Does your program make interns "preround?"

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europeman

Trauma Surgeon / Intensivist
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The one thing I hate about surgery is pre-rounding. *HATE* I don't hate rounding, just prerounding. Having to wake up an hour (sometimes more) as a sub-I to preround on our patients literally made me sick to my stomach. First, I'd have to wake up all these poor patients in order to examine them. Then I'd have to collect vital signs, which, at 5am *SUCKS* because most of the hall lights at that time are still off and it just sucks. Third, my chief wanted our notes written before rounds.

Now, granted this is important for a medical student and sub-I for education and experience.... I'm glad I was forced to do it. I still hated it. Fine. BUT AT MY INSTITUTION THE INTERNS HAVE TO DO THE SAME THING! Freaking go see every patient BEFORE the chief, collect vitals, and write notes BEFORE rounds. This is absolutely ******ed to me.

So my question is.... at your institution do you preround as an intern/second year? SICU doesn't count of course?

haha, I almost find myself ranking places higher based on this stupid ridiculous aspect.
 
Yes, there's still prerounding on a lot of rotations.

And 5 am? That's late for some places here. 🙁
 
europeman said:
Now, granted this is important for a medical student and sub-I for education and experience.... I'm glad I was forced to do it. I still hated it. Fine. BUT AT MY INSTITUTION THE INTERNS HAVE TO DO THE SAME THING! Freaking go see every patient BEFORE the chief, collect vitals, and write notes BEFORE rounds. This is absolutely ******ed to me.
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I think pre-rounding is an important part of rounding. "Discovery rounds" where the Chief Resident walks from bed to bed and finds things out that the intern HAD NO CLUE about in the morning is irritating. As the surgical intern you should be the one who knows every little detail about each of your patients, and if that requires that you get up just one hour before rounds start with your Chief Resident, so be it. I don't think pre-rounds are stupid. I think they're valuable.

europeman said:
So my question is.... at your institution do you preround as an intern/second year? SICU doesn't count of course?
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Yes. My program requires pre-rounding. My interns start their rounds at about 5-5:30AM, depending on the size of the patient list.

europeman said:
haha, I almost find myself ranking places higher based on this stupid ridiculous aspect.
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That IS stupid, but not stupider than any other reason that I used when coming up with my rank list. 🙂
 
yes, interns pre-round. that is part of their job
 
Well I see your point, but I have to say that the majority of places I have interviewed at no longer preround. They mostly cite the 80hour workweek as one reason, which makes sense. If an intern comes in everyday at 5am and leaves at 6-6:30pm (which is earlier than reality!), there's 80 hours for you WITHOUT any call!


Anyway, I understand what you mean about discovery rounds... but in reality, even if the intern discovers something, it's not gonna change how you as the chief handles it. Nor is it going to save time.

Then the question becomes, what's the educational value of the intern "discovering" things on his/her own during prerounds. It would seem to me minor. It's not like prerounding is the only opportunity for an intern to examine and talk to patients alone... that happens on a constant basis throughout the day and on call.

ANYWAY, i'm obviously an idiot 'cuz I haven't even started internship yet. But, I'm just saying that it SUCKED so much and I hated it. And my friends who are interns now feel they hate it and don't see any additional educational value added; in fact, they think that the extra hour of sleep would much more contribute to their brain function.

But, it is what it is, most places, and I interviewed at way WAY too many, simply don't have interns preround period. I will admit that some have the intern collect labs/vitals from a computer for those hospitals which don't have it setup whereby the computer simply prints it all out nicely. But at the places where you have to go bed to bed to get vitals... usually the intern coming in gets it from the night float if at all. And the physical exam is only done on rounds with chief.

It's interesting for me, again, still in the application process, to hear how strongly you feel it adds to the education of the intern and is overall a good thing given that during interviews, I talked to so many chiefs who said just the opposite. "I used to preround, but I don'tn make my interns do it because it doesn't add anything" is a statement i heard over and over again.

What to believe?

I'll just rank the places that don't preround 🙂
 
Yes, mine did and still does.

I'd be wary of believing everything you hear on interviews. If you have done an audition rotation at a program and can really see how it works, that's one thing. But to be honest, people lie to interviewees. Maybe they don't pre-round and they don't go over 80 hours, but don't base your rank link on such a thing especially if you have no first hand knowledge of whether they are telling you the truth or not. At least pick a place you'd like to live, then if they are lying, you'll like the area when you do go home.

I agree with Castro about the benefit of pre-rounding but I also agree that it doesn't necessarily need to be done on every patient or every service. I would always start with the sickest patients on rounds, go to the ones being discharged that day next and finish with the stable, but not yet ready for prime time ones. That way there was no "Chief discovery rounds" (or at least it was minimized) and if I found something awry, I could at least start the work-up...depending on the time, the EKG and labs might be back on Mr. Jones with chest pain in Room 242, as opposed to ordering them an hour or two later when the Chief arrived. Pre-rounding or rounding earlier on potential discharges works well because you often find things that need to be cleared up before DC is possible...perhaps PT hasn't signed off, or the need transportation, etc. The earlier you discover these things, the earlier they can be resolved.

Besides, we ALL hate it. I'm an insomniac but I hated getting up at 3:30 or 4:00 am to go into work during residency. And I hate getting up at 5:00 now to go to the gym...but some things we do have a good reason.
 
A good resident ALWAYS rounds early.

A good intern ALWAYS prerounds.

You should WANT to preround. A good intern would sneak and preround even if this practice was "banned"

I can't even believe someone would ask about eliminating the process of seeing patients.

Do everyone a favor, if you dont want to preround please join an er program. You will free up a spot for someone who wants to be a surgeon and is capable of it, plus you will never have to round.

WTF is surgery coming too?? Who would even think to have the nerve to ask "is it ok not to round cause I dont want to get up early?"
 
I don't understand why this is being a me-bashing party. I'm simply raising the idea about something which, surprisingly, I found is no longer practiced at many surgery residencies (intern prerounding).

The question is not one of work ethic, it is one of reality. By simplying questioning the educational value of a practice doesn't mean I am crazy or should all of a sudden go into another field!

An intern should want to learn about his/her patients, an intern should want to READ about his/her patients, an intern should want to learn to OPERATE. But why should an intern WANT to draw bloods on all their patients, or WANT to cart their patients to CT scan, or WANT to run around the hospital and collect vitals knowing full well that at other hospitals this 30 minutes of practice (translates into 3+ hours a week!) can be saved with an updated computer system! obviously if you're AT the hosptial with out-of-date computers, then, it is what it is... but that doesn't mean you ENJOY doing it and that doesn't mean you don't QUESTION the practice or try to get it changed for the better.

So, back to the basics, all I would like is some explanation as to the educational value and TEAM contribution to interns prerounding in the morning on general surgery services. Interns don't preround on ortho here, but the gen surgeons do. Again, when i interviewed, i was surprised to find out that we are in the minority, apparently, and I'm simply asking what are your thoughts about this?

An extra hour of sleep is worth a lot if in its place you are doing something which is useless. An extra hour of sleep is worth nothing if its for the well-being of a patient or adds educational value or contributes to the team's overall ability to learn or take care of patients. don't worry, i have my priorities.

But, you should be careful because the mentality of simplying thinking such questions are absurd is in and of itself absurd. A decade ago residents were made SLAVES at many institutions, to NO educational value what-so-ever. The 80 hour workweek has, in part, helped facilitate these practices being abandoned. That's a good thing. You don't have to lecture me about the bad things. Just explain to me the benefits and educational value of interns prerounding, because, again, I just don't get it.

rank list time 🙂
 
Eh, we weren't meaning to bash you specifically and I'm sorry if it came across that way.

But surgery, especially general surgery is hide bound and a lot of us resent some of the new attitudes. Believe me, I wanted to go home just as much as anyone else and got heat for it but I developed a respect for the reasons why things are done.

An intern should want to learn about his/her patients, an intern should want to READ about his/her patients, an intern should want to learn to OPERATE.
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Of course, but part of being a surgeon is learning about peri-operative management, about learning how diseases present, what course they run. All of this can be learned at the bedside, not by reading and not in the OR.

But why should an intern WANT to draw bloods on all their patients, or WANT to cart their patients to CT scan,
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I don't think anyone does want to do those things but they are a red herring because they have nothing to do with pre-rounds. Pre rounding is seeing patients, collecting data on their overnight course and examining them. You shouldn't have to collect blood or cart patients to CT in a hospital with good ancillary staff, although it will occasionally happen. If the programs you are interviewing at have interns do these things on pre-rounds, then the problems is with the infrastructure or the practices of the hospital, not with pre-rounding. I pre-rounded for 3 years of residency, and then still rounded before attending rounds as a senior and Chief resident. But doing these chores was a rare event and was not considered part of pre-rounding no should you consider it to be.

...or WANT to run around the hospital and collect vitals knowing full well that at other hospitals this 30 minutes of practice (translates into 3+ hours a week!) can be saved with an updated computer system! obviously if you're AT the hosptial with out-of-date computers, then, it is what it is... but that doesn't mean you ENJOY doing it and that doesn't mean you don't QUESTION the practice or try to get it changed for the better.
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It is fine to question those things. But again, you are complaining about infrastructure and problems with the hospital not with the residency program or pre-rounding. THOSE are reasons to reconsider a certain program but they have nothing to do with pre-rounding, except that lack of an EMR might make your pre-rounds a little longer...but they still have to occur.

That is not to say that there isn't a lot of wasted time in surgery, but as an intern and junior resident I felt I learned a lot by seeing patients on my own, making some preliminary decisions and plans. Finally, the 80 hour workweek has not assisted in abandoning of abusive practices. Those practices still exist and will continue to do so as long as there are abusers who go into surgery. My attendings may have stopped calling the Chiefs to round with them at 11 pm but they are still many practices (such as booking non emergent cases for the weekend, etc.) which have not changed a bit.
 
We almost always prerounded during my internship. In fact, there was discussion about eliminating it and we as interns weren't too happy about the idea. As an intern on a service if you have no info (exam and vitals as well as events) to offer up, what value are you? We found that when we didn't preround all decisions about patient care were decided by the senior/chief resident with little to no input from the intern. What have I learned by watching someone else make a decision? I much prefered to make some sort of plan and be corrected than just stand around while someone else makes the important decisions.

I hear where you are coming from with this discussion but I'll admit that even as one of the non-hardcore folks around here, your posts do come across as less than committed to Gen Surg and what that means in terms of hours and duties.
 
Thanks winged scapula. Anything else... learning a lot by seeing patients on your own and making preliminary plans?

May I ask the other question... do you think at all these institutions where I've interviewed (again a majority!) I will be losing out on a significant portion of my surgeon-development and education if I don't preround?
 
Prerounding is important because it allows rounds to go much faster so the residents can get to the OR in time for the first case. It generally went like this: 5-6:15 prerounding 6:30-7:30 rounding with the senior resident +/- the attending and 7:45 first care started.
At least where I rotated at med students did a lot of the prerounding. I usually saw 3-5 patients and wrote notes for all of them. This made the interns' life much easier because with a couple of competent med student prerounds went really fast because all they had to do is see the patient and make some additions to the med student note.
Only thing that sucked is that morning labs were often not available yet at 5 AM so you could not always make a complete A/P on some patients because the new labs could change the management pretty significantly. So many times the intern had to round again after 8 AM and adjust the plan as the labs trickled in.
I liked prerounding because it allowed me to make my own plan then comparing it to the final plan. It made me read more and it really showed on the shelf. I had very little extra studying to do at the end of the rotation because I had learned most of it along the way.
 
Let me say that I hated hated hated my surgery rotation for a number of reasons. But I loved my patients. I actually didn't mind pre-rounding (well, except for the obscene wake up time it involved). As a med student it helped me learn peri-operative management rather than just listening to what the chief had to say about my patients. It made me feel like a member of the team and I felt good about what I contributed to the team by prerounding. I was happy that I was able to relieve the (incredibly overworked) interns just a little bit. It was also my chance to shine as a med student. Frankly, as an intern or med student you look like a rock star if you can present the patient concisely and relevantly as well as answer any questions that might come up with something OTHER than, "Ummmm....let me check the chart (flip, flip, flip)."
 
The posters here are too old school. Pre-rounding is a waste of time. It's exploitation of the lower levels, from med students, to interns, to chief residents. Why should the medical student go see a patient at 4am, just to tell the intern at 5am, so that the intern could tell the chief resident at 6am, so that the chief resident can tell the attending at 7am? That's inefficient and one of the reasons why surgery is so unnecessarily painful.

A far better educational experience is to have the chiefs and attendings come and round earlier and spend more time doing bedside teaching. Instead of being upset at interns for not wanting to pre-round, we should be upset that the higher levels no longer want to teach at the bedside.
 
For what it's worth. I think pre-rounding is valuable. It gives the intern a chance to assess the patient withou any outside influence. You can gather your information, assess the patient, and begin to formulate a plan all on your own. If someone else is with you, you get influenced by them and their opinion. This is not a bad thing, but it does take the decision making process and planning portion out of your head. Part of intern year is making the jump from medical student, when you were basically an information gatherer, to resident physician where you are suppossed to make plans, begin to see the whole picture and hone your assessment skills. All of this is to prepare you to get out in the real world and make the decisions ON YOUR OWN.

I don't think you can begin to hone those decision making skills without a little independent time and thought process. It also breeds efficiency. You can sleep 15 minutes later if you manage your time correctly. And later in residency it facilitates you seeing that ER consult in the 15 minutes between cases. (See the patient, make the plan, dictate the H&P and still make it to the OR on time!)

And as a side-not, residents are not slave. Slaves imply that you belong to someone and will never be released. I think we are more indentured servants - we do our time, with the knowledge that at some point, we will be released. (Am I the only one that remembers early American history and people coming to American as indentured servants?) They can't stop the clock😉
 
europeman said:
Anything else... learning a lot by seeing patients on your own and making preliminary plans?
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I didn't mind pre-rounding all that much. The hours were bad, but it helped me learn to identify physical exam findings when I'm the first person to see the patient. It helps you learn if you can independently pick up on a developing hematoma/suddenly distended abdomen/new acute abdomen/iatrogenic nerve palsy after surgery, etc.

I learned how to identify sanguinous vs. sero-sanguinous on my own - which was then confirmed by the chief when he saw the patient.

I also had to learn how to strip a drain - because the resident wanted me to do that, on my own, each AM when I pre-rounded - and how to evaluate its contents.

Finally, I think it helps to pre-round because, sometimes, things develop between the time you see the patient and the time that the chief sees the patient, and it helps to have a baseline to compare it to.

filter07 said:
The posters here are too old school. Pre-rounding is a waste of time. It's exploitation of the lower levels, from med students, to interns, to chief residents. Why should the medical student go see a patient at 4am, just to tell the intern at 5am, so that the intern could tell the chief resident at 6am, so that the chief resident can tell the attending at 7am? That's inefficient and one of the reasons why surgery is so unnecessarily painful.
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The way that you've described is inefficient - but does it have to be that way? I don't think that all systems are like that. When I pre-rounded, I gave report only to the chief. I never told the intern, and waited for the intern to tell the PGY-3, who would then be in charge of telling the chief. I would just see the patient, write the note, and then report my findings at AM rounds. There was no middle-man in that system.
 
I do something similar to what was mentioned above: the night floater (if they have time) will get vitals for me, and I'll buzz around to the sickest people first. Then the discharge-ready people, so I can get them ready to go by the end of rounds.

And pre-rounding doesn't have to take that long. Just a super quick physical exam, inspection of any wounds/JP's, and you're out. The nicest thing about waking people up is that they're too tired to come up with stuff to ask you during prerounds 🙂
 
Our system didn't run that way either. The med studs, interns and some junior residents (some tried to pull rank and refused to pre-round, saying it was "intern's work") pre-rounded and then all rounded together with the Chief. The Chief then verbally ran the list with the attendings. On some services the attendings would do team rounds, on others it with be only with the Chief (and whomever else was available) and for some, the attending simply rounded by himself and called the Chief with any changes or concerns.

I agree...it doesn't make much sense for the medical student to pre round before the intern, etc. and I would like to see more attendings teach and do bedside rounds, but this is definitely service and attending dependent rather than system wide. We always did attending rounds on some services.

Finally, many others have noted, it is a valuable lesson in being able to evaluate a patient without the possible influence of others and a great way to monitor changes over time.
 
I like the way we do it here. We meet at 6:30 and the night float signs out to us any overnight events or admits. We then disperse and do rounds (write notes, replace lytes, write a preliminary plan). Depending on the size of the list, the chief will either see patients with us (one person examines the pt, another writes, maybe another gets the dsg supply stuff and changes the dsg), or see the ICU patients while we see the floor, or will show up after we are done seeing all the patients for GI rounds (breakfast😛, we get it almost every day). If we accomplish everything before the OR starts at 7:30, great. If not, whoever doesn't have a case (we generally have rotators who don't operate, and sometimes the intern doesn't have a first case to do) will take care of the rest of the floor work (dsg changes if we didn't get to it, new plan decided during GI rounds, scheduling procedures, etc.). Granted, this is a smaller program so the number of patients on our list at any given time isn't too bad. We have med students, but that don't have to preround (although we had a sub-I a while back that prerounded the entire list, and we loved him). It can get a little hairy sometimes, but the occasional crazy days where things don't get done until the end of the day are bearable since we regularly get more sleep.
 
Just out of curiosity, how large are your services? Our interns don't preround unless the chief is not there by 6am (in the OR or whatever other reason), then they (well, we did when I was an intern) start without the chief and then update the chief on the patients already seen when the chief makes it in. Each service carries around 60 or so patients, divided amongst 2-4 chiefs/fellows, but only 1-2 interns serving all those masters. Sure, the night float sticks around for am rounds to help out and give each chief an intern on rounds, but if we prerounded, we would end up being there at 4:00 just to make sure all patients were seen, something I never needed to do even as a medical student when we did prerounds (our services never had more than 20-25 patients where I went to med school, most only carrying around 15, much more realistic numbers). The night float spends the entire night on the floor (instead of the call room), so they know what has happened with all the patients on service overnight and basically serve as the preround person.

Having been a part of a medical school that prerounded and a residency that doesn't, I can't say I saw any added benefit for prerounds for the residents. It is a good thing for medical students in that it helps with physical exam skills, learning what questions need to be asked and trying to formulate a plan and identify problems. However, I don't think there is anything I gained from prerounding that I don't get from a good signout. Our program has changed somewhat since I was an intern in that the interns spend less time on the floor and more time in the OR than we did, so I don't know if they are as in touch with each patient as we were, but I could tell you at night when I was signing out who would be the problem children overnight and who would not have any issues and nightfloat could do the same in the morning.

In terms of assessing a patient without outside influence, that is what I did on a minute to minute basis during my entire intern year. Our program has changed since I was an intern in that they are currently spending less time managing patients on the floor and more time in the OR. Their skills may be less than mine (I don't know one way or the other), but as I said before, I could tell you how each patient on a 60 patient service looked at the end of the day because I spent the greater part of the day seeing each and every one of them. I don't think prerounds would have added anything to that skill.

To Castro and ESU: I really don't understand your love for the old ways. Is it because you are getting nostalgic now that you are at the end of your training? Is it because your program has taken in ****ty interns that have used the 80-hour rule as an excuse? Believe me, I know what it is like to work your @ss off on a surgical rotation and still wanted to do it; I logged between 110-120 hours a week during my surgical clerkships and my surgical sub-I. I thought that was how it was everywhere, was how it had to be and I still wanted to do this. Then, I matched at a program where people were efficient enough to get things done in 80 hours, yet dedicated enough to the team and their patients that if something did happen, you couldn't kick them out. Our chiefs leave at the same time as our juniors (earlier even on light days when there is nothing to do in the afternoon, but the intern can't leave until the night float shows up); they aren't stuck picking up the slack of the lazy juniors/interns because we don't have them. We have made consolations for our pregnant residents so they could have their time off, but we did it as a team and the burden was lessened, rather than abandoning the team mentality you preach and isolating those who get pregnant. Perhaps if you didn't make them feel bad for taking their federally guaranteed leave or kick them off of the team because they "dun got knocked up," they wouldn't be so apt to dump on you when they "need" to have their yard sale or take their kid to daycare.

To decree that the old way of prerounding at 4:30 and working over 100 hours a week is the only way or is necessary is about the stupidest thing I've ever heard. Just because your program can't make it work (starting with the administration on down) doesn't mean it can't in a place where the administration through the intern buys into the legal necessity and the fact that we are still there for the patients. I'm sorry your program has had such terrible luck matching people who don't want to be real surgeons, but want to play the surgeons they see on TV, but it isn't that way everywhere, and simply because your life sucked as a junior doesn't mean you have to make the same true for your junior; that's like justifying beating your kids because you were beat.

ESU_MD said:
You should WANT to preround. A good intern would sneak and preround even if this practice was "banned"
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This quote just eats at me. Why not just put all of your patients in a large room with their beds facing center and sit at the center of that circle in a chair that is timed to rotate 360 degrees every 60 minutes? Why don't I just collect all the vitals, labs, etc... myself and let my nurses have the night off? Why don't I just sell my house and car and take up true residence in the hospital (just like they did in the old days) so I can have my hand on the pulse of each and every one of my patients within a moments notice?

Why should I want to preround? What am I going to gain from it, other than the scorn of my patient who I am going to wake up twice in the matter of one hour (and all before 6:30am) to ask the same questions over and over? What will I gain?

End of rant. It just gets me sometimes when I hear you guys preaching that the only good residents were those who started pre-80 hour or those who want to go back to the old ways.
 
ESU_MD said:
A good resident ALWAYS rounds early.

A good intern ALWAYS prerounds.

You should WANT to preround. A good intern would sneak and preround even if this practice was "banned"

I can't even believe someone would ask about eliminating the process of seeing patients.

Do everyone a favor, if you dont want to preround please join an er program. You will free up a spot for someone who wants to be a surgeon and is capable of it, plus you will never have to round.

WTF is surgery coming too?? Who would even think to have the nerve to ask "is it ok not to round cause I dont want to get up early?"
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Dude; is it really necessary to specifically call EM (not er) out on this??? I have noticed in quite a few posts you like to bash the ED... Come on now, lighten up...
 
First of all, thank you all for your comments. My question/concern about prerounding however is only directed towards interns - not medical students. When you are a medical student you learn a ton prerounding... simply learning how to interact with patients by yourself. For an intern, there are other opportunities to do this and prerounding therefore isn't necessary to accomplish this.

Thank yous SocialistMD because I think you hit on a lot of very good points. What you explained, actually, is what I heard at a lot of the programs that I interviewed at.

What scares me, and I don't mean this as a flame, is how my simple question ignited such harsh comments from a few. While I understand general surgery is a field which has a 20% attrition rate, and therefore there is a sort-of culture of skepticism of those who hint that they don't like aspects of surgery that they will quit, I assure you I am not one of them. On the other hand, medical school and my experiences have taught me to always look for new and innovative ways to do things, to question why I am doing something a certain way.... not simply to obey by tradition because it's "been done like that forever." That's ******ed. Obviously you have to balance that with reality and the fact that the elders are wiser and have experience you don't, but that doesn't mean I have to completely take-off any leadership qualities I have as an intern, completely leave my brain at home, and blindly do as I'm told all the time.

That said, I'm still not an intern, and I therefore don't know what is best because I've only experienced one way; the way my institution does it where interns preround (i experienced it as a medical student, and my good friend is an intern here). But, my goal is to continue to LOVE surgery, and to learn and become the best surgeon I can be.... and if becoming that entails going somewhere where there is more of a culture of education and will ultimately foster me being a happier person without sacrificing anything, then why not take that route?

Frankly, though, the people who describe alternative systems to prerounding just make more sense. And, also, the people here who are proponents of prerounding don't have anything to compare to; whereas the people who are at places who don't preround and love it are comparing to their medical schools where they did preround.
 
europeman said:
First of all, thank you all for your comments. My question/concern about prerounding however is only directed towards interns - not medical students. When you are a medical student you learn a ton prerounding... simply learning how to interact with patients by yourself. For an intern, there are other opportunities to do this and prerounding therefore isn't necessary to accomplish this.
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So we've established that pre-rounding is educational, at least for med students....

So the programs that DON'T have interns pre-round - I guess they don't have med students rotate through there as well?

Because it seems like it would be hard to have med students pre-round in any meaningful way if interns didn't also pre-round and co-sign notes. I guess you could have the attending co-sign the notes during walk rounds, but I think that that would take a lot of time - and it's doubtful that he'd offer the med student any useful feedback. I think that, from that limited perspective, making your students pre-round, and then checking their notes, teaches the intern how to be an effective mentor and instructor - which isn't a bad skill to learn. (I can think of a few residents and attendings who apparently never learned how to do that....)

And SocialistMD DOES make great points - but I don't know if those points are universally applicable. If nightfloat is really that deeply involved with the patients, and can give you very detailed signout, then sure - maybe pre-rounding isn't necessary. (Well, except for SICU patients.)

But if the program's nightfloat is designed only to cover emergencies - and the nightfloat is still instructed to call the daytime chief if an emergency does happen - then I think that pre-rounding is still important.

It also seemed like SocialistMD was saying that he didn't need to pre-round because he spent all day with this patients as it was - but made up for it by less OR time. Those programs that don't make interns pre-round - do they make up for it by giving the interns minimal OR time? And is that a tradeoff that you're willing to make? I'm genuinely curious - because I think that the interns that I worked with would rather pre-round and spend more time in the OR, than never pre-round, but then spend the day on the floors and go into the OR maybe every other day. Any thoughts on that?
 
europeman said:
What scares me, and I don't mean this as a flame, is how my simple question ignited such harsh comments from a few.
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Not to be snarky, but - did this really surprise you? 😕 You're a 4th year, going into surgery, so you've obviously done surgical sub-Is and spent more time around surgeons. I don't have as much experience with surgeons as you do, but this didn't surprise me at all. Questioning tradition - especially if it means doing "less work" - doesn't go over well.
 
sorry to offend my colleagues by extremist views, I will try to keep them to myself for the rest of this thread.

I think coming in a little early and knowing whats going on before the attendings helps you learn to be a doctor.

Realistically, how long does it really take to eyeball the pt, vitals and jot a note.
typical surgery census of ~30 pts. chief sees the 3 SICU pts, the midlevel, intern and students split the floor pts. Run the list at breakfast. 30 minutes tops if you are efficient.

Versus, come in at 7am and follow the attending around and do whatever they say. How can you present a patient or interact at rounds if you havent seen the patient??

BTW, no matter what you think about prerounds, or your views of work hour restrictions. Asking about that stuff during an interview will probably be taken in the wrong context by the program director and faculty. If you really need to know, ask the juniors when noone else is around.
 
I give up. ESU_MD... you just don't get it. It's like apples and oranges, you're comparing different thoughts and arguments and not making any sense.

For what it's worth, of COURSE i think it's important to come in a bit early and collect information in a way which will best help the team and patient care. I was simply asking.... is traditional "prerounding" on every patient the best way to do this, or are the alternative methods as talked about socialist MD more efficient and worthwhile?

Medical students are a different boat, they should always preround.
 
Good points raised by all here. Wanted to add my perspective as someone who prerounded as a medical student, started residency in the pre-80 hr world, and now a senior resident in a residency that does not preround. It is valuable as a medical student to preround on 2-3 patients because at this stage you are new to the game and this gives some time to independently assess a patient. Once you hit residency though, having your interns/juniors preround can be redundant. The times have changed and we have to conform to certain rules whether we like it or not. We need to be more efficient with how we use our time in-house.

At our institution, the intern/junior comes in half an hour early to get labs and signout from the nightfloat. We meet at 6 and do resident rounds as a team so we all see the patients together just once in the morning. I call the attendings at 7 or run the list with them in the OR. Tests are scheduled, transfers/discharges are written and the juniors take the patient back to the OR by 7:15. Anything floor work left over is signed out to the NP on the service, and all the residents are usually either in the OR or the clinic (where our education is hopefully happening).

The advantage to this system is that the entire team knows what is going on with each patient. There is no redundant work. As a chief, I usually see and examine every patient myself, look at their vitals and meds myself. If anything is missed, the responsibility is on me -- which is the way it should be since I am the one running the service. (Not to say that when things get busy, I won't have juniors see stable patients by themselves.) The juniors write the notes and orders on rounds as we go from room to room. While it may be a downside that juniors are not independently formulating plans, I think it is not a major one. Even having done internship without prerounding, I did not find it difficult to step up to the plate as a PGY-2 to round independently on ICU patients. Although work rounds can be hectic, I do try discuss the rationale behind my decisions with my juniors so that we are all on the same page. My juniors will often contribute with helpful suggestions to the plan that I had not thought of. The attendings then round with me or another resident later in the day at their leisure.

I would have to agree with socialist, filter07, and europeman that the time cost for resident prerounding does not make sense in today's 80-hour world.
 
You don't get it. Its not "prerounding". Its just rounding. You are making morning rounds on your patients. You see them, evaluate them, come up with a plan and implement it if appropriate for your level of training. Those of you who think it is unnecessary (even as an intern), give me a break. What do you think physicians do? I think they should take care of their patients. You can't do that unless you round on them.

Everything you do during your training, especially in the 80 hour era, should be geared towards your education. How will you learn how to manage postoperative complications if you are not evaluating your patients after operations? How are you going to know if a patient will need an operation that day unless you see them yourself?

A huge problem with medicine today, hyperconsultation, and the 80 hour work week is the lack of patient ownership. Your lack of willingness to see patients in the morning on your own reflects this directly. Your whining about "prerounding" being a waste of time is pathetic. It is a mandatory part of your education and you will never be a good physician if you do not take the time to evaluate YOUR patients. If you approach residency training as anything less, you will not be properly trained, you will lean on your partners to take care of your patients, you will never own up to your mistakes (but take credit for your successes I'm sure), and your patients will suffer.

Is that the physician you want to be? Think about it.
 
I think that in the era of the 80-hour work week, prerounding is becoming arcane. At least in the sense of examing every patient and having a note written by the OR. I began internship a few years before the 80 hour work week and would start rounding at 3:45 AM to see all of my patients by 6 am when the chief showed up.

Now as a chief that process seems ridiculous. Yes it does help to have vitals and labs collected, but that is all that is needed. I personally do arrive early to round when the service requires it. I think that it may detract a little from the interns personal interaction with each patient, but as a chief I need to examine each patient anyway.

And with many hospitals having electronic records, there is no need to preround the old way because you can just drag the computer down the hallway and have all of the information at your fingertips.

Are patients getting worse care now? I don't believe so. The modernization of electronic records has made rounding more efficient. Interns are much happier as well.
 
In response to the OP:

I think that you will lose out by not pre-rounding and learning to formulate treatment plans on your own, and then bouncing them off of your chief. I also think that there is tremendous value to examining as many patients on your own as possible.

Being an intern sucks in many ways, but to me the best part of the day was pre-rounding when I got a chance to see my patients first, and get the information first, and discover new physical exam findings first, and be the one to suggest the correct management first. Now that I am a senior resident, I am totally confident in my exam skills, and management skills, and a lot of it I learned from pre-rounding and learning to think independently of my chiefs. I know it means getting up early in the morning, but this was just not a problem for me... I still get up almost as early.

I think that the "old-school" types get pissed because they see it as a valuable experience that is being dismissed as a waste of time by someone who has not done day one of internship. Perhaps their frustration at your posts is simply part of their larger resentment at changes that they don't approve of... I don't know.

I used to be a die-hard "old school" type myself when I was a medical student. Just like you I had strong opinions on stuff I only knew from med student rotations. I now am somewhere in the middle... a moderate so to speak... But I do think that pre-rounds will eventually disappear altogether and so will go a valuable part of resident education.... sacrificed on the 80 hour altar.
 
Interesting. We don't have any prerounds. As med students we come in like 15 mins before the interns and senior residents to make sure the patient list (excel sheet) is updated. Med students write the notes as we round, a resident or med student checks the vitals, stoma/urine outputs etc at the bedside, and the interns usually present the patient's issues. The scutwork is then pretty evenly divided among the interns and students that are on the floor, and you are expected to know what is going on with all the patients.

I can see there might be a value to being forced to write down your plan before the resident arrives, but I think our system is much more efficient. There are like 6-7 people rounding at the bedside, and then the attending checks on the patient later, so the chance that something is missed is not that high. Also because as students we are following all the patients (usually around 20-25) we probably learn how to manage more problems.
 
boston said:
At our institution, the intern/junior comes in half an hour early to get labs and signout from the nightfloat. We meet at 6 and do resident rounds as a team so we all see the patients together just once in the morning. I call the attendings at 7 or run the list with them in the OR. Tests are scheduled, transfers/discharges are written and the juniors take the patient back to the OR by 7:15. Anything floor work left over is signed out to the NP on the service, and all the residents are usually either in the OR or the clinic (where our education is hopefully happening).
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This is how it is at my program now. The attendings don't round until after their first case, but the chief calls them at 7am (or talks with them in the OR) about all the patients. The night float is responsible for checking all the labs at night and addressing anything that may be off. As I said, our interns now spend the majority of the day in the clinic or in the OR, which is different from when I was an intern devoid of physician extenders, and I do sometimes wonder if it is taking away from that knowledge of minute to minute patient care that I gained as an intern (not that they have given me any reason to worry, I just sometimes wonder).

Our system is a little different than those described by most and that is why it works for us. As smq123 stated, it may not work at all institutions, and even at our institution our night float interns have varying levels of involvement on the floor (many are not as in depth as I was; I rounded on each patient on each service I covered at night to make sure they knew who they needed to talk to if they needed anything and to get an idea of who looked okay and who looked like crap), so some may not come away from that with the same experience I had.

Also, we don't have a nightfloat in the SICU, that is still q3.
 
europeman said:
May I ask the other question... do you think at all these institutions where I've interviewed (again a majority!) I will be losing out on a significant portion of my surgeon-development and education if I don't preround?
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I think so. It'll let you think it's okay not to be up to date on your patients and know everything that's happened.

And there will be a lot of...

"I put Mr. Johnson's chest tube to water seal last night." The team walks into the room to find Mr. Johnson's Pleurevac still bubbling for the last three hours.

"Mr. Smith's NG tube is to suction." The team walks into the room to find Mr. Smith's NG tube is now on his bed and he's aspirated.

"The CT scan was done overnight." The Chief asks, "What did it show?" The reply from the intern, "I have no idea."

"Ms. Ulman, the GI bleeder's, blood pressure was stable all of last night and her crit was 40." The team walks in to find the patient out cold in a pool of blood from her butt, a blood pressure that's 60-palp, and the nurse chimes in with, "Oh yeah, we drew another crit a couple of hours ago and it came back as 25."

"This is Mr. Wanker, he's a 60 year old gentlman who was in an MVA with a fractured tib-fib . . . " The team walks in and the Chief starts looking at the injured limb. "How's your leg Mr. Wanker? the Chief asks. The patient, confused, replies, "Uh, it's great doc." "Any pain at all?" "Yeah, in my stomach." "Did your stomach hurt last night after the car accident?" "What car accident? I had an operation on my stomach yesterday!" THEN the intern chimes in, "Uh, Chief? They must've moved Mr. Wanker to another room. I'm really sorry!"

Ahh... Good times.
 
SocialistMD said:
We have made consolations for our pregnant residents so they could have their time off, but we did it as a team and the burden was lessened, rather than abandoning the team mentality you preach and isolating those who get pregnant. Perhaps if you didn't make them feel bad for taking their federally guaranteed leave or kick them off of the team because they "dun got knocked up," they wouldn't be so apt to dump on you when they "need" to have their yard sale or take their kid to daycare.
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What arrogant presumption. First off I am way more accomodating than any of my Chief Residents ever were. When my colleague became pregnant during my time in the SICU, my co-resident and I took every other night call until she came back from her maternity. That's four weeks of contract vacation and the extra two weeks she took for FMLA. Oh yeah, then there was the extra two she tacked on because she "wanted to spend more time at home with her kid."

Fine. We did. Every other in the SICU started to get to me after two months. Then she came back.

Secondly when she came back, it was "my back still hurts from the pregnancy... I need to go lie down. Do me a favor and put in this line for me? Thanks. I owe you one." "Do me a favor and do this consult for me? Thanks. I owe you one." OR it was "my breasts are hurting. I need to go pump." For a while I really thought it took FOUR hours to pump a breast. Apparently pumping your breast with one of those electronic doo-hickeys causes you to get so fatigued, you have to take a nap in the call room in the middle of the afternoon while your in-between colleague (read: NOT on call) is running around the SICU trying to organize everything for you and take care of patients.

I sucked it up. So did my colleague, the one who was every other with me (who, by the way, is also a woman).

Never said one damn thing. Never even treated her differently, and I tried to be understanding. But fast-forward two years and I STILL have to cover for her because she had a kid? Sorry. I just don't think it's fair to me or my training that I have to give up my cases to cover her until noon because she's on-call but she just HAD to take her kid to his "first day of school."

That's just bull$hit. And I won't take it from this "resident" anymore.

So before you burn your bra and imply that I'm oppressing women everywhere and alienating the women in my program, slow down and ask a few questions before you assumptions lead you down the wrong path.

SocialistMD said:
I'm sorry your program has had such terrible luck matching people who don't want to be real surgeons, but want to play the surgeons they see on TV, but it isn't that way everywhere, and simply because your life sucked as a junior doesn't mean you have to make the same true for your junior; that's like justifying beating your kids because you were beat.
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I agree. And I don't beat the juniors. That is, unless they start doing the lazy dance. From my small community program in this corner of New York City, I've done outside elective rotations as a fourth year to three other programs all at academic institutions. Maybe it's just New York City, but they're all like that everywhere. My best friend from college is a Chief over at one of the larger academic programs in Manhattan and he gripes about the same stuff. Those seeking General Surgery residencies today are just different.
 
Castro Viejo said:
I think so. It'll let you think it's okay not to be up to date on your patients and know everything that's happened.

And there will be a lot of...

"I put Mr. Johnson's chest tube to water seal last night." The team walks into the room to find Mr. Johnson's Pleurevac still bubbling for the last three hours.

"Mr. Smith's NG tube is to suction." The team walks into the room to find Mr. Smith's NG tube is now on his bed and he's aspirated.

"The CT scan was done overnight." The Chief asks, "What did it show?" The reply from the intern, "I have no idea."

"Ms. Ulman, the GI bleeder's, blood pressure was stable all of last night and her crit was 40." The team walks in to find the patient out cold in a pool of blood from her butt, a blood pressure that's 60-palp, and the nurse chimes in with, "Oh yeah, we drew another crit a couple of hours ago and it came back as 25."

"This is Mr. Wanker, he's a 60 year old gentlman who was in an MVA with a fractured tib-fib . . . " The team walks in and the Chief starts looking at the injured limb. "How's your leg Mr. Wanker? the Chief asks. The patient, confused, replies, "Uh, it's great doc." "Any pain at all?" "Yeah, in my stomach." "Did your stomach hurt last night after the car accident?" "What car accident? I had an operation on my stomach yesterday!" THEN the intern chimes in, "Uh, Chief? They must've moved Mr. Wanker to another room. I'm really sorry!"

Ahh... Good times.
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Methinks you were listening in on our rounds the day after we got our new interns 😛
 
SoCuteMD said:
Methinks you were listening in on our rounds the day after we got our new interns 😛
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It's cute when it's July. It's frickin' scary when it's JANUARY and they're still doing this. 🙂
 
Castro Viejo said:
It's cute when it's July. It's frickin' scary when it's JANUARY and they're still doing this. 🙂
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It was December, does that make it any better? Also, in their defense it was a site that none of them had been at before.

Don't worry, the med students picked up the slack!
 
SoCuteMD said:
It was December, does that make it any better? Also, in their defense it was a site that none of them had been at before.

Don't worry, the med students picked up the slack!
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Scary, but sometimes that one gem of a med student will chime in with more useful information than the intern who wears an M.D. at the end of his name.
 
From the patient side of things...

It's nice to sleep an extra hour or two and not get asked the same set of questions 3x in a row by the same set of teenager-looking people... (and yes, I have been an inpatient on a surgical service).

Seems like most services could figure out a way that the patients are only woken up once before 7 am, yet the wounds are still seen, juniors taught seniors informed and attendings soothed... all within 80 hours? Not always of course, but I think it's a worthy goal.
 
I am a plastics intern at Michigan and we do not preround (on any of the services both plastics and general included). The only exception is the VA. I came from an institution where both interns and medical students prerounded. Do I see a big difference? Only in terms of time saved. The reason we do not preround is two-fold. The first is our lists are generally big and having interns preround would be impossible to keep everyone within the 80 hour limit. Second, most of the information you collect during morning rounds the computer prints out for us anyway (labs, vitals, medications, consults, etc.) Thus, we have more time to spend on formulating a plan. Dressing changes and physical exam are performed as a team. Overall, I find our rounding scheme to be fast and efficient. With that being said, I do think, everyone should at least spend a little time on a rotation, be it as an intern or medical student, where you do preround. I think it does present an opportunity to hone certain skills in your clinical toolbox which will come in handy down the road.
 
Duke GenSurg works pretty similarly to most of your programs so far as I can tell. Interns, Sub-Is, and MS2s all split up the patients (MS2s taking the patients whose operations they actually saw) and pre-round and SOAP them. This typically starts around 4:30 depending on when conference is that morning and takes maybe 10 min/patient. Then at around 5:30 or 6 the chief comes in, you go through the list from top to bottom with the intern/student presenting and then the chief poking his/her head in and looking for anything else or asking anything else that's relevant; maybe 5 min/patient. I never went to any attending-rounds in the morning but that doesn't mean they don't happen - typically any attending rounds that I witnessed were in the afternoon after the OR was done for the day (and were typically separate from "evening-rounds") that the intern/chief did. In some cases there would be "running the list" with the attending either in the cafeteria (ortho) or from the OR or by the intern from the floor.

At least this way there isn't the medical student prerounding, then the intern checking up on the med student, and then the chief doing rounds and then the attending doing rounds - but everything still gets done and all the patients get seen by everyone up the chain.

I personally *liked* pre-rounding as a med student - patients are typically way more personable when they're not unconscious. 😉

There was one particular instance where we had a crazy (but awesome) Sub-I who pre-rounded on Every Patient on the Service every day b/c she reallyreallyreally wants to come to this program. I swear she was in the hospital at 3:00 am every day for 4 weeks straight and *maybe* took an afternoon off on the weekend.

She was a good influence. 😉
 
Castro Viejo said:
Maybe it's just New York City, but they're all like that everywhere.
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I sort of agree with you there. The problem is when people who train in New York, where things seem to suck, use their limited experiences to make a broad statement about surgery as a whole, when in fact things are a lot different in other places.

JayDoc06 said:
You don't get it. Its not "prerounding". Its just rounding. You are making morning rounds on your patients. You see them, evaluate them, come up with a plan and implement it if appropriate for your level of training.
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I agree with you. I haven't chimed in much in this thread because I've only experienced places, both as a student and resident, where prerounding is the norm, so I can't speak about the places that don't do it.

Still, I can't help but worry that eliminating 1 on 1 evaluations of patients may be a detriment to the junior resident, and definitely the med student. For the student, it makes medicine into much more of a spectator sport. For the junior resident, it prevents autonomy and patient ownership, as all problems are discovered as a group, all orders are written as a group, all decisions are made as a group........it just seems like the chief would be holding your hand the whole time.....

Also, following the chief around and watching him do the work would likely negatively impact the development of physical exam skills and history taking.
 
Castro Viejo said:
What arrogant presumption.
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No more presumptive than when Tired says not prerounding is a great way to kill people without ever having been at a place without prerounds. No more presumptive than you saying there will be more medical errors because interns won't know what is going on simply because they don't preround. I mean, if your intern says they did something last night but it only happened 15 minutes ago, isn't that just as bad? And I know you've had patients who pull their NG tubes the second you walk out of the room.

Perhaps in your system it wouldn't work, and maybe that is why your interns still preround. At places with a nightfloat that is on the floor all night, there is no need. For you to blanketly say you think it is a bad idea without having any firsthand knowledge as to how well it can function at a different system or different institution is no less arrogant than my mentioning how you, on more than one occasion, have dogged out at least one resident that I know of for being pregnant and taking advantage of that even though you are the most vocal proponent of the surgical team on SDN. Most successful teams (of which I've been apart) don't sell out someone who makes work harder; they pick that person up and find a way to motivate him/her to get back with the goals of the team. What about the presumption that thinking about the 80 hour workweek makes one a future lazy intern? You have made far more reaching presumptions on this forum than I ever had. I made mine because I felt that you and your fellow "prerounding is what we do, it is the only way our (lazy, uncaring) interns know the service (because otherwise they would never set foot into a patient's room) and it is the only way to ensure good patient care (for the above mentioned reasons)" types have basically said that every program that does not preround will produce inferior surgeons and will have more patient complications because the interns won't know anything about their service. All of this is said without any firsthand knowledge of whether or not that is the case.

Again, I'm sorry you've had tough luck with finding interns who care about their patients ("their" being the operative word, because it doesn't sound like many people in the pro-prerounds group think their interns take possession of the patients otherwise [see SLUser's post]), but to make it sound like I'm going to be inferior simply because I didn't preround is quite insulting, and that is what set me off.
 
Anyway, thank you for the ideas. I didn't want this question to start flames though.

Nor am I lazy; however, in surgery there is this untold culture whereby it's sometimes difficult to ask questions which go against tradition. This is one example. Given that, I thought a forum like this would be an ideal place to exchange ideas about this given that I've only been exposed to one method (i.e. mandatory prerounding). I was well aware of the potential for perceptions of me being lazy.... i should i have therefore been more clear about my intent and not joked about picking a residency on the basis of prerounding. It was really just that, a joke.

Anyway, it's obvious there are multiple ways to go about taking care of patients. While I haven't been exposed to both methods, I look forward to experiencing whatever method comes my way come June, and I will let you know my thoughts.
 
Sounds like most people that Replied to the OP had chiefs that actually did walk rounds on patients.

Here the call person sees 80-100% of the inpatients. No night float. As a junior you could typically round on 40 patients, and cover the ED if you started at midnight. If things were quiet you could lay down for an 1 or 2 hours. Everyone else would plan on arriving about 30-60minutes (depending on census) before sit down rounds with the chief, typically at 6:30. If you were in the OR you would send out a text page for help and everyone come in to see patients. If you could see everyone you would send out a sleep in page. We round on everyone again in the afternoon and then did sit down rounds again. Chief would typically see the folk he/she operated on between cases and any sick people right after sit down rounds. We had a chief that tried to do walk rounds but we would never be able to hit everyone, and that was with people prerounding.
 
one distinction.

many have talked of prerounding and examining bellies and drains, etc. this is not what i consider an integral part of pre-rounding. on the contrary, those are the things i've done earlier in the night and/or throughout the night if there is some pertinent issue. if not, we will do that on rounds. so there is not always (or most times) a need for a full physical.

however, there is always the need for a quick perusal of the flowsheet prior to rounds. if that perusal allows one to write the numbers so that when rounding and flowsheets are missing (i.e nursing signout time is occuring, someone is in the med room, etc) our rounds can continue without interruption. also, it prevents the embrassing moments as previously mentioned. also, to remind you all that nurses also sign out in the AM. so they may not tally or even mark down drain output, urine output etc throughout the night. they will, for the most part, catch up close to AM rounds (for the same reasons we do). so it is your chance to play catch up on details missed not only secondary to inattention to the flowsheet, but details not previously marked on said flowsheet. it is also time to HLIV, give some lasix/blood, send cx, do things you would/should have done earlier had you known some of the info that you, after prerounding, now know.

i do not consider prerounds something i have to do, but rather something i need to do in order to feel complete and on top of things before i sign off this service to a new group of people. i can not stand to have discovery rounds. if i am on call it is my job to know what is going on on my service. and, call me uptight, i think it is my duty to know this stuff, be aware of this stuff, and address it first.

i guess i am also crossing the boundaries of this discussion by mixing call nights/prerounding and normal nights/prerounding, and they are different issues. pre-rounding by the on call person is different than by the incoming person and that all depends on the system in place. when nightfloat or some other unrelated coverage person had my team, i always felt better seeing the numbers in the AM and knowing what transpired. and as the coverage person, i always needed to round out my night by one last prerounds so i handed back the team in an organized fashion.

as an intern, even when not on call, i considered most of my services MY services (i.e. the intern is the keeper of details that others might miss) so you are in charge of making sure that these details do not disappear into the void. perhaps you all are more comfortable just doing discovery rounds, but i find that things move faster, less things get missed, and all are happier if a little reconaissance is done in advance. numbers for the sake of numbers are useless. but a quick glance and review of material prior to official speedrounds makes things better and the team operate more efficiently.

i hope my juniors feel the same. if not, that will be a sad change. but i think we should take some pride and ownership of our patients and our jobs.
apologies for the tone, but there is some **** in this job that i think we should take seriously. i do what i do to give better care because this is not about an extra 1/2 hr of sleep. these are patient's lives. and sure, it may not seem like a big deal on the floors. but wait 'til you're the only one in the cardiac SICU and the patients are sick as stink and see how blase you want to be. i assure you, apathy and half-assedness has no place in the hospital. and if it takes rounding repeatedly to be on top of that, than that's what you do.

i know i digress, but i think there is a place for prerounding, just not the whole shabang. like i said, reconaissance....
 
Honestly I think both systems can work. I would argue, however, that rounding once as a team is more efficient in this day and age. Admittedly, there is some educational value lost to the intern/junior without the opportunity to independently assess the patient and formulate a plan on morning rounds. However, I would say in the long-run it is not a major issue. Intern/juniors see consults and are called to the bedside for lots of issues which they do have to assess independently and I have found that they are able to step up to the plate when they become a senior. In terms of the patient ownership issue, I am not sure how well that can be taught -- certain people seem to just have it or not.

I don't think our system misses any more than a system that prerounds and just has the chief "poke their head in for 45 seconds." For one thing, as the chief, I personally look at the trend of the vitals on the flowsheet, talk to the patient, examine the abdomen, incisions, and drains. It takes me several minutes per patient. No offense, but I sure as hell don't trust a medical student to just read off the vitals and outputs to me. They are new at it and it's not their fault that sometimes things are recorded in a confusing manner. I let them present to me, but I always double check by looking at the flowsheets myself as they present.

Also, our nightfloat residents give us a pretty detailed update and generally are responsible about following up to make sure things get done. I insist that the pt room numbers be updated before we round so that we can take the most efficient route. Maybe I am a neurotic chief, but I actually try to get signout from the nighfloat junior to make sure I am fully apprised of all the details of issues that occurred overnight.

Honestly, I have seen both systems and they both work -- different advantages / drawbacks.
 
geekgirl said:
...but wait 'til you're the only one in the cardiac SICU and the patients are sick as stink and see how blase you want to be.
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I approached the CTICU call the same as I approached night float; I would check the computer when vitals were reported (q1h) and when labs were due (and react accordingly). I would also do my own personal walk rounds at least 4 times a night (6, 10, 2 and 4:30) to eyeball each patient and find out from the nurses how everyone was doing. In a way, it was easier because I only had 18 patients instead of up to 70 when I was on night float.

i know i digress, but i think there is a place for prerounding, just not the whole shabang. like i said, reconaissance....
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This is exactly the role of the nightfloat intern or the intern on call at night. Running the numbers at the computer is not a hard thing to do and it is something that should be done at least as often as vitals are taken. Also, we have preprinted SOAP notes (that auto-print between 4 and 5 am) that include things like labs, vitals and meds for the last 24 hours already on the sheet. Furthermore, we have a program that manages our patient list automatically that also includes labs, vitals, meds as well as the current room number (updated qid). As I said before, the night float is also responsible for replacing electrolytes at around 2am (usually when labs come back), so it doesn't have to be done on rounds.

Tired-
It's obvious you know how systems function with and without a night float and have an infinite knowledge of how things run with and without formal prerounding (i.e. patients die when they would have otherwise lived, etc...). God bless you for pulling the wool from over my eyes. Now I will start coming in to preround on my patients, and on the patients on other services where the residents are not prerounding so as to ensure patients on a surgery service don't die. I will obviously be in violation of the work hours, but that's okay; I'll just lie about it so I have a program from which to graduate. Wait, don't we all tell our medical students that the worst thing possible on a surgery rotation is to lie...? I don't know what to do!?!😕
🙄
 
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