How to Survive a Case Presentation

From Chest 88(2):292, August, 1985.

Since the dawn of modern medical education nearly two thousand years ago, students [1] of medicine have been faced with the delicate and unenviable task of collecting patient information and presenting it to their clinical mentors. History records that the first case presentation occurred in the year 174 AD when a 12-year-old intern roused Galen at 2:00 AM vith the report of a slothful innkeeper who was choking on the jawbone of an ass. Galen correctly diagnosed an acute phlegmatic incarceration based on the history alone, hence the sanctity of the medical history, and dispatched the lad with the appropriate treatment. [2] Practitioners soon began priding themselves on their ability to arrive at diagnoses by reason alone, without the need of patients. [3] As the knowledge of disease and pathophysiology grew, so did the number of questions one could ask about a patient's case. As noted by Pimph (the h is silent) in his treatise on the case presentation, "Whether or not my questions have anything to do with the patient's disease is irrelevant." [4] Pimph's doctrine was quickly adopted by most prestigious medical schools, and the era of rounding on patients was soon at hand. [5]

Thus began the long history of having to contend with finding an appropriate response to the inquiries of overzealous, egotistical, and shortsighted professors. Being pimphed, as it came to be called, was a dreaded fear of all medical students, compelling them to stay up nights studying instead of attending the needs of their spouses. An example of the far-reaching implications of this difficult lifestyle can be found in a famous case of adultery that was widely publicized in the nineteenth century. [6] It was inevitable, however, that this system would eventually break down, and reports began to appear in the medical literature of omissions and frank fabrications in the presentation of patient information. [7] These practices went unchecked for years until the publication of Quibble's monumental study on the psychology of case presentations and the institutional hierarchy established therein (Table l). [8] As a result of Quibble's work, pimphing became less fashionable, although it is still rumored to be practiced somewhere in New England.

Managing Case Presentations

According to Taube, the solution lies with a technique originally used in the field of education (personal communication, 1979). [10] In order to validate Taube's hypothesis, I have spent the last few years collecting information on well over four million case presentations. An initial review of the material suggested that many faltering presentations were, in fact, salvaged by the use of the clinical excuse (Bennett, unpublished doodling). In order to determine which excuses work best, the data was subjected to a detailed computer analysis using high bias tape. The results of this investigation are presented in Table 2.

Conclusion

Figure 1. The Organization of Case Presentations. Note how the "O" can be used in either approach, but will only solve the clinical problem using the Peeve system.

Table 1. Quibble's Classification of Case Presenters.

The Medical Student	Presents too much information, only half of which is relevant, and does not know what any of it means.
The Intern	Obtains most of the information and probably knows what most of it means, but falls asleep presenting it.
The Resident	Presents all of the information and knows what most of it means, but prefers arguing about the night call schedule.
The Chief Resident	Obtains all the information and knows what all of it means, but is too busy making out schedules to present it.
The Research Professor	Has forgotten what a case presentation is, but will find a reference on it and get back to you.
The Clinical Professor	Could obtain all of the information if he wanted to, but prefers to have others do it for him. Yes, he knows what all of it means, too.
The Chief of Medicine	Does not have time for case presentations. He is too busy editing the definitive text on differential diagnosis.

Table 2. The Utilization of the Clinical Excuse to Save Your Academic Behind -- and Future. (Table slightly edited from the original version).

Type of Information Missing from Case	Suggested Response	% Success	Alternative Response	% Success
History of the present illness	The patient argued that all history, by definition, is in the past.	58	The patient only speaks English.	74
Past medical history	The patient said he has aphasia.	82	The patient said to get his old chart. (He might as well have aphasia.)	79
Family history	The patient is adopted.	47	The patient suspects a history of anthrax.	88
Physical exam	The findings are equivocal; you'll check again after vacation.	38	The area in question is either missing or congenitally absent, you're not sure which.	53
Lab data	The test is only run on the 5th Tuesday of the month.	59	The patient exsanguinated while waiting for the phlebotomy team.	37
Consultant's report	Rounds went overtime; the patient was transferred to their service.	61	Your pet turtle ate it.	99

References

2. Galen. The use of an abdominal thrust to relieve acute phlegmatic incarceration: a case report. J Anachronisms 174 AD 20:188.

3. At least without having to see them. I think they still had to pay a consultant's fee or something.

4. Pimph DI. Bearing down on students for the perfect case presentation: a by-product of early toilet training. J Med Dogma 1646; 4:516.

5. Originally described by Grille (a student of Pimph's) as the 'Age of Rounds.' Grille was instrumental in the development of morning rounds, attending rounds, sign-out rounds, and, of course, ground round.

6. Shyster B, Goose M. Goldilocks and the three milkmen: a study of legal infidelity. Thyme Magazine, April 4, 1878.

7. Fallopian T. A third trimester pregnancy misdiagnosed as ascites due to the misrepresentation of a patient's sex by an intern. Arch Uterus 1896; 9:326.

8. Quibble D. Who follows the chief into the bathroom? A time-motion study of hospital rounds. Pedestal 1924; 44:128.

9. Peeve L. Three cheers for a new approach to the case presentation. Phosphate Q 1976; 16:123.

10. Taube overheard a third-grader tell his teacher that he did not have his English homework because his parakeet had eaten it the night before.