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On Patient Presentations

emily fu

Patient presentations are a strange sort of voyeurism. Though they resemble medical interviews in many ways — the history-taking, the assessment of emotional state and physical function — what was once a private interaction becomes a public play. What was once a conversation intended to benefit the patient becomes a performance to satisfy the curiosity of so many medical students.

When given the microphone, patients wax poetic about their conditions. Family histories become sagas, symptoms become stories. The patients know the deal: they’ve been selected by their physicians for both their exemplary diseases and their eloquence, so they come prepared with metaphors and morbid humor. One patient jokes that he loves ordering carbidopa/levodopa at the pharmacy: it has such a nice ring to it. Another refers his seizure disorder as “one hell of a halftime show.”

His use of the phrase is sadly accurate. At my school, high-yield lectures are the main events while patient presentations seem like intermissions. They are often preceded by a mass exodus from the auditorium. Before the patient takes the stage, many students will already have fled to their study rooms to make flashcards, catch up on lectures, and do extracurricular work. I too have skipped presentations and it’s not something I’m proud of. After all, I was drawn to caregiving by patients’ stories, not their biochemical anomalies.

Testing and lecture notes aside, I will always remember certain patients: the old man who told us that that siblings of those with Huntington’s disease often have survivor’s guilt, the minister whose encephalitis put an end to his sermon readings, the toddler who played hide and seek in our lecture hall while her father discussed their family history of BRCA gene mutation.

Presentations like these reveal the hidden sequelae of disease: crippling medical bills, failed relationships, psychological trauma. They remind us that employers discriminate against chronic illness, that that the truly tireless caregivers are spouses and parents and children, and that doctors are not always the heroes of these stories. If well-performed, presentations like these teach us the importance of humanistic medical practice.

But a well-performed presentation relies on a huge number of hypotheticals. If the patient feels that they can speak freely, without fear of judgment from the doctor on whom they rely for continued care. And if there is a clear understanding of what the patient is willing or unwilling to share. And if the interviewing doctor is careful to highlight the patient’s story rather than appropriating it. Only if these and many other conditions of respect, humility, and patient autonomy are fulfilled can a patient presentation serve its purpose.

Given all these preconditions, it’s easy for a patient presentation to be disrespectful of the patient in question. In these forums, the power imbalance already inherent in the doctor-patient relationship becomes even more precarious. When the patient’s best interests are no longer the focus of the conversation, the presentation runs the risk of becoming a spectacle or a cross-examination. The patient is pushed to address uncomfortable subjects or presented as an example of a disease instead of an individual with a disease.

Two months ago, my school hosted our only mandatory patient presentation as part of the brain sciences unit. That day, the lecture hall was filled to capacity for the first time in weeks. At the front of the hall stood a woman playing an oboe.

This was our patient, Mrs. X, and she was performing a solo — something by Bach, I think — to show that the massive frontal lobe meningioma she’d had removed two years ago hadn’t destroyed her musical ability. It was a stunning performance; Mrs. X was a better oboist than most of the neurotypical musicians I’d met.

The frontal lobe damage caused by the tumor and its excision had, however, resulted in other deficits. Mrs. X described these bravely and with clarity. Formerly introverted and mild-mannered, she’d become outgoing and short-tempered. She tired easily and was more distractible.

Because of her lack of focus, she referenced a written script while speaking. She began her presentation by saying, “You’ll see that I use a lot of notes, and that has to do with my fabulous MRI.” At another point, when her answer to a question had gone off on a tangent, she stopped herself and told us, “I’m supposed to stick to the script, sorry, this is a Frontal Lobe Syndrome moment.”

At first her use of a script was innocuous, even admirable — the coping strategy of a patient with more self-awareness than executive function. But when it was revealed that the text was co-authored by the patient’s neuropsychiatrist, the presentation took on a disconcerting quality. It began to show all the power imbalances inherent in a public doctor-patient interview.

At one point, Mrs. X was asked to describe her interactions with the medical community. She told us about how she’d gone to the ER after having a post-operative seizure. There, she was given a prescription for anticonvulsants and a referral to a neurologist. At the time, she still didn’t have the capacity to realize the urgency of following up on her care. If her family had been told, they would have helped her keep track of her meds and appointments — but they weren’t, and she cited this as an example of sloppy caregiving.

Mrs. X was still elaborating on her story when she was interrupted. Her neuropsychiatrist, sitting next to her at the front of the lecture hall, called her over. The doctor whispered something in her ear, after which she returned to her podium and explained, “Okay, sorry I’ll stick to my dutifully prepared script,” before moving on to the next topic.

At another point she protested, “You don’t even know what’s on here — how do you know I’m following the script?” Later, the neuropsychiatrist explained, “We actually spent many sessions writing up this presentation … she worked really hard on being able to answer these questions.” I wondered what that meant. Who had more control over the script? Did the neuropsychiatrist have veto power over its contents?

The patient certainly didn’t. The most disturbing part of the interview occurred when the neuropsychiatrist asked if Mrs. X would be willing to describe a recent lapse in her judgment. Mrs. X responded with, “This is something I really didn’t want to talk about.” This was followed by a long, awkward pause during which she glared at her neuropsychiatrist, who looked expectantly back at her. Finally, Mrs. X turned back to us and elaborated: she’d put off replacing her car tires even though they were dangerously worn.

The neuropsychiatrist pointed out that they’d “spent a few sessions on this topic and the therapeutic intervention was to avoid driving on the highway so if she blew out a tire she wouldn’t kill anyone … and that made her very angry and she did not comply.”

The neuropsychiatrist cited this as an example of frontal lobe syndrome behavioral disinhibition that was important for us as medical providers to recognize. She called it a situation in which Mrs. X “lost her temper and acted out negatively,” as if the patient were a child throwing a temper tantrum.

What I saw was a situation in which a doctor revealed a personal issue that the patient didn’t want discussed. After the story was told and the lesson learned, Mrs. X seemed betrayed.

“We talked about not bringing up that mortifying example,” she said.

The neuropsychiatrist retorted, “Well, ­you talked about it…”

“[I talked about it] with you, personally.”

Mrs. X and I were not the only people disconcerted by this dialogue; after it took place, there was a murmur of unease among my classmates. Something had shifted in the tone of the event and it had lost the buoyant goodwill with which it had begun. It had become educational in a way that none of us had expected — it brought to our attention the ethical pitfalls of the presentations that had previously seemed so wonderfully humanistic.

Mrs. X’s presentation was the most obvious example of a disrespectful doctor-patient interaction, but other presentations had struck their own false notes. In one session, a physician began with “I want to tell [the patient’s] story” and proceeded to talk for a full 30 minutes before allowing the patient to get a word in. In another, a neurologist asked permission to show us a patient’s mini-mental exam results and then proceeded to display them even though she responded with, “I’ll be mortified if you do.” During one of the most dismal presentations, a woman broke down into tears while discussing her experience with chemotherapy. The doctor, the other patients on stage and my entire class shared a long awkward silence before continuing with the presentation.

These other presentations were attended, discussed and lost in a torrent of other events and exams. But Mrs. X’s talk was the one that moved my class and prompted a small group of students to send a letter to our Office of Medical Education. The letter specifically addressed violations of patient privacy.

“We have had presentations in which physicians have shared or elicited personal information without the patient’s permission,” it read. “In some of these cases the patient explicitly demonstrated disapproval with these disclosures, and at other times they exhibited visible or verbal discomfort.”

The letter requested that faculty “formally address the issue with lecturers” and prompted a meeting with several faculty members, who said that at least one of the presenting physicians had garnered complaints in previous years. Although they had relayed students’ comments to her, the physician kept coming back with the same patient and scripted presentation.

Faculty members decided that presenters might be more receptive to critique from staff than from students and said they would write a guide for presenting physicians. Eight months later, the first draft of this guide is in the works.

It is unclear when the guide will be finalized and given to lecturers. These interoffice communiqués are a mystery to me, yet another example of how medical education changes — or does not change — under the subtle and inscrutable influences of student feedback, technological advancement, social norms, social progress and institutionalism. I don’t know what the contents of the guide will be or how it will be distributed but I’m not overly optimistic.

Protocols for protecting patients’ time, privacy and autonomy are important. But they cannot ultimately ensure that each presenting patient will be treated with nothing but respect. Just as there are doctors who are singularly careful in their interactions, there will always be doctors who — intentionally or unintentionally — dismiss their patients’ narratives or reveal their personal information.

We medical students will encounter any variety of these doctors in our training and future practice. Despite my limited clinical experience, I have already seen many interactions in which patients are treated with extraordinary kindness or shocking contempt. Sometimes the same physician is capable of both.

By recognizing the consideration — or lack of it — in doctor-patient interactions, we can learn how to practice care and avoid the missteps that these physicians present us with. Watching physicians speak with their patients in a public forum should teach us how to interview people in a way that shows respect for their needs, desires and autonomy.

Of course I hope, for the patients’ sake, that a set of patient presentation guidelines will be enacted and followed to the letter. No patient deserves to have their privacy violated or their opinions dismissed, and especially not those who have devoted so much effort to sharing their stories with us.

Beyond that, I hope that when a patient is disrespected or dismissed in this strangely public forum, it does not go unnoticed. These moments of unease may not be as obvious as the overwhelming number of medical facts that comprise each presentation, but I hope they prompt thought and discussion and indignation. Because if we as students learn how to critique a doctor-patient interaction and improve our own communication accordingly, we will have learned the most important skill these patient presentations have to teach us: how to treat people.

Emily Fu Emily Fu (1 Posts)


Warren Alpert Medical School

Emily is a medical student, crossword fiend, and backpacker. She likes reading poetry, cleaning her bicycle, and talking about medical education. Email her! She'd love to chat.