How to present on rounds in a structured way

Let's wait a few more minutes for people to join. I hope all is well where you are. I hope you're excited for today. Let me open the chat in case your internet does not allow you to. And I posted the Zoom link, so hopefully more people will show up. In the meantime, if you can share with me, how did it go last week? It was a very heavy— what we talked about last week, how to, um, present challenging news. I'm well, thank you. I'm well, alhamdulillah. So we're doing good. I don't think anybody else has joined just yet. And what we talked about last week was how to present challenging news, heavy news. And I also, just as a teaser to start, I also shared a little bit of an introduction on what we're going to talk about today. Let me check on LinkedIn if there's anybody who's asking a question there. And we're going to make sure Yeah, this is pretty much it. And, ah, Siham is joining. I hope all is well with you. We are just taking a couple more minutes to see if more people join. And in the same time, I was hoping to check in with you and how are you doing since last week conversation. It wasn't the easiest. But this week, hopefully, it'll be a little bit Ashel, it's about how to present patients when you start clinicals. I believe you haven't started clinicals, if I'm understanding correctly. So I'm just going to wait a couple of more minutes. Nothing more. And we can get started since this is all recorded. So what I'm going to try to do today is to discuss how to present if it is just normal. Presentation on the wards or in the intensive care units, and hopefully it'll give you a clear structure. What I am trying to do is I'm trying not to focus on teaching just medicine, but also how to get through the clinicals, because that is The goal of this session. Okay, so let's get it started. Share screen. And please feel free to interact, ask questions. I'm gonna say it again. This is not for me. This is for you. So if you wish to ask questions and make it a little bit more, that's fine too. That's great. Hmm, it's not sharing correctly. Bear with me 1 second, please. Here we go. Excellent. All right, I hope that you can see. So how I want to do this is a structured approach. A lot of times When we start to present, we have a few things that make us anxious. And those few things that make us anxious are mostly because we feel like what is expected from us is to be perfect, is to know everything, is to be very much structured. But unfortunately, we've never done this before, and so it's unrealistic for us to expect that we will know everything the first time. So how can we get started? I don't know about you, but when I am nervous about presenting, once I start speaking, Then it gets easier. And I don't know if that happens to you as well, but it's one of the tricks is to just know how to start. And you have to approach it not like a performance, but as an exercise. Each time you get better. To do it better each time. And when you are presenting, don't focus on how you are performing, focus on how you're thinking. So when you are thinking about it loudly, that's presenting on rounds. No one expects you to have the diagnosis. They just expect you to know how to reason. That's how we are going to think about it. This is not a presentation. This is organizing our thinking. Most presentations fail even when you're thinking right. Either you give too much data but no story. Number 2, there is no summarization. There is no assessment. There's no synthesis. You are just narrating the facts. You are not presenting them in a cohesive way. The third one is you have the plan, but the plan is hiding at the end. So, And, or you wait until the end. And then when you are in the ICU versus when you are on the floor, the session with an emergency room physician, and you saw that the first things to do is your thinking is about stabilizing the patient. Wasn't thinking about solving the problem. If you are in the medical ward, then you are thinking about solving the problem. So, uh, what is the purpose of rounds? Let's start with that. The purpose of rounds is for you to know how to answer 3 questions. How sick is your patient? Why is your patient here? What's your plan to get them out of here? There was a moment where we discussed already the severity. If your presentation answers these 3 questions, then your presentation is you're doing it right. We've spoken about this before, and that is the one-liner. What is a one-liner? A one-liner is when you summarize everything in one line. I'm going to tell you already that this is one of the difficulties that we have as Arab people. As Arabs, we use multiple words to describe one thing. So that's one of the challenges, is how do you become someone who speaks bi tariqa mula khassa, one-liner. And before we get into the one-liner, why is a one-liner So important. Think about yourselves as not as medical students, but as someone who is just living. If you open a video on your phone, if someone is coming to tell you something and you're in a hurry, well, you usually like it when they're not keeping you your attention to them and just tell you what they need to tell you quickly so that you can move on. If the video is in the first 10, 20 seconds able to tell you what the video is about, then you can give them more time of your attention. But if someone keeps talking and keeps talking and keeps talking, it doesn't keep you engaged. At some point, even if you're physically there, your mind is elsewhere. So it's important to just learn to give the most important information in a one-liner. So how do I start? Usually I start with age. One patient who is young is not the same as old. Age, gender, a woman instead of a man, ethnicity. So are they from, you know, the South, the North? I know wherever they come from, they carry with them a clinical context. And if they have any past medical history, someone who has never had any problem is not like someone who had cancer. It's not like somebody who is a smoker. So what is their past medical history? What's the reason they came here? We discussed this before. The reason why they came to the hospital. We sometimes discover something else and we chase it and we forget what they came in the first place. Did you forget that they came because they passed out? And just because now you have a heart attack, you need to follow the heart attack. You need to go back and check if they— that the heart attack was the reason they passed out or there was something else. And then lastly, what is the current trajectory? I will give you an example. I just saw before I came on a patient, and he's short of breath. And the nurse is telling me he was here for a few hours. We had oxygen. We increased the oxygen. His short of breath got better. Then he got worse. We put him on a mask with pressure, and that helped him. But then in the last hour, he's not doing well. And I started to think, okay, this is— is he a smoker? Yes, he is. Okay. Has he ever been in the hospital before? No, he has not. Does he have any cardiac history? No, he doesn't. Is he diabetic? No. Okay. So this is likely to be his smoking affecting him, a COPD exacerbation. But what if the heart as well may be mixed in all of this? So I said maybe there's fluid buildup in his lungs. Can we give him medication to get the fluid off of him. And she told me, that's the fourth part, which is the current trajectory. We gave it to him and he didn't respond. No fluid came out. I said, okay, then there's no reason to give him more. So we know that he might end up being on the ventilator. So we gave him some more medication, steroids and so on. And we are now seeing how the trajectory is moving. The past medical history, the chronic history. Okay, so that's your one-liner. And it's like a muscle, you need to train it. You can't just get it right the first day, you're not going to. Okay, if the patient has been there in the hospital, this is not the first time they come in and you are just rounding every day. Thank you, Muhammad. If you are coming and you are not there every day, then what you do is the 24 hours. You need to do what is the changed management. You have to understand our bodies are not the same night and day. Sometimes some things can get worse at night. If you think about your cortisol level, your endogenous, your internal cortisol level, it actually peaks at 6:00 AM and it goes the lowest around 8:00 PM. This is why most inflammation, most fevers happen during the night. Your own internal anti-inflammatory is low. So what happened overnight? Did they get worse? Did they have— they start to see things and become delirious. You're now starting to think maybe it's Alzheimer's and maybe it's the sundowning, which we see during the night, they become delirious. I'd say the brain chemistry. So there are things overnight that you need to discuss, but they should be selective. If I'm speaking of fever, I need to finish that file. That fever is infection and inflammation. If I'm speaking about delirium, then I'm speaking of the neurological function. If I'm speaking, So you organize your thoughts. You don't just— it's a fever and I had a headache and had this. It's not just narration by chronological order. It has to be organized. So ask yourself, did this event change what we're doing? If the answer is no, it's probably not— doesn't belong in your presentation. Okay. And the second one is explain that instability. If the patient is not doing well, our job is to give it a description. What does not doing well mean? Is the pain worse? Is the patient less responsive? Is the blood pressure less? Is the heart rate more? Is the fever up? So you have to explain the instability. There's a difference between a medical student and a nursing student. Okay? The nurse helps us by giving us the event. We help by explaining the event or organizing the events in our mind by systems. And then the third one is signal trajectory. Have we taken the patient's tube out? Extubation. Have we reduced any medication that supports their blood pressure? Have we reduced the fluids? So, hal tahaya ratil khutal alajia, hal fi tadahwar out hassun, hal fi adams tikrar. And all of this will give you sard etza fasil al muathira, wil ghayl muathira. If it's not going to change your management, ghali ben mathtaj in naktah, to include it. For example, today one of the nurses says, do you think we should do a chest X-ray? I said the patient is already on the ventilator. We already know that there is fluid in the lung. We already put him on medication and we are seeing fluid come out of the lung. So why am I going to radiate the patient just to satisfy my curiosity? There is no need. So if it's not going to change my management, rethink why you would do it or why you would present it. Are we doing good so far? Question so far? Excellent. So there is something else that we start to learn as we get more experience. And you'll start to hear the word pre-rounding. Shuha'il pre-rounding? Maqabla al-rounds, Sometimes what you do is you come before the rounds and you start to train for the rounds. Before I go see the patient, I sit with the file. I have my own templates. It's a piece of paper where I write down all of the information about the patient. So when I'm in front of the patient and I ask and they say their fever went up, I don't have to go back to the file to open it, the chart, in order to see what about their white blood cell count? Did we get the labs back? What about their chest X-ray? If I review all of this before the rounds, when I'm in rounds, I have all the information in front of me so I can answer the questions immediately. Whenever you interrupt your mind, that's not good. It doesn't help you integrate all of that in one thought. So before rounds, you are thinking about the patient like a movie. If you are thinking that there is an unknown son that popped out of nowhere, and now you're starting to think, wait, how come there's a son? What's happened before the son was born? What's happened when this— okay, let's go back to when the hero of our story was just a child or just a young man. Wait, you have shortness of breath. What's happened before the shortness of breath happened? How long has the shortness of breath been? So you think of it as a movie. Okay? You understand the trajectory, not just the current episode. So when you pre-round, you start to look in the chart. You start to— so you're not distracted by the patient. Have the pressures been increasing or decreasing? What is the oxygen level? Have there been other doctors that came I saw your patient last night. What did they say? Let me summarize the notes. Let me summarize their own thoughts and put it all together. And then when I see a lab test today, the WBC for my patient today was 24,000. Okay, I don't know what to do with one number. But if I go and see that the WBC yesterday was 20,000, well, they're worsening. But if the WBC yesterday were 30 and today they're 24, they're improving. Do you see where the framework changes? Changes. So you have to think of it as a trajectory. You can't think of it as just one frame today. Now, sometimes the patient is in front of you, but they're not responsive, or you do not have their chart. They were displaced from another place. They don't have their family, and it's a child. The child is not talking to you. So you just work with what you have, but at least you try. So pre-rounding is looking at the previous events, the previous labs, the previous story. And that's what we call You know, we have, we look at the Tijahat, an al-alamat al-hayawiyya, Abra Zaman, wa anna itahalil min al-muqtabar kaman bin shufli Tijahat ba'a, anna tagheer, yaani, al-oxygen, tagheer, Idrar al-bawli, for example. What is the urine output? Has it dropped? Has it continued the same? Fa al-marid, houwa mushlak tawahda balhouwa film bintab'ou, houlamabenshuf sharlay, binkoun anna, yani, su'al shou ken el tijah, the trend of that which changed. What about the vital signs and the support? I need you to understand and know the context is important. You can't take something out of context. Sure, context. Context was Siyak. Is Siyak aham min ar-raqm hadh datu? So if I gave you a WBC 24,000, but everything else is fine. The heart rate is good. There is no fever. You start to wonder, Hal WBC li an al yum? Correct? Maybe I will send the lab again to repeat it, to confirm it before I take action on it. That's a possibility. There was a time, for example, where when I see the lab, I say, wait, hold on a second. The day before, the potassium was this. And today— yesterday, the potassium was still this. And today it dropped. Why? Maybe when the person was drawing the blood, they were drawing the blood from the same vein where an intravenous line is running with the fluid. So that potassium that we saw was diluted. So I need to repeat it to see, maybe they should take it from the other arm and to get the potassium. And if it is normal, then that's a lab error. If it's not normal, then we are seeing something that I have to take action on. So, the context, okay? So, when presenting vitals, always mention what is the most recent intervention. For example, if I see the patient, the nurse calls me and says, my patient is not doing well, they're breathing with difficulty. Well, I can't take action until I see what's happened. The patient was doing fine yesterday, doing fine last night, doing fine yet this morning, and then all of a sudden they're not fine. What happened? She tells me we took the patient to get an X-ray. Ah, so moving the patient created something that could be the cause of the difficulty breathing now. Did they move a blood clot and now it's lodged somewhere and it's causing a problem? Did they move mucus plugs? Alburgham. Did they move it and that's why they're feeling this way? Maybe the X-ray is not an X-ray. It's a scan and they gave him a contrast and he's allergic to contrast. Maybe that's an allergic reaction. So if you think about it in context, you think about what are the interventions that were done. Did something work? Did something did not work? What is the trend before? To understand in context. So that's what I mean by context. Any questions?

Yes, excuse me, Doctor, how are you?

Ahlan. Good, good. Fadal Muhammad.

I have one question about the previous page. Is it allowed to us as students to take a look for patient diagnosis, or it's just for the head doctor as a student here?

Very good question. Very good question. There is no one single answer, Muhammad. Not one single answer. It depends on the style of teaching of the head doctor. My style is not the same as the style of Maryam, the other head doctor. What she likes is the traditional way of you don't look at the diagnosis, we discuss it, and then we go and find it. That's the way that we tell a story in Arabic culture. We give the suspense and we leave the end, like Shahrazad, we leave the end story. Unfortunately, some other attendings, and I will be honest with you, I am one of them. I am an attending that I don't like to leave you with the suspense because not every place is an exam. Not every place is a test. I like to include you. I will give you the diagnosis today. And say, why is this diagnosis? And no, it's not important for you as a student to know the diagnosis as much as to know how to get to that diagnosis. Okay.

Yeah. Okay. Thank you, doctor.

It depends. You must ask your attending and not assume that everyone is the same. And there are times where I want to test you. There are times where I want to test you, and in that time, I will tell you. Allow me one second. This is, I just need to tell them. I am on the phone with— Okay, then let's go back. So can you see the slide?

Yes, yes.

Excellent. How else can we organize our presentation? We organize the presentation by the vital signs. We organize the presentation by the one-liner. We organize our presentation by the trends. We organize our presentations also by the context, any interventions. We also organize our presentation by systems. If you are starting as a medical student, this, this is what makes most sense. You already know the system, so you can start by saying neurological system. Patient is alert, oriented, and they were able to speak. They were able to speak. They were able to communicate. So mental status. GI. They were vomiting overnight, so they have not eaten in 2 days. We need to establish something to replace because until they stop vomiting, I can't feed them. Maybe you'll look into the cardiovascular. Their blood pressure was high, so we gave them medication. They didn't respond. We switched to the other medication. So now I'm thinking maybe the blood pressure is not a blood pressure issue. It's a pain issue or anxiety. Hematology and infectious disease. They are on antibiotics. Today is number— day number 3, and so on. Okay? Sometimes instead of looking by systems, jihaaz, tanafus, jihaaz al-qalb, jihaaz— and what you can do is you can actually organize it by problems. We call that the problem list. And the problem list means that there is nothing that makes me think you do not know what you're talking about more than just you listing the labs. If you just start listing the labs for me, then you are just acting as a messenger. I'm sorry, I do not need a recorder that I can replay again and again. You are not a messenger. You are a future doctor with a brain with knowledge. So try as much as you can. Try as much as you can. Okay? And then how you interpret those labs and how you synthesize them with the plan. I have low WBC. I have low hemoglobin. That means maybe they are either bleeding, but I see that their hemoglobin has stabilized. Maybe the bleeding has stopped, or I see the hemoglobin has not improved even after we gave them blood. So maybe they are destroying that blood. If they're destroying that blood, is the anemia not hemorrhagic but hemolytic? Hemolysis. So once you start to list the labs but interpret them, it gives you a bit of a context and interpretation, and you can present your pro— the patient's problems. What is the final takeaway? Rounds, they're not about your performance. They're not about you sounding smart. They're not about, you know, getting everything perfect. They are about you and how you think. It's about, um, how you are organizing your brain. And organizing your brain is an exercise. It's not going to get perfect the first time. وِالْشَالَةِنَّا إِنَّوْ. This organization and structure, while be homogeneous, it doesn't have to be rigid. You can change it if the patient comes different than what you are used to. Okay, so structure allows you to have freedom. Because when some things change, you can change the framework. You can change the reasoning. You can change how you integrate and how you interpret all of that. Rigid. You can change it. You can adapt it. And The second thing is when I'm about to present, I start to calm myself down. How? It's not under control. Maybe it is. If you tell yourself, I don't know the patient, I don't know the diagnosis, I don't know the head doctor, but I know me. And I know what I know. And I'm going to trust me. And if I slip and make a mistake, well, I would rather do a mistake now. Give me 1 second. Stop sharing. And I'm gonna mute. So yes, indeed, that was my patient and his oxygen dropped and he was not doing well. My colleague had to put him on a ventilator. So let's summarize what we were talking about. What I want you to know is, I promise you, these are not just words. I say this to my students, interns, and residents. And what I want you to know is We judge ourselves more than other people judge us. Shuma'anatu. If I make a mistake, I am hard on myself a lot more than other people are hard on me. And I have to be kind to myself. This is the first time I'm doing this, so this is the first year I'm doing this. So let other people yell at you. At least don't you yell at you. And just be kind and say, I'm going to take this as information for the next time. This is what I heard yesterday from one of the most successful CEOs is he says failures are not failures. They are information and lessons for how to do it better the next time. And if you frame it this way, whenever you're about to speak, what do you do? There are multiple techniques. The first technique before you start speaking and your heart is pounding and everybody's looking at you and your head doctor is there and they're impatient and they're like, okay, let's see what you do. And you're like, oh, God, like I needed somebody to make me more nervous. At that moment, all I say to myself is, I don't know the head doctor. I don't know these students. I don't know this patient, but I know me. And I've been through tough stuff before, and I can handle it. And if I make a mistake, I'll be kind to myself. And then I start to speak, and then I shift to the next technique, which is once you start to talk, it gets easier to talk more and to talk more, and your heart starts to settle down a little bit. And once you start to speak, then you say, okay, Now that I'm less nervous, let me get organized. Try as best as you can to make decisions before rounds. If I'm going to choose the systems organized presentation, make that decision before you go to rounds. And once you are presenting, don't move from there anymore. You've already made that decision before. If you want to do problem list presentation, make that decision before. Why? Because you're going to prepare yourself before. You're going to rehearse before. I'm going to teach you a secret. Confidence is not born with. It is trained and practiced. You can be taught confidence. It is not something that you're born with, contrary to what people tell you. What does that mean? It means train for rounds before rounds. And yes, That also means go to a mirror and start to see yourself presenting. That also means use your phone to record yourself and play the voice and see. Yes, it's cringe. I don't like to hear myself do that, but do you really want to wait until other people are listening to you to know how you sound? Or do you want to see how you sound before other people do it? Okay? So I promise you, I did this. I went, you know, to this place where I wanted so badly to do my specialty at that hospital. And I wanted them to like me. So every morning I would come an hour before. And I would see my patient and I would write. I didn't just type. I write all of that in a piece of paper so that my hand memory, not just my brain memory. And then I would go to the bathroom and I use the mirror and I start to recite to myself so that on the moment where I'm presenting, the only problem that I have there is the anxiety of performance, not the remembering and the organization and finding the words and all of that. That I already did before. And eventually, after the first few times, it became second nature. But don't try it on the moment because it heightens the chances of you slipping, which then takes away your confidence and makes you feel bad. So that, that's what I would share with you is prepare when you are by yourself so that when you're with others, you are at your best. And if you slip, well, that's, that's, hey, it's okay. So this is a skill, and like any skill, it improves with practice. So start with the framework, be patient with yourself, commit and promise yourself to constantly, intentionally, deliberately improving. And over time, the structured presentation will become just the way you talk. And you'll find that rounds will become less stressful, and actually you'll start to enjoy them. Because once you take away all of these instruments, then you get to the bottom of what rounds are about. And what rounds are about is the exercise of thinking what is the answer to the most important question that your patient can ask you. Doctor, Doctor, what's wrong with me? Any questions? Any comments? How was it? Did it answer any questions? Is there something else that is happening in your life and I'm just like going off on a tangent and I'm not knowing what happens to you as students? Good, thank you. You can react, you can chat, you can come off mute and speak. Excellent, excellent. Good. As usual, I'm going to post these on the LinkedIn page. And is going to be on the academic solidarity with Palestine.com. They will put that on there as well. But the LinkedIn that is made for you, and I'm going to put in the chat. Do you guys have access to that LinkedIn page? I don't like to make assumptions about the internet, about your ability to access things. So I want to ask so I can give you what is useful to you. And not what I think is.

We have actually access to it, but I think it's better to post it in WhatsApp chat. Maybe all of us can give it— take them.

Excellent. I actually do. So I've learned since I started teaching your colleagues, it's my privilege to do that since I started to do that last year. I knew to post it on YouTube, to post it on WhatsApp, and to post it in different places because, uh, your own reality. But I just want to make sure you have access to, to this. Perfect. Thank you so much, Muhammad. Um, what's your comments? Are you nervous about the clinicals? How are things going?

Uh, we actually have the, do the, the last exam, uh, last Saturday, last Tuesday.

Good.

And tomorrow will be the first lectures in the 4th year clinical year, but it's not from the university. It's maybe another doctor that will pass the courses like bridging courses in internal medicine and surgery. But I didn't, I didn't think all of us register in this course because it's paying. But we will keep going on this from tomorrow until one month after, inshallah.

The transition, uh, and clinicals. I will make it relevant to what you have, inshallah. Um, and This is my privilege. Please tell your friends. I will post something about Research and publications. I do this. I will start a project and I want to ask all of you. I will post it in WhatsApp. I will post it as a poll so that people can answer it. And whomever is interested, I will create a smaller group. And no, I can't— not everybody is interested in research, but those that are interested, um, interested in research. So I created another group. Training will practice how to start with research, how to create the question, how to design the research project, how to do a literature research, and then how to start creating the manuscript, and then how to publish the manuscript. Fa hada habib armilu different interested in research. Ifar, please tell me. Don't hesitate to ask anything. If I can't do it, I will find somebody who can do it.