As a clinical teacher, have you come across the Court Reporter approach in medical student and resident presentations?
These learners, when asked to present the case history of the patient they have just seen, drop into Court Reporter mode. They faithfully regurgitate their list of symptoms, findings and patient statements, sometimes verbatim. They are accurate and detailed. Yet, they lack the ability to draw inferences or conclusions from these findings. It is almost like they don’t see it as their job: that is for the litigants to do, “not me as the mere Court Reporter”.
Even if you prompt them to summarize or to create a problem list or a differential diagnosis, they still tend to revert to stating their findings.
If you find yourself dealing with this Court Reporter phenomenon in your student, we suggest the following approach: Reverse Presentations. This is easy to implement, even on-the-fly, in your teaching clinic. You can also implement this post hoc i.e. after the student has seen the patient and you find them in full-flight Court Reporter mode.
- The student sees the patient as usual, with a focus (as usual) on relevant history and examination.
- The student presents their findings, dropping as usual into Court Reporter mode.
- Tell them to stop.
- Tell them about the Reverse Presentation approach
- Send them off for five minutes to get their thoughts in order and prepare
- Invite them back and evaluate their Reverse Presentation
- Explore their line of reasoning as to why their conclusions were justified by the history and findings
The student has to do the following in their Reverse Presentation:
- Start at the end and work back to the beginning. i.e. start with their conclusions
- The conclusion is a concise statement of problems or possible diagnoses. They must commit.
- It can be helpful to emphasize that you want to hear first “the most likely diagnosis”, not “the most serious diagnosis”.
- State the findings that support this concluding statement.
This has been remarkably effective in our experience. But there are some caveats and context to make it most effective.
a. This works best with undifferentiated presentations which require some diagnostic skill
b. It is pointless for simple procedural visits e.g. a blood pressure check or medication follow up
c. For learners who have good synthesis skills, it is not really needed. They think this way anyway.
d. There is a risk in over-emphasizing this approach as it can lead to premature closure, jumping to conclusions etc.
It is not always easy to find undifferentiated presentations on a given day in clinic. For this reason, we have created a series of virtual patients that we use for students to practise this technique. This can be a good use of their time, rather than simply checking another blood pressure. We will be publishing an article on the use of virtual patients for Reverse Presentations in the near future.
But try it out. The approach is easy to implement and can be fun to do.