Objectives — Data Synthesis

Explanation: This is an absolutely critical and difficult skill to learn during third year. There are three decisions that you must make. They are:

How sick is the patient? You need to be able to determine the level of illness of a patient. This is a 100% skill. A skill that you must get right all of the time. You will learn strategies for determining level of illness and for figuring out which of the patient's problems is the most urgent. The only way to get good at this is to think about the factors which make an illness or problem more or less severe. You are going to have to make choices about what problems take priority when you write admission/progress notes and give presentations. By the fourth week you should be able to prioritize without the help of the interns and residents.

Differential Diagnosis and/or Complications of a Disease: This seems so intuitive to the attendings and residents that they don't always walk you through it, so ask them questions about their thought process. By the fourth or fifth week, it should be clear if you are thinking about the differential diagnosis by the way that you present the patient.

Prioritized Problem List: What is the first thing that you would tell the attending? By the third week you should be able to come up with good reasons for why items are near the top or bottom of the problem list.

Presentation Templates: Presenting is very important. If you are unsure of what the different presentation types are or what is expected of you, ask the attending. This is a very important skill for the third year because most of what the attendings observe about the students comes by way of oral or written presentation of patients. Very rarely will attendings see your clinical skills and attitudes with the patient, and they will infer how you are doing in the room with the patient based on how well or poorly you talk about the patient outside of the room. During the first two weeks of the rotation, you should learn the three basic templates which are:

Bullet: When the attending doesn't have time or you need to see three patients in five minutes, you should give a bullet presentation. Knowing how to prioritize the patient's problems is very important for this presentation because you will only discuss the most pertinent facts. Writing summaries at the end of each note is a good way to practice for bullet presentations on a patient.

SOAP: A SOAP presentation is divided into four sections, subjective, objective, assessment, and plan. In pediatrics many residents like to do the assessment and plan sections of the SOAP note by organ system. However, you should discuss the systems in order of importance based on the patient's problems. For an asthmatic patient you would start with pulmonary. You can find a good and bad example of a SOAP note here.

Formal: New patients should always be presented in a more formal way, following the structure of the admission note. For tips on writing admission notes, click here.

By the second week, you should be using the correct presentation template 60% of the time. By the third week you should be up to 80%, and by the fourth week you should be at 90%. You can find more tips on presentations here.