Blog | Monday, August 13, 2018

Making efficient rounds

Learners value efficiency. As I recall my residency, nothing caused more angst than unnecessarily long rounds. In the 1970s just like in the 2010s, I had much to do after rounds ended.

As an attending physician, my responsibilities involve patient care and aiding learning. I have always worked hard to do that within a time constraint. The time constraint requires that rounds run efficiently.

Like many things in medicine, efficiency only works when we learn to prioritize both patient care and teaching. Rounds at many institutions have evolved into work rounds. Many attending physicians manage almost every detail during these rounds. Is this necessary? This article suggests not, “What Happens When the Attending Comes to Work Rounds?”

Efficiency occurs when the attending physician allows the resident to handle the care details. The attending physician should (in my opinion) focus on the big picture. The resident team should suggest care, and use the attending physician as a sounding board. The attending physician should teach through a discussion of the differential diagnosis, or the appropriate test ordering strategy, and role modeling patient interactions (occasionally repeating the history, demonstrating physical exam findings, and even delivering news to the patient).

The attending physician has a responsibility to prioritize the discussion with consistent awareness of time.

This week I discussed rounds efficiency with my outstanding 3rd year resident. He had some great insights:
1. Table rounds – as most readers know I start each day with table rounds. We review any new developments as well as imaging, lab results, and consultant recommendations. We make certain that everyone on the team understands the plan. When we go to see the patient, we focus on the patient. My resident has had attending physicians who repeat much of the discussion outside the patient's room. He suggested that this repetition led to inefficient rounds.
2. Hallway rounds – many attending physicians have discussions and presentations in the hallway. He said that the problem with that is when you need to see an image, or the student or intern does not know all the lab results.
3. Bedside rounds – some attending physicians like this the best, but some discussions do not fit into bedside only rounds. He felt these hampered some educational discussions.

We now know from research that paying attention to all details need not be an attending physician responsibility. One of my colleagues tells his team to not ask him about constipation treatment or IV fluids unless the resident is uncomfortable.

Efficiency occurs when the attending focusing on the big picture supplementing the work of our residents.

I'd love to hear you thoughts on efficiency.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.