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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 (<.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.
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 Graduate 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 However, 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 understanding 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.
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 medical schools have an institutional representative in CDIM. The 2007 survey included questions addressing demographics and other questions relating to undergraduate internal medicine education, including 20 questions regarding expectations for oral presentations of newly admitted medical inpatients by third year medical students. Specifically, we asked respondents two free response questions: 1) how long (in minutes) they expected these oral case presentations to be and 2) what were the three most important elements of the oral case presentation. We then asked about the importance of 18 specific attributes of an oral case presentation, using a 5-point Likert response ranging from not important to very important.
We based our list of oral case presentation attributes on a prior survey done of teaching physicians,13 a review of the literature, our collective experience as medical educators (>80 person-years of medical student teaching), and feedback from some of the more than 200 participants at workshops on oral case presentations that we have conducted at national meetings. We pre-defined elements we thought would be considered highly important, highly unimportant, and intermediate, and included a mix of all three elements in our survey.
Our initial proposed survey items were reviewed and modified by members of the CDIM Research Committee. The survey was then presented to the CDIM Council and further modifications were made. The survey was also pilot-tested by members of the CDIM Research Committee. CDIM mailed the survey in April 2007, and non-responders were contacted up to three additional times through e-mail, regular mail, and/or telephone contact
We conducted our statistical analysis using SPSS (version 12). We generated descriptive statistics and used chi-squared analysis to compare categorical data. This survey was approved by the Institutional Review Board at the Uniformed Services University of the Health Sciences.
Eighty-two of the 110 institutional members (75%) responded to the survey. In short, the group consisted of full-time, experienced faculty members (70% associate or full professor, mean age 45) roughly equally distributed between men and women (57% men). Most (83%) served as internal medicine clerkship directors, and 18% were deans or vice-chairs (these designations were not mutually exclusive). Seventy-nine of 82 respondents (95%) completed the questions on oral case presentations.
Some aspects of oral case presentations were rated as more important than others (<.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 establish diagnosis, targeted physical exam), organization according to conventional standards, a prioritized problem list, and an assessment and plan guided for important problems, were rated as very important by >50% of respondents (see Table 1). Five items were rated very important by less than 15%. Most of these items, including obtaining a complete review of systems and reporting a complete physical exam, were identified during the survey design process as likely to be of low importance. However, a complete social history, which was identified during the design process and intermediate-to-high value, was only rated “very important” by 15% of respondents. There was little consensus regarding the remainder of the items. A review of the free text responses regarding important elements of the oral case presentation did not reveal any new themes.
There was great variability in educators’ views of the ideal length for a student presentation of a newly admitted medical inpatient being presented. The range was 2–20 minutes with a median of 7 minutes. Sixty percent (60%) believed that an oral case presentation should be between 5–9 minutes while 37% believed that presentations should typically last 10–15 minutes.
We surveyed undergraduate internal medical educational leadership to ascertain their opinions regarding what attributes are most important for student oral case presentations. We found that this group of experienced medical student educators had relatively concordant expectations for oral case presentations. Specifically, they expected students follow commonly accepted standards for organizing the oral case presentation, relay a complete and accurate history of the present illness, include pertinent details from the remainder of 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 summarize succinctly an extensive evaluation of a patient and thus emphasize selected, relevant details from the clinical “database.” Educationally, the oral case presentation allows clinician-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 “interpreters” 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 national 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 presentations in other contexts may be either different or less uniform.
Our study also has several important strengths. We surveyed 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 presentations 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 presentation 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 strategy for teaching oral case presentations based on a common understanding of these goals similar to one we have introduced.10 If accepted, this type of model could be used to guide instruction and evaluation nationally, minimizing variation with and between institutions in this skill and ultimately enhance patient care.
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.
This paper was presented in abstract form at the Society of General Internal Medicine 2008 annual meeting.