is low risk due to her young age without a history of connective tissue disorders and doesn’t have any of the classic symptoms such as radiation of pain to her back, a difference in her pulses, or associated neurologic, abdominal, or lower extremity symptoms. 

This is just one example. Becoming proficient in the art of communication is a journey, not a destination. The path ahead is challenging, but the rewards are immeasurable. With dedicated effort, you will be well on your way to becoming a medical professional who not only possesses the knowledge to heal but also the communication skills to comfort, inform, and inspire confidence in your patients and colleagues.

Summary:

• The Foundation of Effective Presentations
  • Know Your Audience
  • Organize Your Thoughts
  • Clarity is Key
  • Engage Your Audience
  • Stay Calm Under Pressure
• The Anatomy of an ED Presentation
  • Patient Introduction
  • Presenting Complaint
  • History of Present Illness
  • Vital Signs and Physical Examination
  • Laboratory and Imaging Results If Available
  • Assessment and Plan
• Tips for Success
  • Practice, Practice, Practice
  • Seek Feedback
  • Stay Humble
  • Stay Current