clinical presentation meaning in medical

Clinical Presentation

Clinical considerations for care of children and adults with confirmed COVID-19

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• The clinical presentation of COVID-19 ranges from asymptomatic to critical illness.
• An infected person can transmit SARS-CoV-2, the virus that causes COVID-19, before the onset of symptoms. Symptoms can change over the course of illness and can progress in severity.
• Uncommon presentations of COVID-19 can occur, might vary by the age of the patient, and are a challenge to recognize.
• In adults, age is the strongest risk factor for severe COVID-19. The risk of severe COVID-19 increases with increasing age especially for persons over 65 years and with increasing number of certain underlying medical conditions .

Incubation Period

Data suggest that incubation periods may differ by SARS-CoV-2 variant. Meta-analyses of studies published in 2020 identified a pooled mean incubation period of 6.5 days from exposure to symptom onset. (1) A study conducted during high levels of Delta variant transmission reported an incubation period of 4.3 days, (2) and studies performed during high levels of Omicron variant transmission reported a median incubation period of 3–4 days. (3,4)

Presentation

People with COVID-19 may be asymptomatic or may commonly experience one or more of the following symptoms (not a comprehensive list) (5) :

• Fever or chills
• Shortness of breath or difficulty breathing
• Myalgia (Muscle or body aches)
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting

The clinical presentation of COVID-19 ranges from asymptomatic to severe illness, and COVID-19 symptoms may change over the course of illness. COVID-19 symptoms can be difficult to differentiate from and can overlap with other viral respiratory illnesses such as influenza(flu) and respiratory syncytial virus (RSV) . Because symptoms may progress quickly, close follow-up is needed, especially for:

• older adults
• people with disabilities
• people with immunocompromising conditions, and
• people with medical conditions that place them at greater risk for severe illness or death.

The NIH COVID-19 Treatment Guidelines  group SARS-CoV-2 infection into five categories based on severity of illness:

• Asymptomatic or pre-symptomatic infection : people who test positive for SARS-CoV-2 using a virologic test (i.e., a nucleic acid amplification test [NAAT] or an antigen test) but who have no symptoms that are consistent with COVID-19.
• Mild illness : people who may have any of the various signs and symptoms of COVID-19 but who do not have shortness of breath, dyspnea, or abnormal chest imaging.
• Moderate illness : people who have evidence of lower respiratory disease during clinical assessment or imaging and who have an oxygen saturation (SpO 2 ) ≥94% on room air at sea level.
• Severe illness : people who have oxygen saturation <94% on room air at sea level, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO 2 /FiO 2 ) <300 mm Hg, a respiratory rate >30 breaths/min, or lung infiltrates >50%
• Critical illness : people who have respiratory failure, septic shock, or multiple organ dysfunction.

Asymptomatic and presymptomatic presentation

Studies have documented SARS-CoV-2 infection in people who never develop symptoms (asymptomatic presentation) and in people who are asymptomatic when tested but develop symptoms later (presymptomatic presentation). ( 6,7 ) It is unclear what percentage of people who initially appear asymptomatic progress to clinical disease.   Multiple publications have reported cases of people with abnormalities on chest imaging that are consistent with COVID-19 very early in the course of illness, even before the onset of symptoms or a positive COVID-19 test. (9)

Radiographic Considerations and Findings

Chest radiographs of patients with severe COVID-19 may demonstrate bilateral air-space consolidation. (23)  Chest computed tomography (CT) images from patients with COVID-19 may demonstrate bilateral, peripheral ground glass opacities and consolidation. (24,25)  Less common CT findings can include intra- or interlobular septal thickening with ground glass opacities (hazy opacity) or focal and rounded areas of ground glass opacity surrounded by a ring or arc of denser consolidation (reverse halo sign). (24)

Multiple studies suggest that abnormalities on CT or chest radiograph may be present in people who are asymptomatic, pre-symptomatic, or before RT-PCR detection of SARS-CoV-2 RNA in nasopharyngeal specimens. (25)

Common COVID-19 symptoms

Fever, cough, shortness of breath, fatigue, headache, and myalgia are among the most commonly reported symptoms in people with COVID-19. (5) Some people with COVID-19 have gastrointestinal symptoms such as nausea, vomiting, or diarrhea, sometimes prior to having fever or lower respiratory tract signs and symptoms. (10) Loss of smell and taste can occur, although these symptoms are reported to be less common since Omicron began circulating, as compared to earlier during the COVID-19 pandemic. (11,19-21) People can experience SARS-CoV-2 infection (asymptomatic or symptomatic), even if they are up to date with their COVID-19 vaccines or were previously infected. (8)

Several studies have reported ocular symptoms associated with SARS-CoV-2 infection, including redness, tearing, dry eye or foreign body sensation, discharge or increased secretions, and eye itching or pain. (13)

A wide range of dermatologic manifestations have been associated with COVID-19; timing of skin manifestations in relation to other COVID-19 symptoms and signs is variable. (14) Some skin manifestations may be associated with increased disease severity. (15) Images of cutaneous findings in COVID-19 are available from the American Academy of Dermatology .

Uncommon COVID-19 symptoms

Less common presentations of COVID-19 can occur. Older adults may present with different symptoms than children and younger adults. Some older adults can experience SARS-CoV-2 infection accompanied by delirium, falls, reduced mobility or generalized weakness, and glycemic changes. ( 12)

Transmission

People infected with SARS-CoV-2 can transmit the virus even if they are asymptomatic or presymptomatic. ( 16) Peak transmissibility appears to occur early during the infectious period (prior to symptom onset until a few days after), but infected persons can shed infectious virus up to 10 days following infection. (22 ) Both vaccinated and unvaccinated people can transmit SARS-CoV-2. ( 17,18) Clinicians should consider encouraging all people to take the following prevention actions to limit SARS-CoV-2 transmission:

• stay up to date with COVID-19 vaccines,
• test for COVID-19 when symptomatic or exposed to someone with COVID-19, as recommended by CDC,
• wear a high-quality mask  when recommended,
• avoiding contact with individuals who have suspected or confirmed COVID-19,
• improving ventilation when possible,
• and follow basic health and hand hygiene guidance .

Clinicians should also recommend that people who are infected with SARS-CoV-2, follow CDC guidelines  for isolation.

Table of Contents

• › Clinical Presentation
• Clinical Progression, Management, and Treatment
• Special Clinical Considerations
• Bhaskaran K, Bacon S, Evans SJ, et al. Factors associated with deaths due to COVID-19 versus other causes: population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform. Lancet Reg Health Eur. Jul 2021;6:100109. doi:10.1016/j.lanepe.2021.100109
• Kim L, Garg S, O'Halloran A, et al. Risk Factors for Intensive Care Unit Admission and In-hospital Mortality among Hospitalized Adults Identified through the U.S. Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization Surveillance Network (COVID-NET). Clin Infect Dis. Jul 16 2020;doi:10.1093/cid/ciaa1012
• Kompaniyets L, Pennington AF, Goodman AB, et al. Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020-March 2021. Preventing chronic disease. Jul 1 2021;18:E66. doi:10.5888/pcd18.210123
• Ko JY, Danielson ML, Town M, et al. Risk Factors for COVID-19-associated hospitalization: COVID-19-Associated Hospitalization Surveillance Network and Behavioral Risk Factor Surveillance System. Clin Infect Dis. Sep 18 2020;doi:10.1093/cid/ciaa1419
• Wortham JM, Lee JT, Althomsons S, et al. Characteristics of Persons Who Died with COVID-19 - United States, February 12-May 18, 2020. MMWR Morb Mortal Wkly Rep. Jul 17 2020;69(28):923-929. doi:10.15585/mmwr.mm6928e1
• Yang X, Zhang J, Chen S, et al. Demographic Disparities in Clinical Outcomes of COVID-19: Data From a Statewide Cohort in South Carolina. Open Forum Infect Dis. Sep 2021;8(9):ofab428. doi:10.1093/ofid/ofab428
• Rader B.; Gertz AL, D.; Gilmer, M.; Wronski, L.; Astley, C.; Sewalk, K.; Varrelman, T.; Cohen, J.; Parikh, R.; Reese, H.; Reed, C.; Brownstein J. Use of At-Home COVID-19 Tests — United States, August 23, 2021–March 12, 2022. MMWR Morb Mortal Wkly Rep. April 1, 2022;71(13):489–494. doi:http://dx.doi.org/10.15585/mmwr.mm7113e1
• Pingali C, Meghani M, Razzaghi H, et al. COVID-19 Vaccination Coverage Among Insured Persons Aged >/=16 Years, by Race/Ethnicity and Other Selected Characteristics - Eight Integrated Health Care Organizations, United States, December 14, 2020-May 15, 2021. MMWR Morb Mortal Wkly Rep. Jul 16 2021;70(28):985-990. doi:10.15585/mmwr.mm7028a1
• Wiltz JL, Feehan AK, Molinari NM, et al. Racial and Ethnic Disparities in Receipt of Medications for Treatment of COVID-19 - United States, March 2020-August 2021. MMWR Morb Mortal Wkly Rep. Jan 21 2022;71(3):96-102. doi:10.15585/mmwr.mm7103e1
• Murthy NC, Zell E, Fast HE, et al. Disparities in First Dose COVID-19 Vaccination Coverage among Children 5-11 Years of Age, United States. Emerg Infect Dis. May 2022;28(5):986-989. doi:10.3201/eid2805.220166
• Saelee R, Zell E, Murthy BP, et al. Disparities in COVID-19 Vaccination Coverage Between Urban and Rural Counties - United States, December 14, 2020-January 31, 2022. MMWR Morb Mortal Wkly Rep. Mar 4 2022;71(9):335-340. doi:10.15585/mmwr.mm7109a2
• Burki TK. The role of antiviral treatment in the COVID-19 pandemic. Lancet Respir Med. Feb 2022;10(2):e18. doi:10.1016/S2213-2600(22)00011-X
• Jayk Bernal A, Gomes da Silva MM, Musungaie DB, et al. Molnupiravir for Oral Treatment of Covid-19 in Nonhospitalized Patients. N Engl J Med. Feb 10 2022;386(6):509-520. doi:10.1056/NEJMoa2116044
• Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. Dec 17 2020;383(25):2477-2478. doi:10.1056/NEJMc2029240
• Jordan TB, Meyers CL, Schrading WA, Donnelly JP. The utility of iPhone oximetry apps: A comparison with standard pulse oximetry measurement in the emergency department. Am J Emerg Med. May 2020;38(5):925-928. doi:10.1016/j.ajem.2019.07.020
• Iuliano AD, Brunkard JM, Boehmer TK, et al. Trends in Disease Severity and Health Care Utilization During the Early Omicron Variant Period Compared with Previous SARS-CoV-2 High Transmission Periods - United States, December 2020-January 2022. MMWR Morb Mortal Wkly Rep. Jan 28 2022;71(4):146-152. doi:10.15585/mmwr.mm7104e4
• Taylor CA, Whitaker M, Anglin O, et al. COVID-19-Associated Hospitalizations Among Adults During SARS-CoV-2 Delta and Omicron Variant Predominance, by Race/Ethnicity and Vaccination Status - COVID-NET, 14 States, July 2021-January 2022. MMWR Morb Mortal Wkly Rep. Mar 25 2022;71(12):466-473. doi:10.15585/mmwr.mm7112e2
• Johnson AG, Amin AB, Ali AR, et al. COVID-19 Incidence and Death Rates Among Unvaccinated and Fully Vaccinated Adults with and Without Booster Doses During Periods of Delta and Omicron Variant Emergence - 25 U.S. Jurisdictions, April 4-December 25, 2021. MMWR Morb Mortal Wkly Rep. Jan 28 2022;71(4):132-138. doi:10.15585/mmwr.mm7104e2
• Danza P, Koo TH, Haddix M, et al. SARS-CoV-2 Infection and Hospitalization Among Adults Aged >/=18 Years, by Vaccination Status, Before and During SARS-CoV-2 B.1.1.529 (Omicron) Variant Predominance - Los Angeles County, California, November 7, 2021-January 8, 2022. MMWR Morb Mortal Wkly Rep. Feb 4 2022;71(5):177-181. doi:10.15585/mmwr.mm7105e1

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Overview and General Information about Oral Presentation

• Daily Presentations During Work Rounds
• The New Patient Presentation
• The Holdover Admission Presentation
• Outpatient Clinic Presentations
• The structure of presentations varies from service to service (e.g. medicine vs. surgery), amongst subspecialties, and between environments (inpatient vs. outpatient). Applying the correct style to the right setting requires that the presenter seek guidance from the listeners at the outset.
• Time available for presenting is rather short, which makes the experience more stressful.
• Individual supervisors (residents, faculty) often have their own (sometimes quirky) preferences regarding presentation styles, adding another layer of variability that the presenter has to manage.
• Students are evaluated/judged on the way in which they present, with faculty using this as one way of gauging a student’s clinical knowledge.
• Done well, presentations promote efficient, excellent care. Done poorly, they promote tedium, low morale, and inefficiency.

General Tips:

• Practice, Practice, Practice! Do this on your own, with colleagues, and/or with anyone who will listen (and offer helpful commentary) before you actually present in front of other clinicians. Speaking "on-the-fly" is difficult, as rapidly organizing and delivering information in a clear and concise fashion is not a naturally occurring skill.
• Immediately following your presentations, seek feedback from your listeners. Ask for specifics about what was done well and what could have been done better – always with an eye towards gaining information that you can apply to improve your performance the next time.
• Listen to presentations that are done well – ask yourself, “Why was it good?” Then try to incorporate those elements into your own presentations.
• Listen to presentations that go poorly – identify the specific things that made it ineffective and avoid those pitfalls when you present.
• Effective presentations require that you have thought through the case beforehand and understand the rationale for your conclusions and plan. This, in turn, requires that you have a good grasp of physiology, pathology, clinical reasoning and decision-making - pushing you to read, pay attention, and in general acquire more knowledge.
• Think about the clinical situation in which you are presenting so that you can provide a summary that is consistent with the expectations of your audience. Work rounds, for example, are clearly different from conferences and therefore mandate a different style of presentation.
• Presentations are the way in which we tell medical stories to one another. When you present, ask yourself if you’ve described the story in an accurate way. Will the listener be able to “see” the patient the same way that you do? Can they come to the correct conclusions? If not, re-calibrate.
• It's O.K. to use notes, though the oral presentation should not simply be reduced to reading the admission note – rather, it requires appropriate editing/shortening.
• In general, try to give your presentations on a particular service using the same order and style for each patient, every day. Following a specific format makes it easier for the listener to follow, as they know what’s coming and when they can expect to hear particular information. Additionally, following a standardized approach makes it easier for you to stay organized, develop a rhythm, and lessens the chance that you’ll omit elements.

Specific types of presentations

There are a number of common presentation-types, each with its own goals and formats. These include:

• Daily presentations during work rounds for patients known to a service.
• Newly admitted patients, where you were the clinician that performed the H&P.
• Newly admitted patients that were “handed off” to the team in the morning, such that the H&P was performed by others.
• Outpatient clinic presentations, covering several common situations.

Key elements of each presentation type are described below. Examples of how these would be applied to most situations are provided in italics. The formats are typical of presentations done for internal medicine services and clinics.

Note that there is an acceptable range of how oral presentations can be delivered. Ultimately, your goal is to tell the correct story, in a reasonable amount of time, so that the right care can be delivered. Nuances in the order of presentation, what to include, what to omit, etc. are relatively small points. Don’t let the pursuit of these elements distract you or create undue anxiety.

Daily presentations during work rounds of patients that you’re following:

• Organize the presenter (forces you to think things through)
• Inform the listener(s) of 24 hour events and plan moving forward
• Promote focused discussion amongst your listeners and supervisors
• Opportunity to reassess plan, adjust as indicated
• Demonstrate your knowledge and engagement in the care of the patient
• Rapid (5 min) presentation of the key facts

Key features of presentation:

• Opening one liner: Describe who the patient is, number of days in hospital, and their main clinical issue(s).
• 24-hour events: Highlighting changes in clinical status, procedures, consults, etc.
• Subjective sense from the patient about how they’re feeling, vital signs (ranges), and key physical exam findings (highlighting changes)
• Relevant labs (highlighting changes) and imaging
• Assessment and Plan : Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.

Example of a daily presentation for a patient known to a team:

• Opening one liner: This is Mr. Smith, a 65 year old man, Hospital Day #3, being treated for right leg cellulitis
• MRI of the leg, negative for osteomyelitis
• Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf, draining a moderate amount of pus
• Patient appears well, states leg is feeling better, less painful
• T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-160s/70-80s; O2 sat 98% Room Air
• Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
• Right lower extremity redness now limited to calf, well within inked lines – improved compared with yesterday; bandage removed from the I&D site, and base had small amount of purulence; No evidence of fluctuance or undrained infection.
• Creatinine .8, down from 1.5 yesterday
• WBC 8.7, down from 14
• Blood cultures from admission still negative
• Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture pending
• MRI lower extremity as noted above – negative for osteomyelitis
• Continue Vancomycin for today
• Ortho to reassess I&D site, though looks good
• Follow-up on cultures: if MRSA, will transition to PO Doxycycline; if MSSA, will use PO Dicloxacillin
• Given AKI, will continue to hold ace-inhibitor; will likely wait until outpatient follow-up to restart
• Add back amlodipine 5mg/d today
• Hep lock IV as no need for more IVF
• Continue to hold ace-I as above
• Wound care teaching with RNs today – wife capable and willing to assist. She’ll be in this afternoon.
• Set up follow-up with PMD to reassess wound and cellulitis within 1 week

The Brand New Patient (admitted by you)

• Provide enough information so that the listeners can understand the presentation and generate an appropriate differential diagnosis.
• Present a thoughtful assessment
• Present diagnostic and therapeutic plans
• Provide opportunities for senior listeners to intervene and offer input
• Chief concern: Reason why patient presented to hospital (symptom/event and key past history in one sentence). It often includes a limited listing of their other medical conditions (e.g. diabetes, hypertension, etc.) if these elements might contribute to the reason for admission.
• The history is presented highlighting the relevant events in chronological order.
• 7 days ago, the patient began to notice vague shortness of breath.
• 5 days ago, the breathlessness worsened and they developed a cough productive of green sputum.
• 3 days ago his short of breath worsened to the point where he was winded after walking up a flight of stairs, accompanied by a vague right sided chest pain that was more pronounced with inspiration.
• Enough historical information has to be provided so that the listener can understand the reasons that lead to admission and be able to draw appropriate clinical conclusions.
• Past history that helps to shed light on the current presentation are included towards the end of the HPI and not presented later as “PMH.” This is because knowing this “past” history is actually critical to understanding the current complaint. For example, past cardiac catheterization findings and/or interventions should be presented during the HPI for a patient presenting with chest pain.
• Where relevant, the patient's baseline functional status is described, allowing the listener to understand the degree of impairment caused by the acute medical problem(s).
• It should be explicitly stated if a patient is a poor historian, confused or simply unaware of all the details related to their illness. Historical information obtained from family, friends, etc. should be described as such.
• Review of Systems (ROS): Pertinent positive and negative findings discovered during a review of systems are generally incorporated at the end of the HPI. The listener needs this information to help them put the story in appropriate perspective. Any positive responses to a more inclusive ROS that covers all of the other various organ systems are then noted. If the ROS is completely negative, it is generally acceptable to simply state, "ROS negative.”
• Other Past Medical and Surgical History (PMH/PSH): Past history that relates to the issues that lead to admission are typically mentioned in the HPI and do not have to be repeated here. That said, selective redundancy (i.e. if it’s really important) is OK. Other PMH/PSH are presented here if relevant to the current issues and/or likely to affect the patient’s hospitalization in some way. Unrelated PMH and PSH can be omitted (e.g. if the patient had their gall bladder removed 10y ago and this has no bearing on the admission, then it would be appropriate to leave it out). If the listener really wants to know peripheral details, they can read the admission note, ask the patient themselves, or inquire at the end of the presentation.
• Medications and Allergies: Typically all meds are described, as there’s high potential for adverse reactions or drug-drug interactions.
• Family History: Emphasis is placed on the identification of illnesses within the family (particularly among first degree relatives) that are known to be genetically based and therefore potentially heritable by the patient. This would include: coronary artery disease, diabetes, certain cancers and autoimmune disorders, etc. If the family history is non-contributory, it’s fine to say so.
• Social History, Habits, other → as relates to/informs the presentation or hospitalization. Includes education, work, exposures, hobbies, smoking, alcohol or other substance use/abuse.
• Sexual history if it relates to the active problems.
• Vital signs and relevant findings (or their absence) are provided. As your team develops trust in your ability to identify and report on key problems, it may become acceptable to say “Vital signs stable.”
• Note: Some listeners expect students (and other junior clinicians) to describe what they find in every organ system and will not allow the presenter to say “normal.” The only way to know what to include or omit is to ask beforehand.
• Key labs and imaging: Abnormal findings are highlighted as well as changes from baseline.
• Summary, assessment & plan(s) Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• The assessment and plan typically concludes by mentioning appropriate prophylactic considerations (e.g. DVT prevention), code status and disposition.
• Chief Concern: Mr. H is a 50 year old male with AIDS, on HAART, with preserved CD4 count and undetectable viral load, who presents for the evaluation of fever, chills and a cough over the past 7 days.
• Until 1 week ago, he had been quite active, walking up to 2 miles a day without feeling short of breath.
• Approximately 1 week ago, he began to feel dyspneic with moderate activity.
• 3 days ago, he began to develop subjective fevers and chills along with a cough productive of red-green sputum.
• 1 day ago, he was breathless after walking up a single flight of stairs and spent most of the last 24 hours in bed.
• Diagnosed with HIV in 2000, done as a screening test when found to have gonococcal urethritis
• Was not treated with HAART at that time due to concomitant alcohol abuse and non-adherence.
• Diagnosed and treated for PJP pneumonia 2006
• Diagnosed and treated for CMV retinitis 2007
• Became sober in 2008, at which time interested in HAART. Started on Atripla, a combination pill containing: Efavirenz, Tonofovir, and Emtricitabine. He’s taken it ever since, with no adverse effects or issues with adherence. Receives care thru Dr. Smiley at the University HIV clinic.
• CD4 count 3 months ago was 400 and viral load was undetectable.
• He is homosexual though he is currently not sexually active. He has never used intravenous drugs.
• He has no history of asthma, COPD or chronic cardiac or pulmonary condition. No known liver disease. Hepatitis B and C negative. His current problem seems different to him then his past episode of PJP.
• Review of systems: negative for headache, photophobia, stiff neck, focal weakness, chest pain, abdominal pain, diarrhea, nausea, vomiting, urinary symptoms, leg swelling, or other complaints.
• Hypertension x 5 years, no other known vascular disease
• Gonorrhea as above
• Alcohol abuse above and now sober – no known liver disease
• No relevant surgeries
• Atripla, 1 po qd
• Omeprazole 20 mg, 1 PO, qd
• Lisinopril 20mg, qd
• Naprosyn 250 mg, 1-2, PO, BID PRN
• No allergies
• Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2 brothers, one 45 and the other 55, who are also healthy. There is no family history of heart disease or cancer.
• Patient works as an accountant for a large firm in San Diego. He lives alone in an apartment in the city.
• Smokes 1 pack of cigarettes per day and has done so for 20 years.
• No current alcohol use. Denies any drug use.
• Sexual History as noted above; has sex exclusively with men, last partner 6 months ago.
• Seated on a gurney in the ER, breathing through a face-mask oxygen delivery system. Breathing was labored and accessory muscles were in use. Able to speak in brief sentences, limited by shortness of breath
• Vital signs: Temp 102 F, Pulse 90, BP 150/90, Respiratory Rate 26, O2 Sat (on 40% Face Mask) 95%
• HEENT: No thrush, No adenopathy
• Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Dullness to percussion was also appreciated at the right base.
• Cardiac: JVP less than 5 cm; Rhythm was regular. Normal S1 and S2. No murmurs or extra heart sounds noted.
• Abdomen and Genital exams: normal
• Extremities: No clubbing, cyanosis or edema; distal pulses 2+ and equal bilaterally.
• Skin: no eruptions noted.
• Neurological exam: normal
• WBC 18 thousand with 10% bands;
• Normal Chem 7 and LFTs.
• Room air blood gas: pH of 7.47/ PO2 of 55/PCO2 of 30.
• Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci.
• CXR remarkable for dense right lower lobe infiltrate without effusion.
• Monitored care unit, with vigilance for clinical deterioration.
• Hypertension: given significant pneumonia and unclear clinical direction, will hold lisinopril. If BP > 180 and or if clear not developing sepsis, will consider restarting.
• Low molecular weight heparin
• Code Status: Wishes to be full code full care, including intubation and ICU stay if necessary. Has good quality of life and hopes to return to that functional level. Wishes to reconsider if situation ever becomes hopeless. Older brother Tom is surrogate decision maker if the patient can’t speak for himself. Tom lives in San Diego and we have his contact info. He is aware that patient is in the hospital and plans on visiting later today or tomorrow.
• Expected duration of hospitalization unclear – will know more based on response to treatment over next 24 hours.

The holdover admission (presenting data that was generated by other physicians)

• Handoff admissions are very common and present unique challenges
• Understand the reasons why the patient was admitted
• Review key history, exam, imaging and labs to assure that they support the working diagnostic and therapeutic plans
• Does the data support the working diagnosis?
• Do the planned tests and consults make sense?
• What else should be considered (both diagnostically and therapeutically)?
• This process requires that the accepting team thoughtfully review their colleagues efforts with a critical eye – which is not disrespectful but rather constitutes one of the main jobs of the accepting team and is a cornerstone of good care *Note: At some point during the day (likely not during rounds), the team will need to verify all of the data directly with the patient.
• 8-10 minutes
• Chief concern: Reason for admission (symptom and/or event)
• Temporally presented bullets of events leading up to the admission
• Review of systems
• Relevant PMH/PSH – historical information that might affect the patient during their hospitalization.
• Meds and Allergies
• Family and Social History – focusing on information that helps to inform the current presentation.
• Habits and exposures
• Physical exam, imaging and labs that were obtained in the Emergency Department
• Assessment and plan that were generated in the Emergency Department.
• Overnight events (i.e. what happened in the Emergency Dept. and after the patient went to their hospital room)? Responses to treatments, changes in symptoms?
• How does the patient feel this morning? Key exam findings this morning (if seen)? Morning labs (if available)?
• Assessment and Plan , with attention as to whether there needs to be any changes in the working differential or treatment plan. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by confusion. He was brought in by his daughter, who felt that her father was no longer able to safely take care for himself.
• 10 days ago, Mr. X developed left shoulder pain, first noted a few days after lifting heavy boxes. He denies falls or direct injury to the shoulder.
• 1 week ago, presented to outside hospital ER for evaluation of left shoulder pain. Records from there were notable for his being afebrile with stable vitals. Exam notable for focal pain anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of motion. Left shoulder reported as diminished range of motion but not otherwise quantified. X-ray negative. Labs remarkable for wbc 8, creat 2.2 (stable). Impression was that the pain was of musculoskeletal origin. Patient was provided with Percocet and told to see PMD in f/u
• Brought to our ER last night by his daughter. Pain in shoulder worse. Also noted to be confused and unable to care for self. Lives alone in the country, home in disarray, no food.
• ROS: negative for falls, prior joint or musculoskeletal problems, fevers, chills, cough, sob, chest pain, head ache, abdominal pain, urinary or bowel symptoms, substance abuse
• Hypertension
• Coronary artery disease, s/p LAD stent for angina 3 y ago, no symptoms since. Normal EF by echo 2 y ago
• Chronic kidney disease stage 3 with creatinine 1.8; felt to be secondary to atherosclerosis and hypertension
• aspirin 81mg qd, atorvastatin 80mg po qd, amlodipine 10 po qd, Prozac 20
• Allergies: none
• Family and Social: lives alone in a rural area of the county, in contact with children every month or so. Retired several years ago from work as truck driver. Otherwise non-contributory.
• Habits: denies alcohol or other drug use.
• Temp 98 Pulse 110 BP 100/70
• Drowsy though arousable; oriented to year but not day or date; knows he’s at a hospital for evaluation of shoulder pain, but doesn’t know the name of the hospital or city
• CV: regular rate and rhythm; normal s1 and s2; no murmurs or extra heart sounds.
• Left shoulder with generalized swelling, warmth and darker coloration compared with Right; generalized pain on palpation, very limited passive or active range of motion in all directions due to pain. Right shoulder appearance and exam normal.
• CXR: normal
• EKG: sr 100; nl intervals, no acute changes
• WBC 13; hemoglobin 14
• Na 134, k 4.6; creat 2.8 (1.8 baseline 4 m ago); bicarb 24
• LFTs and UA normal
• Vancomycin and Zosyn for now
• Orthopedics to see asap to aspirate shoulder for definitive diagnosis
• If aspiration is consistent with infection, will need to go to Operating Room for wash out.
• Urine electrolytes
• Follow-up on creatinine and obtain renal ultrasound if not improved
• Renal dosing of meds
• Strict Ins and Outs.
• follow exam
• obtain additional input from family to assure baseline is, in fact, normal
• Since admission (6 hours) no change in shoulder pain
• This morning, pleasant, easily distracted; knows he’s in the hospital, but not date or year
• T Current 101F Pulse 100 BP 140/80
• Ins and Outs: IVF Normal Saline 3L/Urine output 1.5 liters
• L shoulder with obvious swelling and warmth compared with right; no skin breaks; pain limits any active or passive range of motion to less than 10 degrees in all directions
• Labs this morning remarkable for WBC 10 (from 13), creatinine 2 (down from 2.8)
• Continue with Vancomycin and Zosyn for now
• I already paged Orthopedics this morning, who are en route for aspiration of shoulder, fluid for gram stain, cell count, culture
• If aspirate consistent with infection, then likely to the OR
• Continue IVF at 125/h, follow I/O
• Repeat creatinine later today
• Not on any nephrotoxins, meds renaly dosed
• Continue antibiotics, evaluation for primary source as above
• Discuss with family this morning to establish baseline; possible may have underlying dementia as well
• SC Heparin for DVT prophylaxis
• Code status: full code/full care.

Outpatient-based presentations

There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of which has its own presentation style and purpose. These include the following, each described in detail below.

• The patient who is presenting for their first visit to a primary care clinic and is entirely new to the physician.
• The patient who is returning to primary care for a scheduled follow-up visit.
• The patient who is presenting with an acute problem to a primary care clinic
• The specialty clinic evaluation (new or follow-up)

It’s worth noting that Primary care clinics (Internal Medicine, Family Medicine and Pediatrics) typically take responsibility for covering all of the patient’s issues, though the amount of energy focused on any one topic will depend on the time available, acuity, symptoms, and whether that issue is also followed by a specialty clinic.

The Brand New Primary Care Patient

Purpose of the presentation

• Accurately review all of the patient’s history as well as any new concerns that they might have.
• Identify health related problems that need additional evaluation and/or treatment
• Provide an opportunity for senior listeners to intervene and offer input

Key features of the presentation

• If this is truly their first visit, then one of the main reasons is typically to "establish care" with a new doctor.
• It might well include continuation of therapies and/or evaluations started elsewhere.
• If the patient has other specific goals (medications, referrals, etc.), then this should be stated as well. Note: There may well not be a "chief complaint."
• For a new patient, this is an opportunity to highlight the main issues that might be troubling/bothering them.
• This can include chronic disorders (e.g. diabetes, congestive heart failure, etc.) which cause ongoing symptoms (shortness of breath) and/or generate daily data (finger stick glucoses) that should be discussed.
• Sometimes, there are no specific areas that the patient wishes to discuss up-front.
• Review of systems (ROS): This is typically comprehensive, covering all organ systems. If the patient is known to have certain illnesses (e.g. diabetes), then the ROS should include the search for disorders with high prevalence (e.g. vascular disease). There should also be some consideration for including questions that are epidemiologically appropriate (e.g. based on age and sex).
• Past Medical History (PMH): All known medical conditions (in particular those requiring ongoing treatment) are listed, noting their duration and time of onset. If a condition is followed by a specialist or co-managed with other clinicians, this should be noted as well. If a problem was described in detail during the “acute” history, it doesn’t have to be re-stated here.
• Past Surgical History (PSH): All surgeries, along with the year when they were performed
• Medications and allergies: All meds, including dosage, frequency and over-the-counter preparations. Allergies (and the type of reaction) should be described.
• Social: Work, hobbies, exposures.
• Sexual activity – may include type of activity, number and sex of partner(s), partner’s health.
• Smoking, Alcohol, other drug use: including quantification of consumption, duration of use.
• Family history: Focus on heritable illness amongst first degree relatives. May also include whether patient married, in a relationship, children (and their ages).
• Physical Exam: Vital signs and relevant findings (or their absence).
• Key labs and imaging if they’re available. Also when and where they were obtained.
• Summary, assessment & plan(s) presented by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic. This typically concludes with a “health care maintenance” section, which covers age, sex and risk factor appropriate vaccinations and screening tests.

The Follow-up Visit to a Primary Care Clinic

• Organize the presenter (forces you to think things through).
• Accurately review any relevant interval health care events that might have occurred since the last visit.
• Identification of new symptoms or health related issues that might need additional evaluation and/or treatment
• If the patient has no concerns, then verification that health status is stable
• Review of medications
• Provide an opportunity for listeners to intervene and offer input
• Reason for the visit: Follow-up for whatever the patient’s main issues are, as well as stating when the last visit occurred *Note: There may well not be a “chief complaint,” as patients followed in continuity at any clinic may simply be returning for a visit as directed by their doctor.
• Events since the last visit: This might include emergency room visits, input from other clinicians/specialists, changes in medications, new symptoms, etc.
• Review of Systems (ROS): Depth depends on patient’s risk factors and known illnesses. If the patient has diabetes, then a vascular ROS would be done. On the other hand, if the patient is young and healthy, the ROS could be rather cursory.
• PMH, PSH, Social, Family, Habits are all OMITTED. This is because these facts are already known to the listener and actionable aspects have presumably been added to the problem list (presented at the end). That said, these elements can be restated if the patient has a new symptom or issue related to a historical problem has emerged.
• MEDS : A good idea to review these at every visit.
• Physical exam: Vital signs and pertinent findings (or absence there of) are mentioned.
• Lab and Imaging: The reason why these were done should be mentioned and any key findings mentioned, highlighting changes from baseline.
• Assessment and Plan: This is most clearly done by individually stating all of the conditions/problems that are being addressed (e.g. hypertension, hypothyroidism, depression, etc.) followed by their specific plan(s). If a new or acute issue was identified during the visit, the diagnostic and therapeutic plan for that concern should be described.

The Focused Visit to a Primary Care Clinic

• Accurately review the historical events that lead the patient to make the appointment.
• Identification of risk factors and/or other underlying medical conditions that might affect the diagnostic or therapeutic approach to the new symptom or concern.
• Generate an appropriate assessment and plan
• Allow the listener to comment

Key features of the presentation:

• Reason for the visit
• History of Present illness: Description of the sequence of symptoms and/or events that lead to the patient’s current condition.
• Review of Systems: To an appropriate depth that will allow the listener to grasp the full range of diagnostic possibilities that relate to the presenting problem.
• PMH and PSH: Stating only those elements that might relate to the presenting symptoms/issues.
• PE: Vital signs and key findings (or lack thereof)
• Labs and imaging (if done)
• Assessment and Plan: This is usually very focused and relates directly to the main presenting symptom(s) or issues.

The Specialty Clinic Visit

Specialty clinic visits focus on the health care domains covered by those physicians. For example, Cardiology clinics are interested in cardiovascular disease related symptoms, events, labs, imaging and procedures. Orthopedics clinics will focus on musculoskeletal symptoms, events, imaging and procedures. Information that is unrelated to these disciples will typically be omitted. It’s always a good idea to ask the supervising physician for guidance as to what’s expected to be covered in a particular clinic environment.

• Highlight the reason(s) for the visit
• Review key data
• Provide an opportunity for the listener(s) to comment
• 5-7 minutes
• If it’s a consult, state the main reason(s) that the patient was referred as well as who referred them.
• If it’s a return visit, state the reasons why the patient is being followed in the clinic and when the last visit took place
• If it’s for an acute issue, state up front what the issue is Note: There may well not be a “chief complaint,” as patients followed in continuity in any clinic may simply be returning for a return visit as directed
• For a new patient, this highlights the main things that might be troubling/bothering the patient.
• For a specialty clinic, the history presented typically relates to the symptoms and/or events that are pertinent to that area of care.
• Review of systems , focusing on those elements relevant to that clinic. For a cardiology patient, this will highlight a vascular ROS.
• PMH/PSH that helps to inform the current presentation (e.g. past cardiac catheterization findings/interventions for a patient with chest pain) and/or is otherwise felt to be relevant to that clinic environment.
• Meds and allergies: Typically all meds are described, as there is always the potential for adverse drug interactions.
• Social/Habits/other: as relates to/informs the presentation and/or is relevant to that clinic
• Family history: Focus is on heritable illness amongst first degree relatives
• Physical Exam: VS and relevant findings (or their absence)
• Key labs, imaging: For a cardiology clinic patient, this would include echos, catheterizations, coronary interventions, etc.
• Summary, assessment & plan(s) by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic.
• Reason for visit: Patient is a 67 year old male presenting for first office visit after admission for STEMI. He was referred by Dr. Goins, his PMD.
• The patient initially presented to the ER 4 weeks ago with acute CP that started 1 hour prior to his coming in. He was found to be in the midst of a STEMI with ST elevations across the precordial leads.
• Taken urgently to cath, where 95% proximal LAD lesion was stented
• EF preserved by Echo; Peak troponin 10
• In-hospital labs were remarkable for normal cbc, chem; LDL 170, hdl 42, nl lfts
• Uncomplicated hospital course, sent home after 3 days.
• Since home, he states that he feels great.
• Denies chest pain, sob, doe, pnd, edema, or other symptoms.
• No symptoms of stroke or TIA.
• No history of leg or calf pain with ambulation.
• Prior to this admission, he had a history of hypertension which was treated with lisinopril
• 40 pk yr smoking history, quit during hospitalization
• No known prior CAD or vascular disease elsewhere. No known diabetes, no family history of vascular disease; He thinks his cholesterol was always “a little high” but doesn’t know the numbers and was never treated with meds.
• History of depression, well treated with prozac
• Discharge meds included: aspirin, metoprolol 50 bid, lisinopril 10, atorvastatin 80, Plavix; in addition he takes Prozac for depression
• Taking all of them as directed.
• Patient lives with his wife; they have 2 grown children who are no longer at home
• Works as a computer programmer
• Smoking as above
• ETOH: 1 glass of wine w/dinner
• No drug use
• No known history of cardiovascular disease among 2 siblings or parents.
• Well appearing; BP 130/80, Pulse 80 regular, 97% sat on Room Air, weight 175lbs, BMI 32
• Lungs: clear to auscultation
• CV: s1 s2 no s3 s4 murmur
• No carotid bruits
• ABD: no masses
• Ext; no edema; distal pulses 2+
• Cath from 4 weeks ago: R dominant; 95% proximal LAD; 40% Cx.
• EF by TTE 1 day post PCI with mild Anterior Hypokinesis, EF 55%, no valvular disease, moderate LVH
• Labs of note from the hospital following cath: hgb 14, plt 240; creat 1, k 4.2, lfts normal, glucose 100, LDL 170, HDL 42.
• EKG today: SR at 78; nl intervals; nl axis; normal r wave progression, no q waves
• Plan: aspirin 81 indefinitely, Plavix x 1y
• Given nitroglycerine sublingual to have at home.
• Reviewed symptoms that would indicate another MI and what to do if occurred
• Plan: continue with current dosages of meds
• Chem 7 today to check k, creatinine
• Plan: Continue atorvastatin 80mg for life
• Smoking cessation: Doing well since discharge without adjuvant treatments, aware of supports.
• Plan: AAA screening ultrasound

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• Published: 13 November 2020

Clinical presentations, laboratory and radiological findings, and treatments for 11,028 COVID-19 patients: a systematic review and meta-analysis

• Carlos K. H. Wong 1 , 2   na1 ,
• Janet Y. H. Wong 3   na1 ,
• Eric H. M. Tang 1 ,
• C. H. Au 1 &
• Abraham K. C. Wai 4  

Scientific Reports volume  10 , Article number:  19765 ( 2020 ) Cite this article

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This systematic review and meta-analysis investigated the comorbidities, symptoms, clinical characteristics and treatment of COVID-19 patients. Epidemiological studies published in 2020 (from January–March) on the clinical presentation, laboratory findings and treatments of COVID-19 patients were identified from PubMed/MEDLINE and Embase databases. Studies published in English by 27th March, 2020 with original data were included. Primary outcomes included comorbidities of COVID-19 patients, their symptoms presented on hospital admission, laboratory results, radiological outcomes, and pharmacological and in-patient treatments. 76 studies were included in this meta-analysis, accounting for a total of 11,028 COVID-19 patients in multiple countries. A random-effects model was used to aggregate estimates across eligible studies and produce meta-analytic estimates. The most common comorbidities were hypertension (18.1%, 95% CI 15.4–20.8%). The most frequently identified symptoms were fever (72.4%, 95% CI 67.2–77.7%) and cough (55.5%, 95% CI 50.7–60.3%). For pharmacological treatment, 63.9% (95% CI 52.5–75.3%), 62.4% (95% CI 47.9–76.8%) and 29.7% (95% CI 21.8–37.6%) of patients were given antibiotics, antiviral, and corticosteroid, respectively. Notably, 62.6% (95% CI 39.9–85.4%) and 20.2% (95% CI 14.6–25.9%) of in-patients received oxygen therapy and non-invasive mechanical ventilation, respectively. This meta-analysis informed healthcare providers about the timely status of characteristics and treatments of COVID-19 patients across different countries.

PROSPERO Registration Number: CRD42020176589

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Introduction.

Following the possible patient zero of coronavirus infection identified in early December 2019 1 , the Coronavirus Disease 2019 (COVID-19) has been recognized as a pandemic in mid-March 2020 2 , after the increasing global attention to the exponential growth of confirmed cases 3 . As on 29th March, 2020, around 690 thousand persons were confirmed infected, affecting 199 countries and territories around the world, in addition to 2 international conveyances: the Diamond Princess cruise ship harbored in Yokohama, Japan, and the Holland America's MS Zaandam cruise ship. Overall, more than 32 thousand died and about 146 thousand have recovered 4 .

A novel bat-origin virus, 2019 novel coronavirus, was identified by means of deep sequencing analysis. SARS-CoV-2 was closely related (with 88% identity) to two bat-derived severe acute respiratory syndrome (SARS)-like coronaviruses, bat-SL-CoVZC45 and bat-SL-CoVZXC21, but were more distant from SARS-CoV (about 79%) and MERS-CoV (about 50%) 5 , both of which were respectively responsible for two zoonotic human coronavirus epidemics in the early twenty-first century. Following a few initial human infections 6 , the disease could easily be transmitted to a substantial number of individuals with increased social gathering 7 and population mobility during holidays in December and January 8 . An early report has described its high infectivity 9 even before the infected becomes symptomatic 10 . These natural and social factors have potentially influenced the general progression and trajectory of the COVID-19 epidemiology.

By the end of March 2020, there have been approximately 3000 reports about COVID-19 11 . The number of COVID-19-related reports keeps growing everyday, yet it is still far from a clear picture on the spectrum of clinical conditions, transmissibility and mortality, alongside the limitation of medical reports associated with reporting in real time the evolution of an emerging pathogen in its early phase. Previous reports covered mostly the COVID-19 patients in China. With the spread of the virus to other continents, there is an imminent need to review the current knowledge on the clinical features and outcomes of the early patients, so that further research and measures on epidemic control could be developed in this epoch of the pandemic.

Search strategy and selection criteria

The systematic review was conducted according to the protocol registered in the PROSPERO database (CRD42020176589). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline throughout this review, data were identified by searches of MEDLINE, Embase and references from relevant articles using the search terms "COVID", “SARS-CoV-2”, and “novel coronavirus” (Supplementary material 1 ). Articles published in English up to 27th March, 2020 were included. National containment measures have been implemented at many countries, irrespective of lockdown, curfew, or stay-at-home orders, since the mid of March 2020 12 , except for China where imposed Hubei province lockdown at 23th January 2020, Studies with original data including original articles, short and brief communication, letters, correspondences were included. Editorials, viewpoints, infographics, commentaries, reviews, or studies without original data were excluded. Studies were also excluded if they were animal studies, modelling studies, or did not measure symptoms presentation, laboratory findings, treatment and therapeutics during hospitalization.

After the removal of duplicate records, two reviewers (CW and CHA) independently screened the eligibility criteria of study titles, abstracts and full-texts, and reference lists of the studies retrieved by the literature search. Disagreements regarding the procedures of database search, study selection and eligibility were resolved by discussion. The second and the last authors (JW and AW) verified the eligibility of included studies.

Outcomes definitions

Signs and symptoms were defined as the presentation of fever, cough, sore throat, headache, dyspnea, muscle pain, diarrhea, rhinorrhea, anosmia, and ageusia at the hospital admission 13 .

Laboratory findings included a complete blood count (white blood count, neutrophil, lymphocyte, platelet count), procalcitonin, prothrombin time, urea, and serum biochemical measurements (including electrolytes, renal-function and liver-function values, creatine kinase, lactate dehydrogenase, C-reactive protein, Erythrocyte sedimentation rate), and treatment measures (i.e. antiviral therapy, antibiotics, corticosteroid therapy, mechanical ventilation, intubation, respiratory support, and renal replacement therapy). Radiological outcomes included bilateral involvement identified and pneumonia identified by chest radiograph.

Comorbidities of patients evaluated in this study were hypertension, diabetes, chronic obstructive pulmonary disease (COPD), cardiovascular disease, chronic kidney disease, liver disease and cancer.

In-patient treatment included intensive care unit admission, oxygen therapy, non-invasive ventilation, mechanical ventilation, Extracorporeal membrane oxygenation (ECMO), renal replacement therapy, and pharmacological treatment. Use of antiviral and interferon drugs (Lopinavir/ritonavir, Ribavirin, Umifenovir, Interferon-alpha, or Interferon-beta), antibiotic drugs, corticosteroid, and inotropes (Nor-adrenaline, Adrenaline, Vasopressin, Phenylephrine, Dopamine, or Dobutamine) were considered.

Data analysis

Three authors (CW, EHMT and CHA) extracted data using a standardized spreadsheet to record the article type, country of origin, surname of first author, year of publications, sample size, demographics, comorbidities, symptoms, laboratory and radiology results, pharmacological and non-pharmacological treatments.

We aggregated estimates across 90 eligible studies to produce meta-analytic estimates using a random-effects model. For dichotomous outcomes, we estimated the proportion and its respective 95% confidence interval. For laboratory parameters as continuous outcomes, we estimated the mean and standard deviation from the median and interquartile range if the mean and standard deviation were not available from the study 14 , and calculated the mean and its respective 95% confidence intervals. Random-effect models on DerSimonian and Laird method were adopted due to the significant heterogeneity, checked by the I 2 statistics and the p values. I 2 statistic of < 25%, 25–75% and ≥ 75% is considered as low, moderate, high likelihood of heterogeneity. Pooled estimates were calculated and presented by using forest plots. Publication bias was estimated by Egger’s regression test. Funnel plots of outcomes were also presented to assess publication bias.

All statistical analyses were conducted using the STATA Version 13.0 (Statacorp, College Station, TX). The random effects model was generated by the Stata packages ‘Metaprop’ for proportions 15 and ‘Metan’ for continuous variables 16 .

The selection and screen process are presented in Fig.  1 . A total of 241 studies were found by our searching strategy (71 in PubMed and 170 in Embase). 46 records were excluded due to duplication. After screening the abstracts and titles, 100 English studies were with original data and included in full-text screening. By further excluding 10 studies with not reporting symptoms presentation, laboratory findings, treatment and therapeutics, 90 studies 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 and 76 studies with more than one COVID-19 case 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 34 , 35 , 36 , 37 , 38 , 39 , 42 , 43 , 44 , 45 , 49 , 50 , 51 , 53 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 67 , 69 , 70 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 98 , 100 , 101 , 102 , 103 , 104 , 105 were included in the current systematic review and meta-analysis respectively. 73.3% 66 studies were conducted in China. Newcastle–Ottawa Quality Assessment Scale has been used to assess study quality of each included cohort study 107 . 30% (27/90) of included studies had satisfactory or good quality. The summary of the included study is shown in Table 1 .

PRISMA flowchart reporting identification, searching and selection processes.

Of those 90 eligible studies, 11,028 COVID-19 patients were identified and included in the systematic review. More than half of patients (6336, 57.5%) were from mainland China. The pooled mean age was 45.8 (95% CI 38.6–52.5) years and 49.3% (pooled 95% CI 45.6–53.0%) of them were male.

For specific comorbidity status, the most prevalent comorbidity was hypertension (18.1%, 95% CI 15.4–20.8%), followed by cardiovascular disease (11.8%, 95% CI 9.4–14.2%) and diabetes (10.4%, 95% CI 8.7–12.1%). The pooled prevalence (95% CI) of COPD, chronic kidney disease, liver disease and cancer were 2.0% (1.3–2.7%), 5.2% (1.7–8.8%), 2.5% (1.7–3.4%) and 2.1% (1.3–2.8%) respectively. Moderate to substantial heterogeneity between reviewed studies were found, with I 2 statistics ranging from 39.4 to 95.9% ( p values between < 0.001–0.041), except for liver disease (I 2 statistics: 1.7%, p  = 0.433). Detailed results for comorbidity status are displayed in Fig.  2 .

Random-effects meta-analytic estimates for comorbidities. ( A ) Diabetes mellitus, ( B ) Hypertension, ( C ) Cardiovascular disease, ( D ) Chronic obstructive pulmonary disease, ( E ) Chronic kidney disease, ( F ) Cancer.

Regarding the symptoms presented at hospital admission, the most frequent symptoms were fever (pooled prevalence: 72.4%, 95% CI 67.2–77.7%) and cough (pooled prevalence: 55.5%, 95% CI 50.7–60.3%). Sore throat (pooled prevalence: 16.2%, 95% CI 12.7–19.7%), dyspnoea (pooled prevalence: 18.8%, 95% CI 14.7–22.8%) and muscle pain (pooled prevalence: 22.1%, 95% CI 18.6–25.5%) were also common symptoms found in COVID-19 patients, but headache (pooled prevalence: 10.5%, 95% CI 8.7–12.4%), diarrhoea (pooled prevalence: 7.9%, 95% CI 6.3–9.6%), rhinorrhoea (pooled prevalence: 9.2%, 95% CI 5.6–12.8%) were less common. However, none of the included papers reported prevalence of anosmia and ageusia. The I 2 statistics varied from 68.5 to 97.1% (all p values < 0.001), indicating a high heterogeneity exists across studies. Figure  3 shows the pooled proportion of symptoms of patients presented at hospital.

Random-effects meta-analytic estimates for presenting symptoms. ( A ) Fever, ( B ) Cough, ( C ) Dyspnoea, ( D ) Sore throat, ( E ) Muscle pain, ( F ) Headache.

For laboratory parameters, white blood cell (pooled mean: 5.31 × 10 9 /L, 95% CI 5.03–5.58 × 10 9 /L), neutrophil (pooled mean: 3.60 × 10 9 /L, 95% CI 3.31–3.89 × 10 9 /L), lymphocyte (pooled mean: 1.11 × 10 9 /L, 95% CI 1.04–1.17 × 10 9 /L), platelet count (pooled mean: 179.5 U/L, 95% CI 172.6–186.3 U/L), aspartate aminotransferase (pooled mean: 30.3 U/L, 95% CI 27.9–32.7 U/L), alanine aminotransferase (pooled mean: 27.0 U/L, 95% CI 24.4–29.6 U/L) and C-reactive protein (CRP) (pooled mean: 22.0 mg/L, 95% CI 18.3–25.8 mg/L) and D-dimer (0.93 mg/L, 95% CI 0.68–1.18 mg/L) were the common laboratory test taken for COVID-19 patients. Above results and other clinical factors are depicted in Fig.  4 . Same with the comorbidity status and symptoms, high likelihood of heterogeneity was detected by I 2 statistics for a majority of clinical parameters.

Random-effects meta-analytic estimates for laboratory parameters. ( A ) White blood cell, ( B ) Lymphocyte, ( C ) Neutrophil, ( D ) C-creative protein, ( E ) D-dimer, ( F ) Lactate dehydrogenase.

Figure  5 presents the distribution of the pharmacological treatments received for COVID-19 patients. 10.6% of patients admitted to intensive care units (pooled 95% CI 8.1–13.2%). For drug treatment, 63.9% (pooled 95% CI 52.5–75.3%), 62.4% (pooled 95% CI 47.9–76.8%) and 29.7% (pooled 95% CI 21.8–37.6%) patients used antibiotics, antiviral, and corticosteroid, respectively. 41.3% (pooled 95% CI 14.3–68.3%) and 50.7% (pooled 95% CI 9.2–92.3%) reported using Lopinavir/Ritonavir and interferon-alpha as antiviral drug treatment, respectively. Among 14 studies reporting proportion of corticosteroid used, 7 studies (50%) specified the formulation of corticosteroid as systemic corticosteroid. The remaining one specified the use of methylprednisolone. No reviewed studies reported the proportion of patients receiving Ribavirin, Interferon-beta, or inotropes.

Random-effects meta-analytic estimates for pharmacological treatments and intensive unit care at hospital. ( A ) Antiviral or interferon drugs, ( B ) Lopinavir/Ritonavir, ( C ) Interferon alpha (IFN-α), ( D ) Antibiotic drugs, ( E ) Corticosteroid, ( F ) Admission to Intensive care unit.

The prevalence of radiological outcomes and non-pharmacological treatments were presented in Fig.  6 . Radiology findings detected chest X-ray abnormalities, with 74.4% (95% CI 67.6–81.1%) of patients with bilateral involvement and 74.9% (95% CI 68.0–81.8%) of patients with viral pneumonia. 62.6% (pooled 95% CI 39.9–85.4%), 20.2% (pooled 95% CI 14.6–25.9%), 15.3% (pooled 95% CI 11.0–19.7%), 1.1% (pooled 95% CI 0.4–1.8%) and 4.7% (pooled 95% CI 2.1–7.4%) took oxygen therapy, non-invasive ventilation, mechanical ventilation, ECMO and dialysis respectively.

Random-effects meta-analytic estimates for radiological findings and non-pharmacological treatments at hospital. ( A ) Bilateral involvement, ( B ) Pneumonia, ( C ) Oxygen therapy, ( D ) Non-invasive ventilation, ( E ) Extracorporeal membrane oxygenation (ECMO), ( F ) Dialysis.

The funnel plots and results Egger’s test of comorbidity status, symptoms presented, laboratory test and treatment were presented in eFigure 1 – S5 in the Supplement. 63% (19/30) of the funnel plots (eFigure 1 – S5 ) showed significance in the Egger’s test for asymmetry, suggesting the possibility of publication bias or small-study effects caused by clinical heterogeneity.

This meta-analysis reveals the condition of global medical community responding to COVID-19 in the early phase. During the past 4 months, a new major epidemic focus of COVID-19, some without traceable origin, has been identified. Following its first identification in Wuhan, China, the virus has been rapidly spreading to Europe, North America, Asia, and the Middle East, in addition to African and Latin American countries. Three months since Wuhan CDC admitted that there was a cluster of unknown pneumonia cases related to Huanan Seafood Market and a new coronavirus was identified as the cause of the pneumonia 108 , as on 1 April, 2020, there have been 858,371 persons confirmed infected with COVID-19, affecting 202 countries and territories around the world. Although this rapid review is limited by the domination of reports from patients in China, and the patient population is of relative male dominance reflecting the gender imbalance of the Chinese population 109 , it provides essential information.

In this review, the pooled mean age was 45.8 years. Similar to the MERS-CoV pandemic 110 , middle-aged adults were the at-risk group for COVID-19 infections in the initial phase, which was different from the H1N1 influenza pandemic where children and adolescents were more frequently affected 111 . Biological differences may affect the clinical presentations of infections; however, in this review, studies examining the asymptomatic COVID-19 infections or reporting any previous infections were not included. It is suggested that another systematic review should be conducted to compare the age-specific incidence rates between the pre-pandemic and post-pandemic periods, so as to understand the pattern and spread of the disease, and tailor specific strategies in infection control.

Both sexes exhibited clinical presentations similar in symptomatology and frequency to those noted in other severe acute respiratory infections, namely influenza A H1N1 112 and SARS 113 , 114 . These generally included fever, new onset or exacerbation of cough, breathing difficulty, sore throat and muscle pain. Among critically ill patients usually presented with dyspnoea and chest tightness 22 , 29 , 39 , 72 , 141 (4.6%) of them with persistent or progressive hypoxia resulted in the requirement of intubation and mechanical ventilation 115 , while 194 (6.4%) of them required non-invasive ventilation, yielding a total of 11% of patients requiring ventilatory support, which was similar to SARS 116 .

The major comorbidities identified in this review included hypertension, cardiovascular diseases and diabetes mellitus. Meanwhile, the percentages of patients with chronic renal diseases and cancer were relatively low. These chronic conditions influencing the severity of COVID-19 had also been noted to have similar effects in other respiratory illnesses such as SARS, MERS-CoV and influenza 117 , 118 . Higher mortality had been observed among older patients and those with comorbidities.

Early diagnosis of COVID-19 was based on recognition of epidemiological linkages; the presence of typical clinical, laboratory, and radiographic features; and the exclusion of other respiratory pathogens. The case definition had initially been narrow, but was gradually broadened to allow for the detection of more cases, as milder cases and those without epidemiological links to Wuhan or other known cases had been identified 119 , 120 . Laboratory investigations among COVID-19 patients did not reveal specific characteristics—lymphopenia and elevated inflammatory markers such as CRP are some of the most common haematological and biochemical abnormalities, which had also been noticed in SARS 121 . None of these features were specific to COVID-19. Therefore, diagnosis should be confirmed by SARS-CoV–2 specific microbiological and serological studies, although initial management will continue to be based on a clinical and epidemiological assessment of the likelihood of a COVID-19 infection.

Radiology imaging often plays an important role in evaluating patients with acute respiratory distress; however, in this review, radiological findings of SARS-CoV-2 pneumonia were non-specific. Despite chest radiograph usually revealed bilateral involvement and Computed Tomography usually showed bilateral multiple ground-glass opacities or consolidation, there were also patients with normal chest radiograph, implying that chest radiograph might not have high specificity to rule out pneumonia in COVID-19.

Limited clinical data were available for asymptomatic COVID-19 infected persons. Nevertheless, asymptomatic infection could be unknowingly contagious 122 . From some of the official figures, 6.4% of 150 non-travel-related COVID-19 infections in Singapore 123 , 39.9% of cases from the Diamond Princess cruise ship in Japan 124 , and up to 78% of cases in China as extracted on April 1st, 2020, were found to be asymptomatic 122 . 76% (68/90) studies based on hospital setting which provided care and disease management to symptomatic patients had limited number of asymptomatic cases of COVID-19 infection. This review calls for further studies about clinical data of asymptomatic cases. Asymptomatic infection intensifies the challenges of isolation measures. More global reports are crucially needed to give a better picture of the spectrum of presentations among all COVID-19 infected persons. Also, public health policies including social and physical distancing, monitoring and surveillance, as well as contact tracing, are necessary to reduce the spread of COVID-19.

Concerning potential treatment regime, 62.4% of patients received antivirals or interferons (including oseltamivir, lopinavir-ritonavir, interferon alfa), while 63.9% received antibiotics (such as moxifloxacin, and ceftriaxone). In this review, around one-third of patients were given steroid, suggestive as an adjunct to IFN, or sepsis management. Interferon and antiviral agents such as ribavirin, and lopinavir-ritonavir were used during SARS, and the initial uncontrolled reports then noted resolution of fever and improvement in oxygenation and radiographic appearance 113 , 125 , 126 , without further evidence on its effectiveness. At the time of manuscript preparation, there has been no clear evidence guiding the use of antivirals 127 . Further research is needed to inform clinicians of the appropriate use of antivirals for specific groups of infected patients.

Limitations of this meta-analysis should be considered. First, a high statistical heterogeneity was found, which could be related to the highly varied sample sizes (9 to 4226 patients) and study designs. Second, variations of follow-up period may miss the event leading to heterogeneity. In fact, some patients were still hospitalized in the included studies. Third, since only a few studies had compared the comorbidities of severe and non-severe patients, sensitivity analysis and subgroup analysis were not conducted. Fourthly, the frequency and severity of signs and symptoms reported in included studies, primarily based on hospitalized COVID-19 patients were over-estimated. Moreover, different cutoffs for abnormal laboratory findings were applied across countries, and counties within the same countries. Lastly, this meta-analysis reviewed only a limited number of reports written in English, with a predominant patient population from China. This review is expected to inform clinicians of the epidemiology of COVID-19 at this early stage. A recent report estimated the number of confirmed cases in China could reach as high as 232,000 (95% CI 161,000, 359,000) with the case definition adopted in 5th Edition. In this connection, further evidence on the epidemiology is in imminent need.

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Acknowledgements

There was no funding source for this study.

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These authors contributed equally: Carlos K. H. Wong and Janet Y. H. Wong.

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Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

Carlos K. H. Wong, Eric H. M. Tang & C. H. Au

Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

Carlos K. H. Wong

School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

Janet Y. H. Wong

Emergency Medicine Unit, Li Ka Shing, Faculty of Medicine, The University of Hong Kong, Hong Kong, China

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C.W., J.W. and A.W. contributed equally to all aspects of study design, conduct, data interpretation, and the writing of the manuscript. C.W., E.T. and C.H.A. contributed to eligibility screening, data extraction from eligible studies, and data analysis and interpretation.

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Wong, C.K.H., Wong, J.Y., Tang, E.H.M. et al. Clinical presentations, laboratory and radiological findings, and treatments for 11,028 COVID-19 patients: a systematic review and meta-analysis. Sci Rep 10 , 19765 (2020). https://doi.org/10.1038/s41598-020-74988-9

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The Clinical Presentation

• First Online: 01 January 2013

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• Sergio V. Delgado 3 &
• Jeffrey R. Strawn 4  

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Presenting case material to colleagues requires preparation, whether the presentation is to be made casually during bedside rounds or in the formal environment of a national meeting. It is rewarding when a presentation is well received, particularly because it may prove helpful to other clinicians, allied health professionals, and researchers. Regardless of the setting, the presenter’s goal is to share their knowledge based on observations they have made and lessons they have learned from the case or cases. The most time-consuming aspect of the patient-oriented presentation is collecting and organizing as much information as possible about the patients, their families, and others who were involved in the patients’ care. Once these tasks are complete, the presenter must summarize the information and place it within the context of treatment data and consensus approaches. Tailoring the talk to the audience is also of paramount importance. Different groups will invariably come from different disciplines, and the presentation will need to be tailored to accommodate each audience’s background, interests and goals.

Make everything as simple as possible, but not simpler —Albert Einstein (1879–1955)

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Delgado, S.V., Strawn, J.R. (2014). The Clinical Presentation. In: Difficult Psychiatric Consultations. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-39552-9_8

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The definition, classification, etiology, and pathophysiology of shock are discussed in this review. The clinical presentation and diagnostic evaluation of undifferentiated shock and the evaluation of patients with specific forms of shock are discussed separately. (See "Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock" and "Evaluation and management of suspected sepsis and septic shock in adults" and "Clinical manifestations and diagnosis of cardiogenic shock in acute myocardial infarction" and "Etiology, clinical manifestations, and diagnosis of volume depletion in adults" and "Approach to shock in the adult trauma patient" and "Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism" .)

EPIDEMIOLOGY

In the emergency department (ED), the percentage of each type of shock seen depends upon the population served by the ED [ 3,4 ]. As an example, busy, urban, level-I trauma centers will see a higher percentage of hemorrhagic shock. In one study of 103 patients with undifferentiated shock presenting to a busy, urban ED, 36 percent of patients had hypovolemic shock, 33 percent had septic shock, 29 percent had cardiogenic shock, and 2 percent had other forms of shock [ 3 ].

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Presentation skills: plan, prepare, phrase, and project

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• laura.brammar{at}careers.lon.ac.uk

In the third of her series on getting the dream job, Laura Brammar looks at giving an interview presentation

Many doctors have extensive experience of delivering presentations at conferences, during research projects, or to medical students during their training. Nevertheless, for many medical professionals having to deliver a presentation is still something they dread rather than relish. Equally, candidate presentations are becoming an established feature of selection and assessment for many roles within medicine.

Applicants may be asked to prepare and deliver a presentation as part of the interview process for anything from a salaried general practitioner post to a senior consultant post. For that reason alone, it’s vital to grasp the nettle and strengthen those presentation skills, which you can draw on throughout your medical career.

Break it down to just four P’s

To prepare most effectively for your presentation, you might find considering four main areas particularly useful: planning, preparation, phrasing, and projection.

Planning —A good presentation begins with the early stage of planning. Common complaints about ineffectual and dull presentations revolve around the apparent lack of structure shown by the presenter.

You will generally be given the topic of your presentation in advance. Topics vary, but they usually relate to your specialty—for example, “What do you see as the main current issues/future direction of this specialty?”—or link to contextual factors related to the role—“How, in your opinion, could the current system of X work more effectively?”

Think of the title as your research question or hypothesis and structure your presentation so that you answer that question directly. A simple but effective framework for any presentation is: tell them what you’re going to say, say it, and tell them what you’ve just said. Whether your presentation relates to the latest National Institute for Health and Clinical Excellence (NICE) guidelines for your specialty or a business plan in response to a proposed polyclinic, this structure will help keep your audience engaged and your presentation within the time limit.

Indeed, timing is crucial when giving a presentation. Most candidates are overambitious about what can be squeezed into just five to ten minutes. Be realistic about what you can achieve in the time limit and plan your presentation accordingly. As a rule of thumb, less is almost always more and remember to build in time for questions at the end.

Preparation —Having a clear structure can give you a useful framework that underpins your presentation. In a similar way, using particular resources to support your point can be a good method to employ during a presentation.

While the use of PowerPoint is becoming increasingly popular, in these circumstances you need to check before slaving over your slides. Remember that you are the focus of the presentation, not the screen; avoid distracting animations and excessive detail. Even if PowerPoint is an option you still need to plan for technological meltdowns; bring hard copies and overhead slides as a back-up.

You may consider it worth while to produce a brief summarising handout of the main points. Aim to distribute this before you begin so that you can create a clear and confident start, rather than compete with the rustle of paper as you try to introduce yourself.

Phrasing —Many candidates get anxious about the fact that they may “um” and “er” during a presentation. The vast majority of people feel nervous when they are presenting. Accept that and remember that, to an extent, it is what your audience will expect; from the selectors’ perspective, a completely laidback candidate might appear unmotivated and flippant. So while you want to aim for a fluid and articulate delivery, it’s not the end of the world if you occasionally need to pause between sentences. Indeed pauses can be an excellent way of emphasising your points and retaining your audience’s attention.

Essentially, use your structure to help you—for example, “First, I’d like to talk about . . .; next, let’s look at . . . ; and, finally, in summary . . ..”Also, be aware of your pace and volume.

Projection —Many people associate the term “presentation skills” with aspects of non-verbal communication, such as gestures and facial expression. Even when you feel nervous there are ways successfully to convey confidence to your audience. The following suggestions will help you to show a positive and calm attitude, which in turn will help you to maintain control over your presentation.

Breathe—If you are particularly nervous before you start, take a few moments to slow down your breathing; it may help to think about balancing the length of your inhalation and exhalation and breathe deeply and evenly.

Share your eye contact—If feasible, make eye contact with all your audience throughout your presentation; if you are presenting to a large group, make sure you address both sides of the room during your session.

Take time to pause—Use pauses to illustrate the structure of your session. Brief pauses can also help you to slow down your delivery and maintain the focus of your audience.

Project your voice—Check that those at the back can hear you before you start. Maintain your volume throughout and aim at projecting your voice to the back of the room.

Own the space—If possible, try not to stay stuck to one spot for the duration of the presentation. Clearly, now isn’t the time to try out gestures that feel unnatural or forced. However, convey your confidence through the way you stand and emphasise your message through your body language.

Smile—Despite feeling anxious, displaying a smile can make you feel more relaxed. Even better, it also gives your audience confidence in you and in your message.

Awkward audience moments

While you may have organised thoroughly your planning, preparation, phrasing, and projection, the one area you cannot control or necessarily predict is your audience’s reactions. Many people find the thought of their audience’s responses, especially during the question and answer session, far more terrifying than the presentation itself.

Here are a few suggestions for how to deal with some common difficult situations.

Random interruptions —If someone asks a question in the middle of your presentation, make a decision whether it would be appropriate to deal with it now or later. Don’t be forced to change your structure unless you believe it is really necessary. Acknowledge the question and reassure the person that there will be opportunities to discuss that later. Equally, if it is an unrelated or irrelevant question remember to acknowledge it but make it clear that such a topic isn’t going to be dealt with explicitly on this occasion. You can always offer to research that question for them at a later opportunity.

Audience looks bored —Many people feel they are poor presenters because their audiences can look distracted or even bored. The key thing here is to ask yourself if they are actually bored or whether they are just presenting you with a professional and impartial expression. In your clinical work you need to be able to focus on a task and not be distracted by personal emotional considerations or anxieties; this is no different. Treat the presentation as a professional exercise and move on.

Someone isn’t listening and is talking to someone nearby —Depending on your audience (senior consultants or medical students, for example) you may want to vary your specific response to this. However, a good technique with any audience is to pause in your delivery, look at the culprits while smiling, and wait for their attention before you start again. This is an effective (and non-aggressive) way of acknowledging that they are distracting both you and the rest of the group. That is usually all it takes to get their full attention. However, if they are persistent offenders maintain your professionalism and carry on regardless.

Questions you can’t answer —Sometimes the dread of the questions at the end of a presentation can overshadow the whole experience. Avoid this by framing your question and answer session with a reassurance that you’ll do your best to deal with any questions now and will guarantee to follow up any additional questions after the session. If you are asked a reasonable question which you genuinely can’t answer you may want to try the following:

Acknowledge that it’s a valid question

Invite any suggestions from the audience first

Admit that you can’t give a full answer at this moment; don’t bluff an answer

Offer to follow up a response and email the person later.

Remember that part of good medical practice is to know your limits and work within the parameters of your knowledge; it sounds far more confident and impressive to admit you can’t answer a question fully at this moment, rather than try to cobble together a poor answer and pretend you know.

Want to practise in a supportive environment?

The BMA Careers Service works with many individual medics who wish to improve their presentation skills through a tailormade practice presentation service. A bespoke practice presentation session, based on your actual material, can be excellent preparation for the real thing. During the session you can rehearse your presentation fully, practise answering focused questions, and gain immediate and constructive one to one feedback on your overall performance ( www.bma.org.uk/ap.nsf/Content/Hubcareersadvicefordoctors ).

Competing interests : None declared.

Tools for the Patient Presentation

The formal patient presentation.

• Posing the Clinical Question
• Searching the Medical Literature for EBM

Sources & Further Reading

First Aid for the Wards

Lingard L, Haber RJ.  Teaching and learning communications in medicine: a rhetorical approach .  Academic Medicine. 74(5):507-510 1999 May.

Lingard L, Haber RJ.  What do we mean by "relevance"? A clinical and rhetorical definition with implications for teaching and learning the case-presentation format . Academic Medicine. 74(10):S124-S127.

The Oral Presentation (A Practical Guide to Clinical Medicine, UCSD School of Medicine)  http://meded.ucsd.edu/clinicalmed/oral.htm

"Classically, the formal oral presentation is given in 7 minutes or less. Although it follows the same format as a written report, it is not simply regurgitation. A great presentation requires style as much as substance; your delivery must be succinct and smooth. No time should be wasted on superfluous information; one can read about such matters later in your admit note. Ideally, your presentation should be formulated so that your audience can anticipate your assessment and plan; that is, each piece of information should clue the listener into your thinking process and your most likely diagnosis."  [ Le, et al, p. 15 ]

Types of Patient Presentations

New Patient

New patients get the traditional H&P with assessment and plan.  Give the chief complaint and a brief and pertinent HPI.  Next give important PMH, PSH, etc.  The ROS is often left out, as anything important was in the HPI.  The PE is reviewed.  Only give pertinent positives and negatives.  The assessment and plan should include what you think is wrong and, briefly, why.  Then, state what you plan to do for the patient, including labs.  Be sure to know why things are being done: you will be asked.

The follow-up presentation differs from the presentation of a new patient.  It is an abridged presentation, perhaps referencing major patient issues that have been previously presented, but focusing on new information about these issues and/or what has changed. Give the patient’s name, age, date of admission, briefly review the present illness, physical examination and admitting diagnosis.  Then report any new finding, laboratory tests, diagnostic procedures and changes in medications.

The attending physician will ask the patient’s permission to have the medical student present their case.  After making the proper introductions the attending will let the patient know they may offer input or ask questions at any point.  When presenting at bedside the student should try to involve the patient.

Preparing for the Presentation

There are four things you must consider before you do your oral presentation

• Occasion (setting and circumstances)

Ask yourself what do you want the presentation to do

• Present a new patient to your preceptor : the amount of detail will be determined by your preceptor.  It is also likely to reflect your development and experience, with less detail being required as you progress.
• Present your patient at working or teaching rounds : the amount of detail will be determined by the customs of the group. The focus of the presentation will be influenced by the learning objectives of working responsibilities of the group.
• Request a consultant’s advice on a clinical problem : the presentation will be focused on the clinical question being posed to the consultant.
• Persuade others about a diagnosis and plan : a shorter presentation which highlights the pertinent positives and negatives that are germane to the diagnosis and/or plan being suggested.
• Enlist cooperation required for patient care : a short presentation focusing on the impact your audience can have in addressing the patient’s issues.

Preparation

• Patient evaluation : history, physical examination, review of tests, studies, procedures, and consultants’ recommendations.
• Selected reading : reference texts; to build a foundational understanding.
• Literature search : for further elucidation of any key references from selected reading, and to bring your understanding up to date, since reference text information is typically three to seven years old.
• Write-up : for oral presentation, just succinct notes to serve as a reminder or reference, since you’re not going to be reading your presentation.

Knowledge (Be prepared to answer questions about the following)

• Pathophysiology
• Complications
• Differential diagnosis
• Course of conditions
• Diagnostic tests
• Medications
• Essential Evidence Plus

Template for Oral Presentations

Chief Complaint (CC)

The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint. Give marital status, race, or occupation if relevant.  If your patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it.  For ongoing care, give a one sentence recap of the history.

History of Present Illness (HPI)

This will be very similar to your written HPI. Present the most important problem first. If there is more than one problem, treat each separately. Present the information chronologically.  Cover one system before going onto the next. Characterize the chief complaint – quality, severity, location, duration, progression, and include pertinent negatives. Items from the ROS that are unrelated to the present problem may be mentioned in passing unless you are doing a very formal presentation. When you do your first patient presentation you may be expected to go into detail.  For ongoing care, present any new complaints.

Review of Systems (ROS)

Most of the ROS is incorporated at the end of the HPI. Items that are unrelated to the present problem may be briefly mentioned.  For ongoing care, present only if new complaints.  

Past Medical History (PMH)

Discuss other past medical history that bears directly on the current medical problem.  For ongoing care, have the information available to respond to questions.

Past Surgical History

Provide names of procedures, approximate dates, indications, any relevant findings or complications, and pathology reports, if applicable.  For ongoing care, have the information available to respond to questions.

Allergies/Medications

Present all current medications along with dosage, route and frequency. For the follow-up presentation just give any changes in medication.  For ongoing care, note any changes.

Smoking and Alcohol (and any other substance abuse)

Note frequency and duration. For ongoing care, have the information available to respond to questions.

Social/Work History

Home, environment, work status and sexual history.  For ongoing care, have the information available to respond to questions.

Family History Note particular family history of genetically based diseases.  For ongoing care, have the information available to respond to questions.

Physical Exam/Labs/Other Tests

Include all significant abnormal findings and any normal findings that contribute to the diagnosis. Give a brief, general description of the patient including physical appearance. Then describe vital signs touching on each major system. Try to find out in advance how thorough you need to be for your presentation. There are times when you will be expected to give more detail on each physical finding, labs and other test results.  For ongoing care, mention only further positive findings and relevant negative findings.

Assessment and Plan

Give a summary of the important aspects of the history, physical exam and formulate the differential diagnosis. Make sure to read up on the patient’s case by doing a search of the literature. 

• Include only the most essential facts; but be ready to answer ANY questions about all aspects of your patient.
• Keep your presentation lively.
• Do not read the presentation!
• Expect your listeners to ask questions.
• Follow the order of the written case report.
• Keep in mind the limitation of your listeners.
• Beware of jumping back and forth between descriptions of separate problems.
• Use the presentation to build your case.
• Your reasoning process should help the listener consider a differential diagnosis.
• Present the patient as well as the illness .
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Effectiveness of Clinical Presentation (CP) Curriculum in teaching clinical medicine to undergraduate medical students: A cross-sectional study.

Saroj adhikari yadav.

1 Patan Academy of Health Sciences, Kathmandu, 44600, Nepal

Sangeeta Poudel

Swotantra gautam.

2 B P Koirala Institute of Health Sciences, Dharan, Nepal

Sanjay Kumar Jaiswal

Samikchya baskota, aaradhana adhikari, binod duwadi, nischit baral, sanjay yadav.

3 Institute of Medicine, Kathmandu, 44600, Nepal

Associated Data

Underlying data.

Figshare: CP Curriculum Raw data updated in Excel and PDF. https://doi.org/10.6084/m9.figshare.18666410.v1 10

This project contains the following underlying data:

• - Analysis and Raw data.xlsx

Extended data

This project contains the following extended data:

• - CP Questionnaire for Faculties.pdf
• - CP Questionnaire for students.pdf
• - CP Surprise exam Questionnaire.pdf

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Peer Review Summary

Introduction:  The Clinical Presentation (CP) curriculum was first formulated in 1990 at the University of Calgary, Canada. Since then, it has been adopted at various medical schools, including Patan Academy of Health Sciences (PAHS), a state-funded medical school in a low-income country (LIC), Nepal. This study aims to evaluate the perceived effectiveness of the CP curriculum by students and faculty at PAHS, and test knowledge retention through a surprise non-routine exam administered to students. 

Method:  This is a cross-sectional study to evaluate the efficacy of the CP curriculum in teaching clinical medicine to the first batch of MBBS students of PAHS School of Medicine. Ethical approval was obtained from the Institutional Review Committee (IRC)-PAHS (Ref no std1505911069). Perceived effectiveness was evaluated using a set of questionnaires for faculty and students. A total of 33 students and 34 faculty filled the perception questionnaires. Subsequently, a questionnaire consisting of 50 Multiple Choice Questions (MCQs) from different clinical medicine disciplines was administered to test students’ knowledge retention. Out of 49 students, 38 participated in the surprise non-routine exam.  

Result:  A significantly higher number of faculty preferred the CP curriculum compared to the traditional system of teaching clinical medicine (16 vs 11, Kruskal Wallis: 0.023, ie. P-value < 0.05). A significantly higher number of the students liked and recommended CP curriculum in the clinical year of medical education (20 vs. 13 with p-value < 0.05). In the non-routine surprise exam, two thirds of the students scored 60% or above. 

Conclusion: Both faculty and students perceive that the CP curriculum system is an effective teaching and learning method in medical education, irrespective of their different demographic and positional characteristics. The students’ overall performance was good in surprise, non-routine exams taken without scheduling or reminders.

Introduction

Sir William Osler, considered the father of modern medicine, emphasized the teacher's role in helping students to observe and reason. He recommended abolishing the traditional lecture method of instruction. 1 Medical education is evolving in response to scientific advances and societal needs. 2 A well-organized comprehensive knowledge domain has practical implications in clinical problem solving, and appropriate teaching and learning methods play an important role in achieving the educational goals. 3

Clinical presentation (CP) is a relatively new and innovative approach to teaching medicine. CP engages medical students in their understanding of the disease process from clinical feature to diagnosis. Students begin studying abnormalities of complaints, examination, and laboratory findings; i.e., signs, symptoms, and laboratory investigations which a patient presents to the doctor with. Students then progress towards diagnosis. The underlying philosophy of the CP Curriculum is that: “The reaction of the human body to an infinite number of insults is always finite and stable over time”. 4 For example, if there is any attack on the respiratory system, whether infectious, inflammatory, immunological, traumatic, or iatrogenic; the respiratory system responds through coughing, cyanosis, chest pain, difficulty breathing, noisy breathing, or hemoptysis. 4 Thus, the CP Curriculum aims to help students understand the process of moving from “symptoms to diagnosis.”

The CP curriculum was first formulated in 1990 at the University of Calgary Faculty of Medicine in Canada. 5 The curriculum was adopted and redesigned based on local needs at various medical schools worldwide. Patan Academy of Health Sciences (PAHS), a state-funded medical school in Nepal, has adopted several new and innovative approaches in teaching and learning medicine. The CP Curriculum is one of the several approaches adopted by PAHS. 6

PAHS medical education team assumes that the CP curriculum is better than traditional lecture-based teaching. In this study we are testing the perceived effectiveness of students and faculty, and the level of knowledge among the students trained by the CP curriculum. The level of knowledge was assessed by marks scored by the students in a surprise non-routine exam without prior information. Perceived effectiveness was based on the thinking/perception of the students and faculty on the effectiveness of the CP curriculum. We assume the CP curriculum is at least not inferior to traditional lecture-based teaching.

Study design

This is a cross-sectional study that aims to evaluate the efficacy of the CP curriculum in teaching different disciplines of clinical medicine to undergraduate medical students of PAHS, which is currently the only medical school implementing the CP-curriculum in undergraduate medical education. A new Multiple-Choice Question (MCQ) based questionnaire was designed to evaluate the level of knowledge and two separate questionnaires were developed for faculty to evaluate perception about CP-curriculum.

Study population

All consenting medical students from 2016 of PAHS School of Medicine currently in clinical clerkship years and all clinical sciences faculty who had delivered at least one teaching-session with the CP curriculum to these students were included in the study. Consenting students were asked to fill the questionnaire together in class, whereas faculty were approached personally and asked to complete the questionnaires. Students and faculty who were part of the study team, those who didn’t provide consent, and those who participated in the pilot survey section of the questionnaire developed for this study were excluded. All 34 faculty completed the perception questionnaires, with zero non-response rate. Out of 49 students, 33 completed the perception questionnaires and 38 turned up to the surprise non-routine exam for assessment of knowledge retention.

Ethics and consent

This study was approved by the Institutional Review Committee (Ethical Committee) of Patan Academy of Health Sciences (PAHS), Kathmandu, Nepal (Ref No std1505911069). Written informed consent was obtained from all participants before completing the questionnaire. Students who gave verbal consent were asked to complete the questionnaire together in class. Faculty were approached personally and requested to complete the questionnaires. At the start of each questionnaire, a tick box was used for participants to indicate written consent. Participants were informed verbally and in writing that their names and identifiying information would be kept anonymous, and their data would only be used for research purposes.

Data collection

Three sets of questionnaires were used. The first set of questionnaires were designed to test the perceived effectiveness of the CP curriculum from the faculty perspective. It contained seven questions on background information (age, sex, job position, highest academic degree, etc) and 13 questions on perceived effectiveness.

Similarly, the second set of questionnaires for the students included 11 questions on background information and 15 questions on perceived effectiveness. The perception questionnaire had questions about effectiveness or satisfaction in regard to different aspects of the CP curriculum. Participants had to respond with a tick mark in a Likert scale ranging from one (strongly agree) to five (strongly disagree) for each question.

The third set of questionnaires tested the students' clinical knowledge and contained 50 MCQs from different clinical medicine disciplines. Based on curriculum of the university, there were seven MCQs each from surgery, medicine, pediatrics, obstetrics and gynecology, and two questions each from orthopedics, emergency medicine, general practice, otolaryngology, anesthesiology, dermatology, dentistry, psychiatry, radiology, ophthalmology, and forensic medicine. The questions were randomly selected from the question pool of the Examination section of university. The selected questions were randomly arranged, and a surprise non-routine written exam was conducted with this questionnaire. A maximum time of one hour was provided to solve these 50 questions.

These questionnaires were compiled and discussed in the research group and reviewed by the research advisors to establish content validity. Copies of all three questionnaires can be found under Extended data. 10 They were administered to randomly selected 15 students and 15 faculty in a pilot study to establish the face validity and feasibility. The students and faculty randomly selected for the pilot study were administered the questionnaires to complete. Then they were asked in detail about the questionnaire and any suggestions for revisions or editing needed. The pilot survey was not powered for statistical comparisons. Only a few grammatical corrections were made after review and feedback from the pilot study. Subsequently, the final study was conducted.

The faculty participants were also involved in the development of the CP curriculum at PAHS, hence, responder bias in favor of CP curriculum may be present in this study.

The data collected were digitalized using Epi-Info version 7 software. These raw data were exported to MS-Excel. The excel sheet is made available in the public domain for readers. 10 SPSS version 13.0 was used for statistical test and analysis. Shapiro-Wilk test was used first to test the normality. Non-parametric tests (Mann-Whitney and Kruskal Wallis) was used for normal distribution. Classical ANOVA for equal variance and Welch ANOVA for unequal variance were used after testing the homogeneity of variance, and post-hoc/tukey test was used for significant classical ANOVA results.

In this study, we calculated the total score via forced Likert scale, ranging from 1 (strongly agree) to 5 (strongly disagree) for each respondent determined as the dependent variable, and compared it with other variables i.e., background information. The total score of all the Likert scale questions was calculated, and the normality test was performed, keeping “total score” as the dependent variable. The full dataset can be found under Underlying data. 10

Response from faculty on perceived effectiveness of the CP curriculum

The data of the total score did not follow a normal distribution (Shapiro-Wilk Test, p < 0.05), so a non-parametric test was used to compare the dependent variable. We used Mann-Whitney and Kruskal Wallis tests for the variables containing two groups and more than two groups, respectively.

Among the 34 respondents from the faculty group, 24 (70.59%) were male, and 10 (29.41%) were female. 20 (58.82%) of the faculty respondents were lecturers, and the remaining 14 (41.18%) were senior professors, associate professors, and assistant professors. Out of the 34 respondents, 31 (91.18%) were involved in developing the CP curriculum at PAHS. However, 3 (8.82%) were involved in teaching the curriculum but not in developing the CP curriculum.

As many as 15 (44.12%) respondents favored the CP curriculum system over the traditional system, 11 (32.35%) preferred the traditional teaching system, and 8 (23.53%) preferred both. Overall, the faculty liked the CP curriculum more than the traditional system of teaching clinical medicine (Kruskal Wallis = 0.023, p-value < 0.05). The majority of faculty, 27 (79.41%), would suggest future students to join a medical school that implemented the CP curriculum system rather than the traditional system. Only 12 (35.29%) of them thought that the CP curriculum system should be the sole leading teaching and learning system in clinical medicine, meaning more faculty preferred a hybrid system of both the CP curriculum and the traditional system. However, these differences were not statistically significant (p-value > 0.05).

As shown in Table 1 , a significant number of faculty (p values > 0.05) perceive the CP curriculum to be more effective than the traditional system for teaching clinical medicine to undergraduate medical students. There is no significant difference in the perception of the effectiveness of the CP curriculum among faculty based on academic rank, gender, highest academic degree, or the institution of their residency training (p-value > 0.05). The median number of faculty who perceive the CP curriculum system to be more effective and suggest future students to study medicine in this system rather than the traditional system is higher. But, the difference was not statistically significant (p > 0.05). There was no significant difference in faculty foreseeing the CP curriculum as the leading method of teaching and learning medical education in the future (p > 0.05).

Response from students on perceived effectiveness of the CP curriculum

The normality test shows that the total score data follows a normal distribution (Shapiro-Wilk, p > 0.05) with a mean value of 50.57 with a standard deviation of 8.17. Therefore, we used a parametric test to compare the test variable with others. We subsequently tested for homogeneity of variance: we used classical ANOVA for equal variance, and Welch ANOVA for unequal variance. Finally, if significant classical ANOVA results were obtained, we used the post-hoc/tukey test.

There were 33 respondents, among which 23 (69.70%) were males, and 10 (30.30%) were females. The age group of respondents was between 20 to 30 years. A significantly higher number (20 i.e., 60.61%) of the respondents recommended studying in a medical school implementing CP curriculum (p < 0.05). No significant differences were seen between educational or geographical backgrounds and scholarship categories (p > 0.05) as shown in Table 2 .

Assessment for knowledge retention of the students

An hourly surprise non-routine written exam was conducted to test the knowledge of the students. A copy of this exam can be found under Extended data. 10 The exam included 50 MCQs from different disciplines of clinical medicine. The surprise test was conducted without prior reminders, and 38 out of 49 students participated. The findings, as outlined in Table 3 , show that 24 out of 38 (65.79%) of the students scored 60% or higher. The results demonstrate that approximately two-thirds of the students passed the surprise test, indicating good test performance.

The current study shows a higher preference for the CP curriculum by undergraduate medical students and faculty at PAHS for teaching and learning clinical medicine in medical school. These findings further substantiate previous reviews on the principles of teaching methods and the acceptability of the curriculum.

This curriculum was chosen in part because of confidence in the comprehensiveness of the knowledge it encompasses. Equally important was the organization of medical knowledge that this curriculum engenders: each clinical presentation is organized according to a variable number of causal diagnostic categories. Each of these categories is identified by a prototype. Exhaustive lists of diagnoses belonging to a given category are avoided. As students' clinical experiences increase and they encounter more diagnoses, the students can add them to the appropriate causal categories stored in their memories. How the diagnostic prototypes are presented allows students to identify the discriminating features within and between each. The process by which students can compare and contrast the distinctive features of each disease is facilitated. It is so because the CP curriculum is well organized and comprehensive. 3 , 7 Since the CP curriculum is simple to follow and to organize the learning content, students in the CP curriculum also reported less stress due to the volume and complexity of study materials and examinations. 7

Prior studies at the University of Calgary demonstrated a substantial effect size on students’ retention of basic science knowledge while participating in the CP curriculum. 8 Our study conducted on clinical clerkship year participants showed that two-thirds of students achieved 60% (passing scores) or more in the surprise non-routine exam, signifying a high retention of clinical discipline knowledge. Findings from the current study expand on the effectiveness of the curriculum across medical school years with respect to knowledge retention.

A study done among medical students utilizing the CP curriculum showed a favorable response to the use of schema in the CP curriculum. 9 In our study, we could not evaluate the use the schemas of CP to perform clinical assessment in order to reach the appropriate diagnosis. We recommend further studies in this respect. Additionally, long-term knowledge retention was not tested in our study, which could be another important area of investigation.

This study has several other limitations as well. The study was conducted at a single institution, thereby potentially reducing the overall generalizability of the findings. The faculty members recruited as participants for assessing the perceived effectiveness of the curriculum were also involved in the adaptation and development of curriculum at PAHS, hence, potentially increasing responder’s bias in the study by some degree. The cross-sectional nature of the study provides only a limited understanding of the effects of the curriculum over the long term.

Based on this study, we can conclude that both faculty and students perceive the CP curriculum system as an effective teaching and learning method in medicine, irrespective of their demographic and positional characteristics. The findings suggest higher knowledge retention in knowledge by implementing the CP curriculum during clinical clerkship years. Since the 1990s, CP Curriculum has been established as a multidimensional teaching-learning method in many medical school systems. In the evolving medical education world with rapid digitization, massive turnover of medical and education data, and increased use of remote learning methods, a deeper understanding of influencing variables will help effectively utilize this highly valued curriculum.

Data availability

Authors' contributions.

SAY, SKJ, AA, and BD conceptualized and designed the study. All 9 authors; SAY, SJ, SP, SG, SB, AA, BD, NB, and SY contributed to data analysis and interpretation. SAY and SP wrote the first draft of the article. All 9 authors, SAY, SP, SG, SJ, SB, AA, BD, NB, and SY critically revised the manuscript and approved the final version of manuscript for publication.

Acknowledgements

We thank Prof. Dr. Kedar Prasad Baral and Prof. (Associate) Shital Bhandary for their immense help during this research. We thank all respondent faculty and medical students of PAHS for participating in the study.

[version 1; peer review: 1 approved

Funding Statement

The author(s) declared that no grants were involved in supporting this work.

Reviewer response for version 1

1 Health Action and Research, Kathmandu, Kathmandu, Nepal

2 International Agency for Research on Cancer, Lyon, France

Dear author(s),

Thank you for your hard work on this research manuscript. Please find my comments/ queries below.

The research article deals with the effectiveness of Clinical Presentation (CP) curriculum in teaching clinical medicine to undergraduate medical students. CP curriculum is yet to be adopted in many low- and middle-income countries. The results show that the medical students and the faculty were satisfied with the CP curriculum and believed CP as a stand-alone method of teaching as well as in conjunction with traditional methods of teaching could benefit medical students.

Study design:

“This is a cross-sectional study that aims to evaluate the efficacy of the CP curriculum in teaching different disciplines of clinical medicine to undergraduate medical students of PAHS, which is currently the only medical school implementing the CP-curriculum in undergraduate medical education.”

• Is PAHS the only medical school implementing the CP-curriculum in Nepal or worldwide?

Ethics and consent:

“Students who gave verbal consent were asked to complete the questionnaire together in class.”

• Please elaborate on this sentence.
• Was any faculty member present in the class?
• Was the test compulsory or optional?
• Did the students have the right to refuse the test or leave the test in between?

Data collection:

• Was the questionnaire in English?
• How long did the questionnaire take to complete?
• How much time were the respondents given to complete the questionnaire?
• What were the minimum and maximum possible scores (total or based on questionnaire sets)?

I hope the comments are useful and would enable the author(s) to strengthen this study.

Is the work clearly and accurately presented and does it cite the current literature?

If applicable, is the statistical analysis and its interpretation appropriate?

Are all the source data underlying the results available to ensure full reproducibility?

Is the study design appropriate and is the work technically sound?

Are the conclusions drawn adequately supported by the results?

Are sufficient details of methods and analysis provided to allow replication by others?

Reviewer Expertise:

Global health, gerontology, cancer

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Jayadevan Sreedharan

1 Department of Community Medicine, Gulf Medical University, Ajman, United Arab Emirates

Title: Effectiveness of Clinical Presentation (CP) Curriculum in teaching clinical medicine to undergraduate medical students: A cross-sectional study.

This study aimed to assess the perceived effectiveness of students and faculty and the level of knowledge among the students trained by the CP curriculum. The authors assume the CP curriculum is not inferior to traditional lecture-based teaching.

Are sufficient details of methods and analysis provided to allow replication by others?: 

It is not clear why the authors have given MCQ to the faculty (their score is given and statistical test done).

If applicable, is the statistical analysis and its interpretation appropriate?:

The authors mentioned in the article that "Classical ANOVA for equal variance and Welch ANOVA for unequal variance were used after testing the homogeneity of variance, and post-hoc/Tukey test was used for significant classical ANOVA results", where they have used this test is not clear in the manuscript.

The p-value is given in exact value; the importance of p-value is to check whether to accept the null or alternate hypothesis. In the methodology, they mentioned that p-value >0.05 is not significant. Then what more information do the readers get if they include the actual p-value? 

The sample size of this study is very small and the conclusion from this study can not be generalised to the entire population. 

The authors mentioned in the conclusion that "The findings suggest higher knowledge retention in knowledge by implementing the CP curriculum during clinical clerkship years" . How the authors reach this conclusion is unclear.

Epidemiology, Biostatistics, Medical education, Public health

Priyanka Panday

1 California Institute of Behavioral Neurosciences & Psychology, Fairfield, CA, USA

This article focuses on the importance of the clinical presentation (CP) curriculum in a particular institute (Patan Academy of Health Sciences (PAHS)) among medical students and faculty in terms of their preference and performance on a surprise non-routine exam. 

• Cross-sectional study is appropriate as a study design for this article.
• Relevant articles from 2020, 2019, and 2004 have been appropriately cited as references.
• The methods used for data collection, as well as the result of the study has been elaborated in detail to ensure accuracy.
• Results are presented in a tabular form and the conclusion derived coincides with the results indicating the effectiveness of the CP curriculum system as an effective teaching and learning method in medicine.
• As far as the statistical analysis is concerned, it is not my area of expertise. However, p< 0.05 for response of effective implementation of the CP curriculum and the response from faculty is statistically significant.

I cannot comment. A qualified statistician is required.

Endocrine disorders, Heart conditions, Medications, COVID-19, Obstetric conditions, Epilepsy, HIV, etc.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Expanding Clinical Spectrum of Anti-GQ1b Antibody Syndrome : A Review

• 1 Department of Neurology, Korea University Medical Center, Seoul, South Korea
• 2 Neurotology and Neuro-ophthalmology Laboratory, Korea University Anam Hospital, Seoul, South Korea
• 3 Biomedical Research Institute, Seoul National University Bundang Hospital, Seongnam, South Korea
• 4 Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
• 5 Deparment of Neurology, Seoul National University College of Medicine, Seoul, South Korea
• 6 Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Pusan, South Korea

Importance   The discovery of the anti-GQ1b antibody has expanded the nosology of classic Miller Fisher syndrome to include Bickerstaff brainstem encephalitis, Guillain-Barré syndrome with ophthalmoplegia, and acute ophthalmoplegia without ataxia, which have been brought under the umbrella term anti-GQ1b antibody syndrome . It seems timely to define the phenotypes of anti-GQ1b antibody syndrome for the proper diagnosis of this syndrome with diverse clinical presentations. This review summarizes these syndromes and introduces recently identified subtypes.

Observations   Although ophthalmoplegia is a hallmark of anti-GQ1b antibody syndrome, recent studies have identified this antibody in patients with acute vestibular syndrome, optic neuropathy with disc swelling, and acute sensory ataxic neuropathy of atypical presentation. Ophthalmoplegia associated with anti-GQ1b antibody positivity is complete in more than half of the patients but may be monocular or comitant. The prognosis is mostly favorable; however, approximately 14% of patients experience relapse.

Conclusions and Relevance   Anti-GQ1b antibody syndrome may present diverse neurological manifestations, including ophthalmoplegia, ataxia, areflexia, central or peripheral vestibulopathy, and optic neuropathy. Understanding the wide clinical spectrum may aid in the differentiation and management of immune-mediated neuropathies with multiple presentations.

Read More About

Lee S , Kim H , Choi J , Choi K , Kim J. Expanding Clinical Spectrum of Anti-GQ1b Antibody Syndrome : A Review . JAMA Neurol. Published online May 13, 2024. doi:10.1001/jamaneurol.2024.1123

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• Open access
• Published: 14 May 2024

Designing for student autonomy combining theory and clinical practice – a qualitative study with a faculty perspective

• Charlotte Silén 1 ,
• Katri Manninen 1 , 2 &
• Angelica Fredholm 1 , 3  

BMC Medical Education volume  24 , Article number:  532 ( 2024 ) Cite this article

Metrics details

Although extensive research exists about students’ clinical learning, there is a lack of translation and integration of this knowledge into clinical educational practice. As a result, improvements may not be implemented and thus contribute to students’ learning. The present study aimed to explore the nature of clinical faculty members’ learning related to how they apply research about student autonomy.

A course, “Designing learning for students’ development of autonomy in clinical practice” was conducted for faculty responsible for students’ clinical education. Within the frame of the course the participants designed a project and planned how they would implement it in their clinical context. Fourteen clinical faculty members participated in the study. The participants’ interpretation of the educational intervention, which combines complex theory with the equally complex clinical practice, was explored by studying how the participants’ approaches and understanding of the facilitation of autonomy were manifested in their projects. The projects in the form of reports and oral presentations were analyzed using qualitative content analysis together with an abductive approach.

One identified domain was “Characteristics of the design and content of the projects”. This domain was signified by two themes with different foci: Preparing the soil for facilitating student autonomy ; and Cultivating opportunities for students to actively strive for autonomy. A second identified domain, “ Embracing the meaning of facilitating autonomy ” was connected to participants understanding of theories underlying how to support the development of autonomy. This domain contained two themes: Connection between activities and autonomy is self-evident and Certain factors can explain and facilitate development of autonomy.

Education directed to strategic clinical faculty members to develop evidence-based approaches to student learning can be productive. To succeed there is a need to emphasize faculty members individual understanding of actual research as well as learning theories in general. Faculty trying to reinforce changes are dependent on their own mandate, the structure in the clinic, and recognition of their work in the clinical context. To achieve a potential continuity and sustainability of implemented changes the implementation processes must be anchored throughout the actual organization.

Peer Review reports

Clinical education is a comprehensive part of health care education programs and therefore important and vital for health care students to become knowledgeable well-educated professionals. Research on students’ clinical learning has been extensively reported but there is still a lack of translation and integration of this knowledge into clinical educational practice. This is a problem when trying to improve clinical training and there is a need to understand more of this matter. Hence, this study explores clinical faculty members’ learning related to how they apply research.

Introduction

The clinical environment offers a rich and powerful setting for learning and professional development [ 1 , 2 , 3 ]. In the clinical environment, abstract knowledge becomes tangible through its application in patient care. Students’ encounters with patients and staff representing their own and other professional groups provide unique experiences to reflect on and integrate in their learning. They can train and test their skills, observe, and examine patients, and provide care and treatment. Generalizable knowledge about diseases and their impact on people’s lives can be realized in each patient encounter. The variation that every patient encounter and personal experience offer enhances this knowledge. Learning in every encounter is not only related to the clinic as a physical place per se, but to relationships and experiences relating to this encounter [ 4 , 5 , 6 ]. As such, the clinic and the activities that occur in the clinic offer an inherent space for learning. This learning space provides contact with the reality of future professions, provides challenges, motivational factors, and feedback on behavior and thoughts. In this way, knowledge and professional development increases [ 2 , 3 , 7 , 8 ].

Crucial aspects of creating and taking care of the rich opportunities for students’ learning are linked to the clinical environment, clinical supervisors and other stakeholders involved in the organization and implementation of clinical education. Responsible actors must engage, understand and be able to apply knowledge about how to support student learning to contribute to development. There is extensive research available regarding how to make the clinical learning environment fruitful for learning and to support students to reach their learning goals, while becoming well educated and well-functioning professionals (cf. [ 2 , 3 , 4 ], [ 8 , 9 , 10 , 11 ]).

However, several researchers point out that there is a lack of translation and integration of research-based knowledge into educational practice in the clinic [ 12 , 13 , 14 , 15 , 16 ]. This means that the main problem is not a lack of knowledge about student learning in the clinic, but the issue is why available research-based knowledge is not sufficiently applied. The complex nature of healthcare, the many faculty members involved, the lack of continuity related to education, and the fact that the education takes place in two different arenas – the university and the clinic – may explain some of the hindrances [ 14 , 15 , 16 , 17 ]. A major challenge in the development of health-care education is reaching and motivating faculty members to enhance their knowledge on how to improve student learning. This is especially true for faculty members involved in clinical education since their role mainly focuses on patient care and not on student education [ 12 , 13 ]. There is an expressed need for research illuminating how further professional development for faculty members can lead to improvement of clinical education [ 12 , 13 , 14 , 15 , 16 ]. In particular, studies are needed to examine the connection between the individual clinical faculty member and their application of knowledge in the clinical context. A more in-depth understanding of these connections is paramount to support clinical faculty members to integrate research and thereby enhance student learning.

In the present study, an educational intervention directed to faculty responsible for students’ clinical education was designed, executed, and studied. The intervention sought to improve how clinical faculty understand and apply research regarding what may influence and stimulate student autonomy in clinical education. In connection with the educational intervention, a study was carried out that aimed to examine faculty learning in terms of integration of theoretical knowledge in the clinic. The findings were meant to contribute to the understanding of how to support clinical faculty members to apply educational research on autonomy and thus enhance learning and consequently professional development for students in the clinic.

Autonomy and professional development

Development of autonomy is known to be crucial for student learning and professional development in the clinical setting. This concept was therefore chosen as the core of the intervention and this study. Nevertheless, autonomy is a complex concept, and its meaning is not possible to cover fully in the context of this study. The most fundamental aspects deemed important for this study will be presented below.

According to substantial research, autonomy is a fundamental need to experience self-governance and ownership of one’s actions [ 3 , 18 , 19 , 20 , 21 , 22 , 23 ]. Development of autonomy in learning is the foundation of life-long learning, meaning the ability to move on, constantly reevaluate your own knowledge, ability to obtain and use information, and understanding of your learning processes [ 18 , 19 , 24 ]. Studies about promoting self-directed and/or self-regulated learning have shown the importance of taking into account factors such as student motivation, experience of control, ability to seek and apply knowledge, ability to discern learning needs and ability to evaluate the outcome of learning [ 18 , 25 , 26 , 27 ]. Clinical practice needs autonomous health care providers, and here autonomy means something more than independence and control over your own learning. It has been shown that autonomy fosters personal identity and meaning, independent choices, responsibility, and critical thinking [ 19 , 20 , 21 , 22 , 23 ]. Important for professional competence is the ability to discern, assess, and pose new questions in unclear and incalculable situations [ 23 , 24 ]. Research shows how a curriculum designed to strengthen autonomy can create a qualitatively different understanding of a subject or professional field, as demonstrated in student’s ability to link theory and practice with abstract thinking [ 22 , 24 ].

In this study autonomy has been particularly connected to the meaning of authenticity and attachment. These concepts are identified as important parts of autonomy related to learning and professional development [ 2 , 3 , 22 , 28 , 29 ]. The rationale for this statement is outlined below. Autonomy is connected to authentic experiences in clinical training. It is also indicated that transformative learning processes that contribute to the development of a professional identity can be triggered by authentic experiences and the meaning-making of these processes [ 3 , 28 ]. Manninen et al. [ 29 ] showed how authenticity in clinical education functions as a driving force for learning by creating meaning and relevance. Furthermore, Manninen [ 2 , 29 ] has identified how authenticity can be both an external and an internal phenomenon, where external authenticity is produced by education and the surrounding environment – such as the interaction with patients in a clinical setting. Internal authenticity is experienced when students form mutual relationships with patients, feel a sense of belonging and perceive themselves as part of the team [ 2 , 29 ]. Levett-Jones & Lathlean [ 30 ], stress the positive effects on learning that occur when students experience a sense of belonging in their clinical practice. These experiences of relationships and sense of belonging are captured in the concept of attachment and linked to the development of autonomy [ 3 , 28 ]. Students need to be offered participation as well as actively strive to attach themselves to the actual clinical context in order to experience authenticity and autonomy in their learning. Prerequisites for students to experience and to seek attachment are based on mutual trust and respect [ 31 , 32 ]. Several studies [ 3 , 21 , 22 , 28 , 29 ] showed how both autonomy and authenticity are social phenomena having to do with the relationships that students can form in their clinical education and the clinical relevance of given tasks. Thus, students can develop as autonomous professionals when they experience both external and internal authenticity. This includes opportunities to experience attachment and gain responsibility for relevant parts of patient care, as well as the opportunity to follow up on administered care [ 2 , 3 ]. Students need to have access to and responsibility for entire processes, such as being able to evaluate the results of care and not just isolated actions or events. This reasoning applies to students, regardless of the clinical placement level since the complexity and length of processes can vary [ 33 , 34 ].

Designing for learning in the clinic

To further professional development, the design of learning in the clinic should offer students opportunities to experience through emotion and action what it means to be a professional nurse, doctor, or physiotherapist, etc [ 35 ]. By doing so, the risk for a narrow and static approach to knowledge decreases, thus making it easier to focus on knowledge application and the complexity of professional knowledge. A comprehensive review of the literature by Trede et al. [ 36 ] shows that the development of a professional identity is facilitated by learning based on cooperation and dialogue in practice and characterized by authentic experiences. Education should be designed to raise awareness of what autonomy means in clinical education to enhance student learning and the development of a professional identity. In turn this demands that clinical faculty members understand the concept and can integrate it in clinical education. The clinical application of evidence-based concepts means the ability to combine concepts and theory with a complex clinical practice [ 12 , 14 , 16 , 17 ]. This is regarded as a challenge for faculty responsible for developing clinical education and supporting students in their learning.

For the purpose of this study, an educational intervention was designed to present, explain, and illuminate theory and research related to supporting students’ development of autonomy. The study reached out to participants working in strategic positions in different clinical settings that enabled them to contribute to the design and development of clinical education in collaboration with different universities and educational programs. The participants designed and planned the implementation of a project aimed at enhancing student autonomy in their clinical context. The aim of this study was to explore the nature of clinical faculty members’ learning related to how they apply research about student autonomy in their projects .

The research approach was qualitative, interpreting participants’ experiences from a life-world perspective. The interpretation of meaning and lived experience was made possible through the tradition of phenomenological hermeneutics founded by Heidegger and further developed by Gadamer and Ricouer [ 37 ]. It is argued here that the lifeworld is mediated through narratives where individuals’ subjective understanding and sense-making of their lifeworld become visible [ 38 ]. Thus, the individual projects portrayed and studied here are viewed as narratives that manifest understanding of the phenomena under examination, the meaning of which is revealed through interpretation.

Pedagogical framework for the intervention

The pedagogical framework described in the background regarding the development of autonomy and professional identity formed an important part of the content of the designed educational intervention and the present study. Additionally, the educational intervention was based on constructivist learning theories that emphasize active, creative processing of information, including cognitive, emotional, and social aspects as well as testing and practical actions (cf. [ 35 , 39 , 40 , 41 , 42 ]). In the applied pedagogical framework, the lifeworld is seen as the total sum of the environment and everyday experiences that forms the individual’s world, thus forming the basis for the individual’s interpretations, thoughts, reactions, and actions [ 43 ]. Learning was seen as fundamentally situated in a physical as well as social and cultural context [ 39 , 40 , 43 ].

The intervention, a course, “Designing learning for students’ development of autonomy in clinical practice”, was designed for health-care professionals responsible for students’ clinical practice in Stockholm County Council, or other participants with similar overarching clinical pedagogical work assignments. The relevant faculty role for this in Sweden is often an adjunct clinical lecturer (ACL) and this term will be used in the following description of the participants. They have their main employment and activities in the health care sector outside of a higher education setting and provide the university with specific expertise not found within the organization. The ACL supports both clinical supervisors and students at the clinical workplace, has the possibility to influence prerequisites for clinical education and functions as a bridge between the university and the local clinical education organization.

The intervention – “Designing learning for students’ development of autonomy in clinical practice.”

The purpose of the course that constitutes the intervention in the present study was to strengthen the pedagogical competence of the ACL for her/him to understand the meaning of research-based knowledge about learning, and how to apply this knowledge in clinical supervision and teaching. The goal was that the ACL should be able to contribute to and support students’ opportunities to develop autonomy in learning. The intervention was designed aiming to help ACLs understand research about how to facilitate autonomy in clinical practice. The intervention design was built on the pedagogical framework described above. In one extensive and concluding learning activity, participants designed and implemented projects aiming to enhance student autonomy in their clinical context. These projects constitute the focus for analysis in this study.

The course was given online and included 5 weeks full-time study. The online design was believed to enhance accessibility and enable adaptation to individual clinical contexts. It was spread over 6 months to allow time for the participants to process the content of the course and to plan and implement their projects. The course consisted of both asynchronous parts and synchronous meetings using Zoom. However, the online design of the course and the analysis of outcomes related to this design is not within the scope of this study. Two of the authors, (CS, AF) were responsible for the course and acted as lectures and tutors. Other experts were invited to the synchronous meetings giving lectures and participating in discussions. A digital learning platform was created, and the participants were divided into groups of 4–5 participants and one tutor, who worked together mainly asynchronous online. The groups were mixed in terms of professional background and the nature of their clinical workplace to learn from each other and provide a range of perspectives while working with different learning activities. The content of the course was focused on the meaning of autonomy in learning and its application in clinical practice for students. The participants worked individually with written tasks and communicated with their group members and the tutor. They were asked to build on their previous knowledge and experiences and actively apply new knowledge and thoughts. The tutor facilitated communication in the group by posing questions and commenting on the written work and discussions. All learning activities were designed to allow participants to discern the relevance and implications of theory in their own individual clinical context and describe this with concrete examples. The core concepts of autonomy, authenticity and attachment were presented in lectures online and discussed synchronously. These lectures were also available on the digital platform.

In one extensive and concluding learning activity, participants designed and implemented projects aiming to enhance student autonomy in their clinical context. Participants worked on the project throughout the course, from a preliminary project plan to implementation, and evaluation. The projects were discussed in their groups as well as individually with the tutor. The projects were presented as written reports and final oral presentations synchronously in zoom. In the written reports, they described the design, theoretical background, implementation, and outcome of the projects. For the oral presentations, participants were asked to focus on what they perceived as most meaningful in their projects and how they applied pedagogical knowledge and reasoning.

Participants

The course was open to all ACLs in the region. A written invitation to the course was spread through the regional network where ACLs are registered. A pedagogical course within higher education comprising at least 5 weeks full time study was required to take the course. The participants of the course were informed about the study and could volunteer to take part or not. There were 15 ACLs that took part in the course and fourteen of them participated in the study: seven registered nurses (five with postgraduate specialist nursing education), two radiology nurses, two biomedical analysts, one physician, one speech therapist and one occupational therapist. All participants were women, aged 36 to 63, with ACL experience from 1 to 13 years.

The context in which the study participants were active as ACLs mirrored the variations of the health-care field. Variations came to the fore related to in-patient and out-patient care, medical specialty and whether the unit offered a specialized service, such as a laboratory, radiology, or anesthesia at an operating department. The responsibilities and tasks of the ACLs were different. Some of them were responsible for students from one profession at various sites and others responsible for one unit and all students at that site. Others coordinated both supervisors and students within one unit, while others mainly acted as supervisors with a special assignment to act as an ACL at a specific site. The number of and kinds of students placed at the different units varied. In most cases, the ACLs were responsible for students from one profession and one educational level – undergraduate or postgraduate – but there were also examples involving several professions and different educational levels. The organization of the students’ clinical placements governed the ability for the ACL to plan activities. There were variations in the length of the placement and whether students stayed in one place or rotated between different departments. What could be designed to stimulate student autonomy depended on what the students were supposed to learn for their profession and on their educational level.

Data collection

As described above the participants’ projects were chosen as objects for analysis. Data were collected using the written and oral accounts of the projects that constituted the concluding learning activity in the course. There were 11 projects included in the data. Three of them were collaborative projects where participants worked together; in two cases in the same clinic and specialty, and in one case from two different hospitals but in the same clinical specialty. Written accounts in the form of project reports were used together with video- and audio-recorded oral presentations of the projects.

Data analysis

Based on the learning theories presented in the pedagogical framework for the intervention, the point of departure for the analysis was that ACLs showed what they had learned by planning and implementing projects in their own clinical setting with the aim of contributing to and supporting the students’ opportunities to develop autonomy. The application of the theory they had studied, i.e., the discernment of the meaning of the theory in the clinical context and in everyday practice, was made by the ACLs. Thus, it was the participants who expressed how they would use what they had learned to bridge the gap between theory and practice.

The participants’ learning was analyzed based on the written projects together with the oral presentation of these projects. An interpretative content analysis of both the manifest and latent content was performed [ 44 , 45 ]. The manifest content refers to data close to the expressions used by the participants, in this case the written and oral descriptions of the projects. The latent content refers to the authors’ interpretation of the meaning of what is expressed related to the development of autonomy. An abductive approach was also applied, and thus data were analysed iteratively going back and forth between parts and wholes, both inductively, and deductively informed of theoretical perspectives during the research process [ 46 ]. The theoretical foundation for analysis was the above-described concepts furthering the development of autonomy. The inductive part of the analysis aimed to contribute to new perspectives and a development of how these concepts can be interpreted.

Condensed meaning units were extracted in the written projects and the video- and audio- recordings and subsequently coded. The codes were compared for differences and similarities and grouped into categories describing variations in focus and approaches to support development of student autonomy. In the next step, categories were interpreted and designated as latent themes. The identification of manifest and latent content of the participants understanding of theories underpinning autonomy, was built on revisiting the condensed meaning units and codes with focus on critical features, the relationship between concepts and practice, and how concepts were connected [ 44 , 45 ]. Thus, one project can be represented in both themes and several of the categories. Examples illustrating the steps of the data analysis process are described in Appendix 1. Two of the authors (CS, AF) performed the basis of the analysis iteratively independently and together. Emphasis was put on reflexivity concerning preconceived interpretations related to the researchers’ involvement in the course. The preliminary findings were critically reviewed by the third author (KM), less involved in the course, and then discussed and negotiated between all the authors to achieve consensus. All authors have extensive knowledge and experiences of clinical education as teachers, clinical supervisors, and as experienced qualitative researchers in medical education. The researchers’ collaborative analysis was meant to contribute richness and credibility to the findings.

The analysis of the content and implementation of the participants’ projects is described in two domains. A: Characteristics of the design and content of the projects, and B: Embracing the meaning of facilitating autonomy. Domain A was related to the description of the projects based on who was engaged and the focus of the content of the implementation. The categories and themes related to domain A illustrate the outcome of learning in terms of how they organize activities to implement student autonomy. The basis for the categories and themes in domain B was the analysis of the meaning of the projects and how the participants talked about how to achieve autonomy. The findings in Domain B relate to the participants’ learning in terms of their understanding of how to apply the theories underlying the support for the development of autonomy. An overview of the findings is displayed in Fig.  1 . Quotes are presented with numbers of the participants and marked with oral account (oa) and written account (wa).

- Overview of findings

Domain A: Characteristics of the design and content of the projects

The way the participants designed and described their projects on how to support students’ development of autonomy in clinical practice varied. Two themes with different foci were identified; Preparing the soil for facilitating student autonomy; and Cultivating opportunities for students to actively strive for autonomy . The first theme comprised two categories; Engaging supervisors to support student autonomy and Emphasizing organizational dimensions that have an impact on implementation. The second theme was characterized by the two categories Activities involving students during significant parts of their clinical placement and Specific activities focused on certain knowledge and skills. The content of Domain A is illustrated in Table  1 .

Preparing the soil for facilitating student autonomy

Several participants chose to prepare the soil , that is, they utilized their knowledge of developing student autonomy to prepare the clinical practice environment for the students. Within this theme two categories were identified: Engaging supervisors to support student autonomy and Emphasizing organizational dimensions that have an impact on implementation. The first category focused on the supervisors, and the second took a broader approach, including the structural factors of the clinical placement, the supervisors’ role, and managers on different levels.

Engaging supervisors to support student autonomy

To reach the goal of fostering independence in students, the supervisors in the clinic were engaged by the ACLs. One approach within this category was to focus on support for supervisors by offering written plans, advice and thoughts on factors that have an impact on student independence in the clinic.

The documents written by the ACL varied between concise information sheets, and comprehensive plans on activities. The documents contained hints and advice about how supervisors should act to facilitate student independence. The supervisors’ responsibilities in relation to the students were also pointed out. A document could be created by the ACL, presented, and handed over to the supervisors to use. Other documents were authored by the ACL, presented, discussed, and adapted to the supervisors’ comments before they were finalized and used.

“In the meeting with the supervisors, we used time to discuss the guide (advice to the supervisors to support student autonomy). Many supervisors attended the meeting …we believe we have created a great participation” (No 12 and 13, oa).

Another example was a comprehensive operational plan aiming to develop a pedagogical framework for supervision that would increase the supervisors’ own confidence, allowing the students to practice autonomy in their professional role.

“The plan is that the supervisor guides the student from Active Observations, involves the student to Work Together, then invites the student to Take a Lead and finally Work Independently “ (No 1, wa).

The ACLs instructions to the supervisors differed. In some cases, the content of the documents was left for the supervisors to use as they saw fit, while other documents contained prompts on how to use it and how to act.

Follow ups of the content of the created documents and usefulness of the initiated guidance for the supervisors varied. In some cases, there were no systematic plans for follow up, while others discussed and revised the content of the document.

Another approach within the category of preparing the soil was signified by activities that process the meaning of and facilitation of autonomy. The aim of these activities was to stimulate reflection on factors affecting the development of autonomy to ensure continuation.

“To make the implementation [new activities] work, there is a need for careful and long-term planning ….it takes even more communication [ between different stakeholders ] …and it must be adapted to the students’ actual clinical placement” (No 8 and No 14, wa).

An activity taking the form of a workshop was characterized by the ACLs presenting what autonomy and factors stimulating student development might mean for the students.

“I created a workshop and gave a lecture about the concepts we had studied in the course – about how to facilitate autonomy…. I talked about attachment, trust, and authenticity and how that relates to autonomy” (No 10, oa).

One activity consisted of recorded lectures by the ACL combined with prepared tasks for the supervisors to complete. In the lectures, the different factors presented in the course that the ACLs had attended were presented. Through the tasks, the supervisors were encouraged to reflect on what these factors might mean for their students in their own clinical context. It was up to the supervisors to decide when they wanted to study the recorded material.

“The recorded lectures combined with tasks were meant to provide those responsible for the students in clinical practice knowledge about factors influencing students’ possibilities to reach autonomy during their placement……It would provide them with tools and ways of thinking to be able to change the organization of the clinical practice towards the goal of increased autonomy for students” (No 11, wa).

Emphasizing organizational dimensions that have an impact on implementation

In this category, the importance of considering organizational structures of both the health-care unit and the students’ clinical education when implementing measures to stimulate student autonomy were pointed out. The dimensions brought up and considered in the participants’ projects were the structure of the clinical practice, such as how responsibility of supervision was distributed, and the total number of students at the unit, but also the spread of students over a semester. The ACLs considerations included the duration of the placement, how and whether the students were rotating between different sections at the unit or stayed in one place. To enhance development of student autonomy, the idea of continuity in supervision was emphasized, and to maintain sustainability, managers on several levels were engaged in the planning, as were supervisors.

” We involved managers and administrative assistants in our planning…. administrative assistants plan supervisors’ work schedules and thus influence their work…. a pedagogical encounter was set up to engage them [ managers and administrative assistants ] in a pedagogical discussion…. We also created a group with supervisors from different departments of the clinic to discuss the project and the purpose of the idea of achieving continuity” (No 8 and No 14, wa).

Communication and cooperation with the university was stressed as crucial for whether the supervisors succeeded in facilitating student autonomy. There was an agreement among the ACLs in this category on the importance of including managers from different levels to succeed with the planned project.

” We contacted our manager and presented the project to her, and we contacted our administrative assistants and informed them about who the main supervisors were so that their shift work would not be affected” (No 4, oa).

Cultivating opportunities for students to actively strive for autonomy

In this theme, cultivating opportunities for students , another significant approach to use the knowledge of autonomy was identified. The ACLs planned activities directly to students to stimulate their development of autonomy. The theme consists of two categories: Activities involving students during significant parts of their clinical placement and Specific activities focused on certain knowledge and skills.

Activities involving students during significant parts of their clinical placement

Activities in this category were planned to capture multiple competences and were integrated throughout most of the practice period. A characteristic activity planned by the ACLs included in this category involved assignments that were identified and described for the specific students to complete in pairs.

“Learning activity: The students listen and observe a professional encounter with a patient. Afterwards they attend a workshop about how to document data in a patient’s chart…. The students work together and give each other feedback …. they are asked to go on working like this, writing on their own, discussing with each other and after that consulting the supervisor” (No 10, oa).

The planned activities were related to students’ vocational training and involved ideas about progression regarding students’ possibilities to act autonomously and the complexity of the assignment itself. Students trained different skills on their own and did not only watch their supervisors. They had to make choices between different actions, such as how to proceed in a certain situation, as well as judge when an assignment was finished and how it should be reported. Similar activities were also planned for other students without emphasis on peer learning. Instead, the supervisor continuously identified learning tasks for one student at a time, and thus independence was gradually required.

Variations could be noted in the ACLs approach to stimulating autonomy in these activities. In some cases, the learning tasks were planned in detail by the ACL and the training was limited to certain skills and behaviors. Other approaches were planned to continuously encourage the student to take responsibility and perform independently.

…the supervisors were encouraged to give students increased responsibility, e.g. by allowing them to be supervised by colleagues/other professions/other students and receive more assignments to solve themselves…. such as that they can develop a sense of autonomy in parallel with a sense of belonging with the whole health-care team and the workplace.” (No 10, wa).

Students’ reflections on their own performance were emphasized as important to stimulating development of autonomy. Sometimes, the reflection sessions were mainly about how the tasks had been carried out. In other cases, the students’ own perceptions about their progression towards autonomy were also important to discuss.

“The ACL met the student and the supervisor every week to reflect, based on a certain model. The core concepts of autonomy, authenticity, attachment, trust, and professional identity were discussed to evaluate whether the students felt that they experienced autonomy at the clinical placement. The students were asked to write in their logbook and their questions were discussed during the weekly reflection time.” (No 7, wa).

Specific activities focused on certain knowledge and skills

In this category, ACL’s planned projects contained learning tasks that focused on single skills completed at a specific time during the placement. The aim was to stimulate the development of autonomy in different ways connected to this learning task. A typical kind of activity was characterized by the ACL creating conditions for the students’ training but leaving the implementation to the students. These kinds of activities could be about connecting well-planned written tasks to common clinical issues for the patients who were cared for on the ward. The students could choose when to review the written tasks and how to perform them.

” It is difficult for students to feel attachment and ‘to be nurses’ on the ward when they are there for a short period of time, the patients are very ill, and they don’t have the right knowledge and skills to independently take care of them. I created written learning activities for students to work with on their own or together with other students…it meant that they could select a patient to talk to, search for knowledge and consider questions about a patient’s status and appropriate care” (No 5, oa).

Another activity took the form of a room prepared with equipment, offering opportunities for students to independently train important professional skills. The aim of this activity was to facilitate autonomy and critical thinking within postgraduate nursing specialist training.

“The students can practice together to supervise the monitoring and treatment of a simulated patient based on an authentic scenario. This means that they themselves lead the activity and must make important decisions and reflect on the outcome after a presentation of a project (No 2, oa).

Most activities planned by the ACLs focused on one profession at a time but there was one example targeting interprofessional learning. Interprofessional seminars were implemented for students to learn about other professions from their peers, and these seminars were followed up with reflections on what professional teamwork meant for the development of professional autonomy.

Domain B: Embracing the meaning of facilitating autonomy

The participants’ choices of design and the ways they described and talked about their projects also reflected a dimension of their learning related to their theoretical understanding of development of students’ autonomy. The analysis of the participants’ descriptions of how different factors facilitate and relate to the development of autonomy resulted in the outcome of two qualitatively different perceptions, here designated as two themes: Connection between activities and autonomy is self-evident and Certain factors can explain and facilitate development of autonomy. The first theme consists of one category: Lack of reasoning about the meaning of autonomy . In the second theme, two categories emerged: The concept of autonomy as a core value and Various factors are linked to the development of autonomy. The content of the domain is illustrated in Table  2 .

Connection between activities and autonomy is self-evident

One category denoted this theme, namely the lack of reasoning. The activities were described as facilitating autonomy, but there was no explanation for the underlying ideas of why the activities facilitated autonomy. One example is that a project was meant to introduce peer learning and activities for the students were thus described. These activities could involve students training skills on their own and they were asked to make their own decisions and discuss with their peers. However, there was no elaboration on how and why these activities were supposed to result in students becoming more autonomous. The relationship between activities and the ability to make choices and more independent decisions seemed to be taken for granted. Another example is the notion that activities directed at interprofessional education led to autonomy, which also was never explained.

“They develop autonomy as they see their own responsibilities as they are reflected in what other professions perform and are responsible for. It promotes their own professional development.” (No 9, wa).

Certain factors can explain and facilitate development of autonomy

The main qualitative difference between this theme compared to the first is that the participants explained and reasoned about how and why certain activities stimulated and led to independence. However, which factors that were brought up varied, as did the complexity of related explanations and reasoning.

The concept of autonomy as a core value

The level of understanding in this category was characterized by explanations and reasoning linked to the use of autonomy as an overarching concept. Here, an activity such as being asked to independently use a skill or to handle an encounter with a patient was chosen because this training would lead to student autonomy. When the project was introduced to supervisors or managers, the planned activities were mainly motivated by claiming that if students were given opportunities to act independently, it would foster autonomy in them. Factors brought up in the course as influencing development of autonomy were not used by the ACLs to elaborate on how to facilitate autonomy. They didn’t elaborate on any other factors brought up in the course as influencing the development of autonomy.

“When we thought about how to work with student autonomy, we decided to use peer learning. The students’ assignments are described, they work together, and the students take responsibility to carry them out. The students can stand on their own two feet… they are trusted” (No 6, oa).

Various factors are linked to development of autonomy

This category was characterized by an elaborate understanding of the meaning of autonomy and factors that have an impact on the development of autonomy. The ACLs reasoning about autonomy and other factors influencing autonomy was complex to a varying degree. Some participants explained and related their activities to one or more factors.

“…the students meet new supervisors very often, generally speaking every day… this leads to obstacles for student learning, and it makes it difficult to develop autonomy and authenticity. Both the students and the supervisors become ambivalent when they must create new relationships almost every day” (No 8 and No 14, wa).

Others reasoned about how different factors were interdependent and related to facilitation of autonomy in a broader sense.

From a guide for supervisors: … we think this is about attachment, the students are invited, and they have got a place when they arrive….and this next guiding advice is connected to trust… we trust the student that they know a lot, but it takes time to learn this new specialty. It is about autonomy too – that the students take responsibility and think for themselves… Some supervisors are very controlling, so the students don’t have the possibility to practice how to really be critical care nurses, so they don’t experience authenticity” (No 12 and No 13, oa).

We argued in the background that a hindrance for development of a rich learning environment in clinical education is that available research-based knowledge is not sufficiently applied [ 12 , 13 , 14 , 15 , 16 , 17 ]. A way to face this problem is to enhance knowledge about how clinical faculty members understand and integrate theoretical knowledge in clinical practice. In this study we examined projects designed and implemented by clinical faculty members to find out how they, in this case, applied research about student autonomy in clinical education. The projects were the final part of a course introducing theories and research on the importance of students’ development of autonomy in clinical education. The purpose of describing and reasoning about these participants’ learning was to contribute to a deeper understanding of how to support clinical faculty to acquire and apply theoretical knowledge in clinical practice.

Two different domains mirroring the participants’ learning outcome were identified when their projects were analyzed. One domain concerned what they had decided to focus on to facilitate students’ development of autonomy and how they went about implementing their ideas in the clinic. The other identified domain involved the interpretation of the participants’ understanding of the theoretical framework underpinning autonomy as a concept. These findings expose different perspectives on how a course with a specific design directed at faculty members impacted their actions and understanding, i.e., the faculty members’ learning. The outcome of the course was encouraging in relation to the facilitation of student learning in clinical practice. All the participating ACLs projects contained activities and/or documents that involved some form of application of theories on how to facilitate student autonomy Some projects aimed to “prepare the soil”, such as educating supervisors and creating fertile ground for learning for the students. Another group of projects were planned directly for students, signified by “cultivating opportunities ” for them to practice autonomy through certain activities. Several studies have shown that the nature of clinical education is complex [ 12 , 14 , 16 , 17 ]. The students’ education takes place in two different arenas – the university and the clinic. Many faculty members are involved in clinical education, and their role mainly focuses on patient care and not on student education [ 12 , 13 ]. It became obvious that this complexity of clinical education influenced what the ACLs assessed possible to accomplish. This was mirrored in the choices that the ACLs made concerning the content and to whom they directed their projects. A comprehensive review of research on student learning in clinical practice found that issues about how to organize students’ learning were the most researched, indicating that organizational issues are an essential part of change [ 47 ]. The significant features of the health-care units in which the ACLs acted had a large impact on how they planned and implemented their projects. This underlines the importance of being familiar with the nature of context to introduce changes. The projects that were targeted supervisors, managers, and the organization presumably had an impact on a wider group of students compared to projects that were designed directly for a minor group of students or supervisors. This is important in relation to issues about sustainability. If faculty members on different levels in the clinic are engaged, ideas and knowledge about how to facilitate student learning can continue to develop and gain a foothold [ 14 , 48 , 49 , 50 ]. Projects involving managers and system levels are far more likely to become sustainable [ 13 , 15 , 17 , 48 ]. The activities planned directly for students, and where the ownership of the ideas was closely linked to the ACLs, run the risk of being dependent on a limited group of faculty members, and may cease as soon as the person in charge is not there.

The variety of planned activities and documents created by the ACLs displayed comprehensive understanding, challenges and shortcomings related to the meaning of autonomy. Two qualitatively different levels of understanding of autonomy and how different factors facilitate and relate to the development of autonomy emerged [ 3 , 22 , 24 ]. One level of understanding relied on a presumed self-evident relationship between an activity and student autonomy. The other level of understanding involved explanations for how different factors, such as authenticity, trust, and belonging, relate to the development of autonomy. These differences in learning outcomes are very important to consider in faculty development. We claim that a level of understanding that includes the ability to discern the meaning of theory in the clinical context and in everyday practice, is necessary to support others, such as supervisors and students, and implement sustainable change. The understanding of a situation and the understanding of the phenomenon that gives this situation meaning are connected. According to Marton and Booth [ 24 ] a situation is understood based on the phenomena involved – and the phenomena are perceived in light of the specific situation. When viewed in relation to the participants’ projects this meant that the understanding of the theory could be seen in the choices the participants made regarding their projects, what they perceived as important issues, how they proposed to solve these issues, etc. From a variation theory perspective, this is viewed as a matter of discrimination and differentiation, and learning is seen as the ability to discern these differences [ 24 , 35 ]. The space for learning, therefore, is the potential variation or difference provided by the situation [ 24 , 35 ]. Opportunities to participate in continuing professional courses and forums for discussions between ACLs may support the development of a deeper understanding of theory when it is linked to clinical practice.

In the design of the course emphasis was placed on participants creating and implementing a project. What did that mean for their learning? Some projects were quite limited, as they sometimes only comprised one document, or when an activity only reached a small group of students or a minor group of supervisors. This can be a shortcoming, but it is possible that further development and successful implementation is more dependent on the properties of the document or activity related to theoretical understanding and the ACLs ability to identify meaningful problems. If an initiative is well substantiated, there will be more opportunities to build on it [ 35 , 43 ]. Some projects were broader, where several activities were planned to be repeated and continued over time and they engaged both supervisors and students. These projects carry a high potential for successful implementation and impact on supporting student learning, since continuity and engagement increases opportunities for faculty members to learn [ 17 , 35 , 50 ].

Above, we have discussed how the ACLs’ learning manifested itself in the participants’ projects and how that reflected their understanding of theories about learning processes, connected to development of autonomy. The group of ACLs is particularly interesting as they support both supervisors and students and are responsible for bridging the education gap between the university and clinical practice. Understanding of the actual subject matter – in this case facilitating autonomy – turns out to be very important for the individual ACL to manage to drive development and change. It impacted problems that they discerned and identified, and the choices they made in their planning [ 24 , 35 ]. Successful implementation also seems to depend on the mandate of the change agents, in this case the ACLs and their awareness of the practices at their unit and on different management levels [ 13 , 17 , 48 , 49 , 50 ]. In addition to these requirements, we would argue that understanding how people learn in general is also critical to the implementation of new ideas. This statement is based on the application of the constructivist pedagogical framework underpinning this study [ 35 , 39 , 40 , 41 , 42 , 43 ]. If development is to occur, all stakeholders must process and understand the meaning of autonomy and be able to relate and link it to their practice [ 13 , 17 , 48 , 49 , 50 ]. The way the ACL communicated with and involved affected parties in their projects revealed their awareness of learning processes not only directed at facilitating autonomy. There were examples of projects in which an activity and/or a document was created by the ACL and the main strategy during implementation was to provide information about it to supervisors, managers, and students. This strategy essentially meant that no learning processes were initiated to facilitate understanding. In other projects, supervisors and/or students were involved to different extents in creating and making their own choices about how to perform suggested activities and review documents. These strategies encouraged the stakeholders to think about and react to practice, as well as reflect on what autonomy meant to them personally. Other factors conducive to active learning processes that were identified were planned follow-up opportunities, interactive feedback, and shared recurrent encounters to discuss documents and/or activities.

Strengths and limitations

The strength of this study lies in the theoretical and conceptual rigor applied throughout both the design process and the implementation of the educational intervention. There is also considerable procedural rigor due to the intervention being implemented with particularity and a firm epistemological stance. Limitations are connected to the sample of the study with only interested and ambitious learners who decided to take this course. However, this also contributes to rich data descriptions. There are notable challenges in studying an intervention that we as researchers have designed and the outcomes of this intervention. These challenges have been counteracted through constant reflexive discussions and questioning of assumptions.

This study shows that an educational intervention that emphasizes application of theoretical knowledge in clinical practice can enhance the development of evidence-based approaches to support students’ learning. Targeting a strategic group, such as the ACLs in this study, can be a successful way to strengthen faculty development. All participants in the intervention demonstrated the ability to use theoretical knowledge and create activities to support students’ learning. However, their applications differed in terms of underlying reasoning, reach and potential sustainability. To some extent these differences were due to a deeper understanding versus a more superficial understanding of the central concepts related to autonomy. Another critical factor affecting implementation was the ACLs understanding of learning processes in general. Lessons to learn for professional faculty development are that there is a need to stress individual understanding of actual theoretical concepts as well as learning theories in education addressing clinical faculty. The outcome of the ACLs planned projects turned out to be very dependent on their own mandate, the structure in the clinic, and acknowledgement of their work in the clinical context. This study also highlights that in order to achieve a potential continuity and sustainability of implemented changes in the clinic the implementation processes must be anchored throughout the actual organisation.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to ethical reasons connected to the participant’s informed consent. The data generated during this study consists of written reports and transcribed audio recordings of participants who have been guaranteed confidential handling of data. On reasonable request, data can be made available from the corresponding author.

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Acknowledgements

We thank the adjunct clinical lecturers who kindly took part in the study.

Open access funding provided by Karolinska Institute. The study was funded by ALF, the Regional Agreement on Medical Training and Clinical Research between Region Stockholm and Karolinska Institutet.

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All authors were active in designing and executing the intervention and the study. CS and AF performed the analysis and wrote the manuscript. KM critically reviewed and contributed to the description of the results, read, and revised the manuscript. All authors read and approved the final manuscript.

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Silén, C., Manninen, K. & Fredholm, A. Designing for student autonomy combining theory and clinical practice – a qualitative study with a faculty perspective. BMC Med Educ 24 , 532 (2024). https://doi.org/10.1186/s12909-024-05514-y

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The National Kidney Foundation’s 2024 Spring Clinical Meetings Late-Breaking Presentation on New Therapy Shows Promising Results for IgAN Patients

(May 14, New York, NY)  – During a late-breaking abstract presentation at the annual 2024 NKF Spring Clinical Meetings (SCM) tomorrow Dr. Dana Rizk, from the University of Alabama at Birmingham (UAB) Medical Center, will present data on the impact and safety of Fabhalta (iptacopan) in the treatment of patients with IgA nephropathy (IgAN) also known as Berger disease. Iptacopan was approved by the FDA in 2023 for the treatment of another disease entity, paroxysmal nocturnal hemoglobinuria. IgAN is an incurable glomerular disease that can cause chronic kidney disease (CKD) and is a leading cause of end-stage renal disease (ESRD). The presentation entitled, Efficacy and Safety of Iptacopan in Patients with IgAN: Interim Analysis (IA) of the Phase 3 APPLAUSE-IgAN Study will be held at the Long Beach Convention Center, 300 East Ocean Blvd, on Wednesday, May 15 from 2:30 to 4:30 p.m. (PT).

          In the analysis, patients treated with iptacopan in addition to standard supportive care, achieved a 38.3% (p<0.0001) proteinuria reduction (as measured by 24-hour urine protein to creatinine ratio [UPCR]) at 9 months when compared to placebo 1 .) Proteinuria reduction is an increasingly recognized surrogate marker correlating with progression to kidney failure and has been used in IgAN clinical trials to support accelerated approvals 7 . The study also showed that iptacopan was well tolerated by IgAN patients with a favorable safety profile consistent with previously reported data 1,8 .

Quote from Researcher

          “In IgAN, part of the immune system called the alternative complement pathway can become overly activated in the kidneys, which causes an inflammatory response, leading to progressive kidney damage and gradual loss of kidney function. The loss of kidney function, together with potential side effects of IgAN treatments available until recently, significantly impact patients’ lives,” said Professor Dana Rizk, Investigator, APPLAUSE-IgAN Steering Committee Member, and Professor in the UAB Division of Nephrology. “Fabhalta is the first potential treatment for IgAN that specifically targets the alternative complement pathway.”

Highlights of the Study

          APPLAUSE-IgAN is the first Phase III multicenter, randomized, placebo-controlled study to demonstrate significant proteinuria reduction by targeting the complement system in patients with IgAN. This pre-specified interim analysis included 250 patients for the efficacy analysis and 443 for the safety analysis 1 . The APPLAUSE-IgAN study continues in a double-blind fashion until the final analysis of the primary endpoint related to iptacopan's ability to slow IgAN progression by measuring the annualized total estimated glomerular filtration rate (eGFR) slope over 24 months. Those results are expected at study completion in 2025 9,10 .

          The two primary endpoints of the study for the interim and final analysis, respectively, are proteinuria reduction at 9 months as measured by UPCR, and the annualized total eGFR slope over 24 months 9,10 . At the time of final analysis, the following secondary endpoints will also be assessed: the proportion of participants reaching UPCR <1 g/g without receiving corticosteroids/immunosuppressants or other newly approved drugs or initiating new background therapy for treatment of IgAN or initiating kidney replacement therapy (KRT), time from randomization to first occurrence of composite kidney failure endpoint event (reaching either sustained ≥30% decline in eGFR relative to baseline or sustained eGFR <15 mL/min/1.73 m 2  or maintenance dialysis or receipt of kidney transplant or death from kidney failure), change from baseline to 9 months in the fatigue scale measured by the Functional Assessment Of Chronic Illness Therapy-Fatigue questionnaire 9,10 .   

          The main study population enrolled patients with an eGFR ≥30 mL/min/1.73 m 2  and UPCR ≥1 g/g based on a 24 hr urine collection at baseline 9,10 . In addition, a smaller cohort of patients with severe renal impairment (eGFR 20–30 mL/min/1.73 m 2  at baseline) was also enrolled to provide additional information but will not contribute to the main efficacy analyses 9,10 .

          “There is a need for effective, targeted therapies for IgAN patients and the detailed Applause-IgAN study gives valuable, promising insights to healthcare providers and patients living with IgAN,” said NKF President Dr. Sylvia Rosas. “The alternative complement pathway has been implicated in the pathogenesis of IgAN, so it gives patients hope that a novel therapeutic intervention may lead to slowing progression of chronic kidney disease and avoiding kidney failure.” 

          The annual 2024 NKF Spring Clinical Meetings (SCM) will be held in Long Beach, CA from May 14 – 18.

NKF Spring Clinical Meetings

For the past 32 years, nephrology healthcare professionals from across the country have come to NKF’s  Spring Clinical Meetings  to learn about the newest developments related to all aspects of nephrology practice; network with colleagues; and present their research findings. The NKF Spring Clinical Meetings is designed for meaningful change in the multidisciplinary healthcare teams’ skills, performance, and patient health outcomes. It is the only conference of its kind that focuses on translating science into practice for the entire healthcare team. 

About Kidney Disease

In the United States, more than 37 million adults are estimated to have kidney disease, also known as chronic kidney disease (CKD) - and approximately 90 percent don't know they have it. About 1 in 3 adults in the U.S. are at risk for kidney disease. Risk factors for kidney disease include:  diabetes ,  high blood pressure ,  heart disease ,  obesity , and  family history . People of Black or African American, Hispanic or Latino, American Indian or Alaska Native, Asian American, or Native Hawaiian or Other Pacific Islander descent are at increased risk for developing the disease. Black or African American people are about four times as likely as White people to have kidney failure. Hispanics experience kidney failure at about double the rate of White people.

NKF Professional Membership

Healthcare professionals can join NKF to receive access to tools and resources for both patients and professionals, discounts on professional education, and access to a network of thousands of individuals who treat patients with kidney disease. 

• Perkovic V, Kollins D, Renfurm R, et al. Efficacy and Safety of Iptacopan in Patients with IgA Nephropathy: Interim Results from the Phase 3 APPLAUSE-IgAN Study. Presented at the World Congress of Nephrology (WCN); April 15, 2024; Buenos Aires, Argentina.
• Kidney Disease: Improving Global Outcomes (KDIGO) 2021 Clinical Practice Guideline for the Management of Glomerular Diseases.  Kidney Int . 2021;100(4):S1-S276. doi:10.1016/j.kint.2021.05.021
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• Zhang H, Rizk DV, Perkovic V, et al. Results of a Randomized Double-Blind Placebo-Controlled Phase 2 Study Propose Iptacopan as an Alternative Complement Pathway Inhibitor for IgA Nephropathy.  Kidney Int . 2024;105(1):189-199. doi:10.1016/j.kint.2023.09.027
• Rizk DV, Rovin BH, Zhang H, et al. Targeting the Alternative Complement Pathway with Iptacopan to Treat IgA Nephropathy: Design and Rationale of the APPLAUSE-IgAN Study.  Kidney Int Rep . 2023;8(5):968-979. doi:10.1016/j.ekir.2023.01.041
• ClinicalTrials.gov. NCT04578834. A Multi-Center, Randomized, Double-Blind, Placebo-Controlled, Parallel Group, Phase III Study to Evaluate the Efficacy and Safety of LNP023 in Primary IgA Nephropathy Patients. Available from:  https://clinicaltrials.gov/ct2/show/NCT04578834 . Accessed April 2024.
• Novartis. Novartis receives FDA approval for Fabhalta® (iptacopan), offering superior hemoglobin improvement in the absence of transfusions as the first oral monotherapy for adults with PNH. Available from:  https://www.novartis.com/news/media-releases/novartis-receives-fda-approval-fabhalta-iptacopan-offering-superior-hemoglobin-improvement-absence-transfusions-first-oral-monotherapy-adults-pnh . Accessed April 2024.
• Novartis. Novartis Fabhalta® (iptacopan) receives positive CHMP opinion as first oral monotherapy for adult patients with paroxysmal nocturnal hemoglobinuria (PNH). Available from:  https://www.novartis.com/news/media-releases/novartis-fabhalta-iptacopan-receives-positive-chmp-opinion-first-oral-monotherapy-adult-patients-paroxysmal-nocturnal-hemoglobinuria-pnh . Accessed April 2024.
• McGrogan A, Franssen CF, de Vries CS. The Incidence of Primary Glomerulonephritis Worldwide: A Systematic Review of the Literature.  Nephrol Dial Transplant . 2011;26(2):414-430. doi:10.1093/ndt/gfq665
• Xie J, Kiryluk K, Wang W, et al. Predicting Progression of IgA Nephropathy: New Clinical Progression Risk Score.  PLoS ONE.  2012;7(6):e38904. doi:10.1371/journal.pone.0038904
• Novartis. Novartis completes acquisition of Chinook Therapeutics. Available from:  https://www.novartis.com/news/media-releases/novartis-completes-acquisition-chinook-therapeutics . Accessed April 2024.