As a hospitalist at an academic center, every morning I listen to my residents present their new admissions. After the age and sex of the patient, more often than not, I am given a list of past medical problems before hearing the patient's chief symptom or the reason for admission. I look around to see if medical students or other residents are paying attention, and often I see in their faces that they are not. When I ask presenters why they tell me the list of past medical problems, most of them say it is because they want their audience to have a good idea of who the patient is.
So who are these patients? Are they just a list of medical problems? My answer is simple: They are people. People with families, jobs, and hobbies. Therefore, “A 54-year-old mother of 5 children who currently works at a local grocery store presents with 2 days of diarrhea” is more interesting than “A 54-year-old female with a past history of hypertension, diabetes, hypothyroidism presents with 2 days of diarrhea.”
As a hospitalist, I believe one of my goals each day is to make sure my residents stay engaged and interested in their patients and in their colleagues' presentations. Thus, I think there are at least 3 reasons why residents should present their patients as people, not past medical problems.
Reason #1. If you set the tone in your mind and for your audience that this patient is a person and not a disease, you provide better care. For example, if a celebrity were to be admitted to your service, naturally you would do your best taking care of him. You would control his pain, communicate well, and make sure he was getting everything he needed. Because you would already know a lot about him, you would feel as if you really knew him as a person. So, why not get to know your patients and make them all famous? This does not mean you need to spend hours with them. Simple questions regarding their occupations, hobbies, and family can help you create a better connection. Furthermore, when you ask them questions that are not medical, your patients may become more comfortable with you, which tends to lead to a more accurate history. So, instead of focusing on all the past medical problems a patient has, you should focus on who they are first.
Reason #2. A good presentation keeps the listeners listening and increases the engagement of residents in the diagnosis and management process during rounds. Most often, when an intern is presenting, the other interns are not listening, thinking instead about their own presentations. How can you blame them? Every presentation sounds the same when it focuses on a list of past medical problems. I myself end up remembering my patients based on their medical problems and not based on who they are. Rounds get boring and monotonous, so what better way to engage your colleagues than to present your patients in an exciting way. I have noticed that the audience gets quite excited when the presenter says there is no medical history. So, let us all assume from the beginning that all these patients do not have a medical history.
Reason #3. Less focus on previous history helps avoid the “past medical history trap.” There are many clinical reasoning errors, but this is a common one—a resident blames a current problem on a past medical problem. For example, if a resident presents a 54-year-old woman with a history of COPD who has been short of breath for 2 days, the audience more often than not would say that this patient has a COPD exacerbation. Past medical problems can overwhelm and cloud beginning learners' assessment of patients. At the outset of a presentation, it's better to focus on the elements of the chief symptom, rather than on past medical problems.
In addition to these 3 reasons, patients are becoming more complicated and carrying many medical problems. To define them as a “complicated medical history” or by some or all of their medical problems dehumanizes them, which I believe leads to poor care and disgruntled residents. So, let us all stop treating our patients like diseases and start treating them like people.