• R J Haber and L A Lingard.
• Medical Service, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, Calif 94143-0862, USA. rhaber@itsa.ucsf.edu
• J Gen Intern Med. 2001 May 1;16(5):308-14.

ObjectiveOral presentation skills are central to physician-physician communication; however, little is known about how these skills are learned. Rhetoric is a social science which studies communication in terms of context and explores the action of language on knowledge, attitudes, and values. It has not previously been applied to medical discourse. We used rhetorical principles to qualitatively study how students learn oral presentation skills and what professional values are communicated in this process.DesignDescriptive study.SettingInpatient general medicine service in a university-affiliated public hospital.ParticipantsTwelve third-year medical students during their internal medicine clerkship and 14 teachers.MeasurementsOne-hundred sixty hours of ethnographic observation. including 73 oral presentations on rounds. Discoursed-based interviews of 8 students and 10 teachers. Data were qualitatively analyzed to uncover recurrent patterns of communication.Main ResultsStudents and teachers had different perceptions of the purpose of oral presentation, and this was reflected in performance. Students described and conducted the presentation as a rule-based, data-storage activity governed by "order" and "structure." Teachers approached the presentation as a flexible means of "communication" and a method for "constructing" the details of a case into a diagnostic or therapeutic plan. Although most teachers viewed oral presentations rhetorically (sensitive to context), most feedback that students received was implicit and acontextual, with little guidance provided for determining relevant content. This led to dysfunctional generalizations by students, sometimes resulting in worse communication skills (e.g., comment "be brief" resulted in reading faster rather than editing) and unintended value acquisition (e.g., request for less social history interpreted as social history never relevant).ConclusionsStudents learn oral presentation by trial and error rather than through teaching of an explicit rhetorical model. This may delay development of effective communication skills and result in acquisition of unintended professional values. Teaching and learning of oral presentation skills may be improved by emphasizing that context determines content and by making explicit the tacit rules of presentation.

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