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The Oral Case Presentation: What Internal Medicine Clinician–Teachers

Expect From Clinical Clerks

Article  in  Teaching and Learning in Medicine · January 2011

DOI: 10.1080/10401334.2011.536894 · Source: PubMed

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Expectations for Oral Case Presentations for Clinical Clerks:
Opinions of Internal Medicine Clerkship Directors
Eric H. Green, MD, MSC1, Steven J. Durning, MD2, Linda DeCherrie, MD3, Mark J. Fagan, MD4,
Bradley Sharpe, MD5, and Warren Hershman, MD, MPH6
1
Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; 2Department of Medicine,
Uniformed Services University of the Health Sciences, Bethesda, MD, USA; 3Department of Medicine, Mount Sinai School of Medicine, New
York, NY, USA; 4Department of Medicine, Brown Medical School, Providence, RI, USA; 5Department of Medicine, University of California, San
Francisco, CA, USA; 6Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
BACKGROUND: Little is known about the expectations
of undergraduate internal medicine educators for oral
case presentations (OCPs).
OBJECTIVE: We surveyed undergraduate internal med-
icine educational leaders to determine the degree to
which they share the same expectations for oral case
presentations.
SUBJECTS: Participants were institutional members of
the Clerkship Directors of Internal Medicine (CDIM).
DESIGN: 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.
RESULTS: 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.
CONCLUSIONS: Undergraduate internal medicine edu-
cation leaders from a geographically diverse group of
North American medical schools share common expec-
tations for OCPs which can guide instruction and
evaluation of this skill.
KEY WORDS: education leaders; oral case presentations; clinical clerks.
J Gen Intern Med 24(3):370–3
DOI: 10.1007/s11606-008-0900-x
© Society of General Internal Medicine 2009
This paper was presented in abstract form at the Society of General
Internal Medicine 2008 annual meeting.
Received June 25, 2008
Revised November 6, 2008
Accepted December 16, 2008
Published online January 13, 2009
370
INTRODUCTION
The oral case presentation is one of the primary modes of
physician–physician communication. The importance of
physician–physician communication as an educational goal
for trainees has been recognized by the Clerkship Directors
in Internal Medicine(CDIM),1 the Association of American
Medical Colleges (AAMC),2 the Accreditation Council for Gradu-
ate Medical Education (ACGME),3 as well as other medical
educators.4 A well-done case presentation has the potential to
facilitate patient care, improve efficiency on rounds, direct
individual and group learning to areas of uncertainty, and allow
for student and resident evaluation. However, medical students
are often observed struggling with oral case presentation skills.
In part, their difficulties may reflect the complexity of the
oral presentation.5–7 Educators expect students to engage
clinical reasoning skills to determine which details to select
from the patient’s history, physical, and ancillary study
database while simultaneously utilizing rhetorical skills to
optimize organization and clarity of the presentation.5 Howev-
er, students may also struggle because they have an unclear
understanding of the expectations of their teachers regarding
oral case presentations. In their study of presentations by 12
medical students at the University of California San Francisco,
Haber and Lingard found that clinicians viewed the oral case
presentation as a flexible form of communication whose
content is dictated by the clinical case, context, and audience.
Students, in contrast, perceived the need to apply simplistic
“rules” when creating a presentation and had poor under-
standing about what is “relevant.”5,8
We9,10 and others11,12 have attempted to build on this prior
research and construct frameworks to help students create (and
teachers evaluate) oral case presentations. To date, however, the
foundation for these interventions — a presupposition that
medical educators nationally share common expectations similar
to those described previously at single institutions — has not
been verified. We surveyed undergraduate internal medicine
educational leaders to determine the degree to which they share
the same expectations for oral case presentations.
METHODS
In April 2007, CDIM conducted an annual, voluntary, and
confidential survey of its 110 US and Canadian institutional
members (1 institutional member per medical school). Not all
JGIM Green et al.: Expectations for Oral Case Presentations 371

medical schools have an institutional representative in CDIM. Table 1. Ratings of Aspects of Oral Case Presentations from CDIM
National Survey of Internal Medicine Medical Education Leaders
The 2007 survey included questions addressing demographics
(n=79)
and other questions relating to undergraduate internal medi-
cine education, including 20 questions regarding expectations Item Mean ± SD* Very important
for oral presentations of newly admitted medical inpatients by (percent)**
third year medical students. Specifically, we asked respon-
Organized systematically according 4.85±.36 85%
dents two free response questions: 1) how long (in minutes)
to usual standards
they expected these oral case presentations to be and 2) what Accurately describes of the 4.82±.38 82%
were the three most important elements of the oral case patient’s symptoms
presentation. We then asked about the importance of 18 Identifies a chief complaint 4.76±.54 80%
specific attributes of an oral case presentation, using a 5-point Includes detailed assessment and 4.68±.69 75%
plan for the most important problems
Likert response ranging from not important to very important. (or issues)
We based our list of oral case presentation attributes on a Includes sequence of events that 4.62±.53 66%
prior survey done of teaching physicians,13 a review of the preceded the current hospitalization
literature, our collective experience as medical educators (>80 Includes all pertinent facts that are 4.59±.61 66%
needed to establish the diagnosis
person-years of medical student teaching), and feedback from
Includes a prioritized problem list 4.47±.92 66%
some of the more than 200 participants at workshops on oral Includes a targeted physical 4.54±.68 62%
case presentations that we have conducted at national meet- examination germane to the
ings. We pre-defined elements we thought would be considered patient’s complaint
highly important, highly unimportant, and intermediate, and Structured to guide the listener to the 4.24±.79 43%
same conclusions as the speaker
included a mix of all three elements in our survey. (e.g. “makes a case”)
Our initial proposed survey items were reviewed and Clearly spoken 4.13±.71 30%
modified by members of the CDIM Research Committee. The Uses precise terminology 4.05±.70 23%
survey was then presented to the CDIM Council and further Describes of the impact of the 3.67±1.02 19%
medical illness on the patient
modifications were made. The survey was also pilot-tested by
Excludes all facts that are NOT 3.62±1.04 16%
members of the CDIM Research Committee. CDIM mailed the needed to establish the diagnosis
survey in April 2007, and non-responders were contacted up Includes detailed social history 3.96±1.00 15%
to three additional times through e-mail, regular mail, and/or Includes an assessment and plan 3.41±1.17 13%
for all problems (or issues) addressed,
telephone contact
both major and minor
We conducted our statistical analysis using SPSS (version Includes complete physical 2.76±1.29 10%
12). We generated descriptive statistics and used chi-squared examination
analysis to compare categorical data. This survey was ap- Includes detailed family history 3.00±1.16 8%
proved by the Institutional Review Board at the Uniformed Includes full review of systems 2.47±1.13 5%
Services University of the Health Sciences. * Likert scale of 1–5 ** p<.001 for overall difference of percentage rated
very important

RESULTS
intermediate-to-high value, was only rated “very important” by
Eighty-two of the 110 institutional members (75%) responded
15% of respondents. There was little consensus regarding the
to the survey. In short, the group consisted of full-time,
remainder of the items. A review of the free text responses
experienced faculty members (70% associate or full professor,
regarding important elements of the oral case presentation did
mean age 45) roughly equally distributed between men and
not reveal any new themes.
women (57% men). Most (83%) served as internal medicine
There was great variability in educators’ views of the ideal
clerkship directors, and 18% were deans or vice-chairs (these
length for a student presentation of a newly admitted medical
designations were not mutually exclusive). Seventy-nine of 82
inpatient being presented. The range was 2–20 minutes with a
respondents (95%) completed the questions on oral case
median of 7 minutes. Sixty percent (60%) believed that an oral
presentations.
case presentation should be between 5–9 minutes while 37%
Some aspects of oral case presentations were rated as more
believed that presentations should typically last 10–15 minutes.
important than others (p<.001 for difference among all items).
Eight items, including elements of the history and physical
exam (chief complaint, description of symptoms and sequence
of events prior to hospitalization, inclusion of facts needed to
DISCUSSION
establish diagnosis, targeted physical exam), organization
according to conventional standards, a prioritized problem We surveyed undergraduate internal medical educational
list, and an assessment and plan guided for important leadership to ascertain their opinions regarding what attri-
problems, were rated as very important by >50% of respon- butes are most important for student oral case presentations.
dents (see Table 1). Five items were rated very important by We found that this group of experienced medical student
less than 15%. Most of these items, including obtaining a educators had relatively concordant expectations for oral case
complete review of systems and reporting a complete physical presentations. Specifically, they expected students follow
exam, were identified during the survey design process as commonly accepted standards for organizing the oral case
likely to be of low importance. However, a complete social presentation, relay a complete and accurate history of the
history, which was identified during the design process and present illness, include pertinent details from the remainder of
372 Green et al.: Expectations for Oral Case Presentations
the “clinical database” (history, physical exam, and studies)
and create a prioritized assessment and plan focused on the
most important problems. In contrast, clerkship directors
discounted the need for a complete recitation of family history
or a complete review of systems.
The respondents’ shared expectations reflect the presumed
“goals” of an oral case presentation for both clinical care and
education. Clinically, oral presentations are used to summa-
rize succinctly an extensive evaluation of a patient and thus
emphasize selected, relevant details from the clinical “data-
base.” Educationally, the oral case presentation allows clini-
cian-teachers to assess the progress of learners in becoming
independent clinicians. One common benchmark used to
assess this transformation is the “RIME” model which tracks
students as they progress from “reporters” of data to “inter-
preters” of data in clinical context to “managers” of illness to
“educators” of others regarding the clinical situation.14 In the
“RIME” model, third year medical students are expected to be
consistent “reporters” who are learning data “interpretation”:
their presentations would be expected to include a selected,
accurate clinical data base.
The respondents’ opinions regarding the importance of
the social history or the impact of the illness on the patient
in the oral case presentation needs to be interpreted in
context of earlier research.5 These elements clearly have
greater importance in some scenarios than others. Thus, the
lesser value attributed to these elements may reflect this
understanding of the fluid nature of the presentation rather
than a devaluation of these aspects of the patient’s history.
This concept of flexibility is also seen in the lack of
consensus for the time expected for oral case presentation.
These data suggest that the clinical case/scenario and the
context in which the presentation takes place dictates the
length of an oral case presentation rather than an arbitrary
stopwatch.
Despite the relative homogeneity of respondents’ opinion
there is some variability. Some variation can be explained on
the basis of sample size. However, it is clear that there are still
differences among respondents in some areas. For example,
although most respondents felt that a complete review of
systems was of low importance (mean 2.67), 5% of respondents
believed it was very important. Further research is needed to
best understand whether these differences reflect idiosyncratic
individual expectations or are reflective of differing regional or
other opinions regarding the oral case presentations. Any
broad-based educational intervention designed to improve
education and evaluation of presentation skills will need to
incorporate an understanding of these differences.
Our study had several limitations. Although we obtained
responses from a national sample of educational leadership
within internal medicine, not all US and Canadian medical
schools have institutional representatives in CDIM. Clerkship
directors are among the leaders in undergraduate medical
education; however, their opinions may not be representative
all teaching faculty. Our survey, which was based on our
collective experience individually and from feedback at nation-
al meetings of medical educators may not have included all
potentially important elements of the oral case presentation.
However, our review of free text comments for themes did not
reveal any new elements. We limited our questions to a single
context — the new patient presentation of an internal medicine
core clerk in the inpatient setting — and the expectations for
JGIM
presentations in other contexts may be either different or less
uniform.
Our study also has several important strengths. We sur-
veyed a national audience and achieved a high response rate.
Our questions are based on a mixture of literature review and
extensive educational experience. To date, we are aware of no
similar surveys looking at opinions regarding oral case pre-
sentations on a national scale.
In summary, we found a national group of internal
medicine student educators have similar opinions regarding
the content of the oral case presentation. While others have
examined faculty ratings of oral case presentations,15 their
content,5,8 or specific interventions to improve case presen-
tation skills12,16 each of these studies has been limited to a
single institution and context. If similar concordance is found
in other groups, our data suggest that internal medicine
medical educators could introduce a single consistent strat-
egy for teaching oral case presentations based on a common
understanding of these goals similar to one we have intro-
duced.10 If accepted, this type of model could be used to
guide instruction and evaluation nationally, minimizing var-
iation with and between institutions in this skill and
ultimately enhance patient care.
Acknowledgement: The data used in this report are the property of
CDIM and are used with permission. The authors gratefully
acknowledge the assistance of the CDIM Research Committee in
the preparation, distribution, and management of the survey.
Conflicts of Interest: None disclosed.
Corresponding Author: Eric H. Green, MD, MSC, Montefiore
Medical Center, Primary Care Clinic C 111 E 210th St, Bronx, NY
10467, USA (e-mail: ergreen@montefiore.org).
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