The Art of the Surgical Presentation

Cut to the Chase: General Surgery Survival Series — Post 18

Seventy-one years old, four days out from a hip replacement upstairs, and medicine wants you to look at her belly. You went up, took a real history, the kind you were trained to take, and you're a little proud of it.

You catch your senior between beds, get four sentences in, “she has hypertension and mild dementia at baseline, admitted Tuesday for,” and she cuts you off.

“Is this an obstruction or is she just not moving?”

The presentation you rehearsed in your head dies in your throat.

Almost nobody names this when you cross over from the medicine wards. You think a presentation is the report of what you found. The surgeon hears a request for a decision.

You're showing your work. She's deciding whether to operate, image, decompress, or wait. You keep getting cut off because you are answering a question nobody asked while sitting on the one they did.

A medicine presentation builds. It lays the case down brick by brick and arrives at the assessment somewhere near the end.

The surgical presentation inverts that. It opens with the conclusion already forming and spends the rest of its breath defending it.

So lead with the frame. Your first sentence has to carry who she is, the piece or two of history that matters, and the surgical question you're answering.

“Seventy-one-year-old woman, day four from a hip replacement, distended and hasn't passed gas since surgery, and I'm trying to sort ileus from obstruction.”

Now the surgeon knows how to listen. Everything after that becomes evidence for or against the frame you just set.

Without it, you are handing someone findings and asking them to hold all of them at once until you get to the end.

Your first sentence should answer three things: who, what is wrong, and how sick. Until you've said them, nobody is listening to you. They're waiting.

The history is your next move, and it should read as an argument, not a transcript.

When you say she's had three doses of oxycodone a day since surgery, no flatus since Tuesday, and no prior abdominal operations, you aren't padding. You're closing doors. You've considered the narcotics, you've considered adhesions, and you've told me which one has anything behind it.

The inverse matters just as much. Any detail that doesn't move the diagnosis is something I have to hold onto while I wait for the part that does.

The fact that she vomited twice this morning moves this. Her cholesterol from a physical two years ago does not.

Knowing the difference is most of the skill.

A pertinent negative isn't padding. Say the two or three you actually worked through, and skip the rest of the review of systems.

Your hands are worth more than your numbers here, and say them in that order. Tell me what the belly felt like before you give me the white count.

Soft or rigid. Focal or all over. Did she let you press, or did she grab your wrist.

The exam is the one finding that didn't come off a machine or through a tech, and it is usually the reason we go see her tonight instead of tomorrow.

“Abdomen benign” is a phrase that has quietly preceded more missed diagnoses than anyone would like to count. Say what you found, where, and how she responded.

Tell me what the abdomen felt like before you tell me the labs. Soft or rigid is the finding that decides what time of night I come in.

Then commit. This is where trainees hedge hardest, because saying what you think out loud feels like the moment you can be wrong in front of somebody.

So they retreat into the differential, six diagnoses recited as if breadth were the same as thought. It isn't.

I want two things: what you think it is, and what you'd do about it. “I think this is an ileus and not an obstruction. I'd stop the oxycodone, get a film, keep her NPO, and call you if the film looks like more than that.”

You'll be wrong sometimes. I can fix a wrong read in ten seconds. I can do nothing with a presentation that refuses to land.

Say what you think it is, even when you're about ten percent sure, and say how sure you are. Being wrong out loud costs you ten seconds of correction. Saying nothing costs the patient her evening.

And if one thing you found changes what we do tonight, it goes near the front, said plainly, before it disappears under past history and home meds.

My first year as an attending I called the anesthesiologist in charge at one in the morning to add on a case. I gave it to her in the order it had happened to me: the admission, the CT, the exam at nine, the exam at midnight.

Somewhere past a minute she asked whether he was on pressors. He had been since twelve-thirty.

It was the one fact that decided whether she opened a room now or at six, and I had saved it for last.

She opened the room. I've started that call with the pressor ever since.

None of this is special to a floor consult. The ED, a clinic referral, a curbside in the hallway, same shape every time.

The patient changes. The way you hand them over does not.

So when she cuts you off, don't flinch. It isn't a verdict on your work. It's her telling you she's ready for the part that matters.

Hand her the answer and let the rest follow.

Tomorrow there will be another consult, and you'll get about forty seconds with somebody who is walking. Lead with the sentence. She'll nod and keep walking, and that's the whole thing working.

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What to Read Next: Post 19, “Read a CT Like a Surgeon.” You just committed to an impression and ordered the film. Now learn to read it yourself, so you walk in with your own impression instead of waiting for radiology to tell you whether you were right.