How permissible is it to skip rounds?

MacGyver said:

So here's my plan. I'm going to talk to the surg attendings directly and just ask them if I can scrub in on cases all morning long, and forget the stupid rounds.

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Bad plan.

MacGyver said:

OK after my first day on surgery clerkship I have deemed rounds absolutely and totally worthless. The residents and interns know its worthless too, thats why there are zero attendings on rounds, and thats also why they ceded most of the floor duties to PAs and NPs.

Since surgery by its own admission deems these rounds worthless, I see no reason to be there either. My yield would be MUCH BETTER in the OR, or reading surgical textbooks. Rounds, at least the way they are set up in surgery, is the LEAST EFFECTIVE USE OF MY TIME.

So here's my plan. I'm going to talk to the surg attendings directly and just ask them if I can scrub in on cases all morning long, and forget the stupid rounds.

P.S. For the record, I'm not against floor work/rounds in general. On the medicine service, rounds were absolutely critical, and a great use of my time for teaching and learning about patients. Surgery rounds are very, very different.

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of late i've been too lazy to respond to much of what i read - but your post, as well as your associated quote, disturb me enough to bother halting my mid-dinner edamame in order to respond.....

are you for real? i hope not. i really, sincerely, with all my heart, hope not. because if you are, your entitled atitude and sense of self-importance are very frightening.

1. doctors are here as service professionals - i.e. it is NOT about you, it is about the patient
2. residents do NOT work their own hours, nor do they have a say in them
3. your patients are not accesories to your learning - they are the focal point of what you do. it is more important to do the right thing for them, despite your inconvenience than to "learn more" by doing less for them

ah, i will stop nibbling this bait. but really...... whew.... yeah, i have so much to say. that i must stop now..... but beware this attitude....

You need to know what to do for a patient before and after surgery before you should be allowed to operate on one. This is even more true if you plan on being a surgeon when you graduate medical school; you would think you would want to know what to do so you don't look like a complete ***** your first day of internship and wind up killing someone because you skipped rounds while in medical school.

MacGyver said:

If floor rounds were really as important as you guys say they are, then surg attendings would be present. The fact that they turf 100% of their floor work to others (residents, PAs, NPs) speaks volumes.

Besides, its hard to take it seriously when every single surg resident states over and over again how worthless and crappy floor work is.

The truth is that if surg residents could eliminate floor work completely and give it over 100% to the PAs so they could be in the OR they'd do it in a heartbeat. Be honest with yourself and admit this fundamental truth.

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Quit being stupid for the sake of being stupid. I really can't take you seriously because (a) you are you and (b) this is only your first day on the rotation and even you would not be so bold as to suggest what you are implying.

Attendings do make floor rounds, just in between cases or in the afternoon, not at 6am. That is the benefit of being an attending-you get to sleep in. If am rounds were not made, the patients would sit on the floor all day without a plan and would not be able to progress in their hospital course.

There is a big difference between floor work and am rounds. Yeah, sorting out the social work, physical therapy, wound therapy and other details of the hospital stay is rather boring and I would much rather be in the OR than dealing with these things. It is the planning that happens on am rounds that is important. That is the reason they are done and that is where, if you would just listen to what is being said, you can learn a great deal about post-operative patient care.

MacGyver said:

So here's my plan. I'm going to talk to the surg attendings directly and just ask them if I can scrub in on cases all morning long, and forget the stupid rounds.

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Sounds good to me. I did it here at my hospital and they promoted me to chief of surgery for being so bold, intelligent, and solution-oriented.

In all seriousness, what you should do to further leapfrog my accomplishments is to not even talk it over with the attendings. Today's modern surgeon needs to be a take-charge kind of doctor. Just kick open the doors of the OR and cut where you damn well please.

Oh yea...when this is all done, let me know how your evals read

Obvious trolling is ooooooobvious. Mac's just looking for attention. Ignore him.

This thread is now about Keurig coffee makers:


Great invention or greatest invention?

MacGyver, you are sooo far off the deep end.

Although, it is nice to know that you approve of PAs when they suit your purposes

-Mike

Sorry, it is directed at the OP.

-Mike

I am sorry to hear that you (and your residents) find floor rounds so useless. While my attendings did not come to am rounds with the Chiefs, they ALWAYS rounded on their patients, but it may have not been with the entire team, depending on the OR schedule, etc. The Chiefs discuss the morning rounds with the attendings who then round on the patients as time permits that day, unless there is an emergency which the residents call to the attending's attention.

Many surgeons and many services do team teaching rounds and these are a valuable opportunity. I would advise against approaching your attendings about simply coming to te OR - this will be seen as not an indictment of the way rounds are run at your hospital but rather as evidence of your indifference (at best) or arrogance ( at worst) in learning about peri-operative management - which really is the mainstay of surgical treatment.

Perhaps a better tactic would be to ask whether there are teaching rounds on the service, or whether or not you can find out when the attendings DO round on their patients and whether or not you can attend.

MacGyver said:

OK after my first day on surgery clerkship I have deemed rounds absolutely and totally worthless. The residents and interns know its worthless too, thats why there are zero attendings on rounds, and thats also why they ceded most of the floor duties to PAs and NPs.

Since surgery by its own admission deems these rounds worthless, I see no reason to be there either. My yield would be MUCH BETTER in the OR, or reading surgical textbooks. Rounds, at least the way they are set up in surgery, is the LEAST EFFECTIVE USE OF MY TIME.

So here's my plan. I'm going to talk to the surg attendings directly and just ask them if I can scrub in on cases all morning long, and forget the stupid rounds.

P.S. For the record, I'm not against floor work/rounds in general. On the medicine service, rounds were absolutely critical, and a great use of my time for teaching and learning about patients. Surgery rounds are very, very different.

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First, It's your first day, so you are really in no position to make such sweeping judgements on the necessity/utility of morning rounds.

Morning rounds serve several functions. Each patient needs a note on their chart every day documenting their progress. Surgical patients have just gone thru a huge physiological stress and many things can go wrong. They need to be checked every day to make sure they don't have fever, that their incision is okay, their lungs are okay, fluid status is okay etc. A senior resident can often assess these things very quickly and you may not even realize what they are doing. I garantee - if the residents didn't round every morning many of these issues would get missed and would present a day or two later with serious complications (hypovolemia becomes ATN and renal failure, Undiagnoses wound infection spreads and patient gets septic, line infection not diagnoses and patient gets vegetation on heart, .....).

Surgery accomplishes before 7 am what medicine takes all day to do. Therefore they must be efficient and don't have time to tell the clerks everything they are doing with every patient.

When i was a resident (i love saying that) I would often choose one patient on morning rounds to do a little bedside teaching with the clerks -- let them try to assess fluid status or let them try to figure out why the patient has a fever. That way they know what we're doing in high speed every morning.

Attendings don't do mornign rounds because they trust the resident to do it for them. They will often call the resident after rounds and check in and make sure there are no problems with their patients. They then do leisurely rounds between cases to see their patients. They trust that the residents have written notes and made sure the issues are taken care of so that they don't have to. That's one of the benefits to being an attending. If you go to a non-teaching hospital you'll find the attendings doing morning rounds.

Finally, I doubt the residents think rounds are useless. They may not be the funnest part of the day, but they are necessary to the good care of the patients.

Surgery is more than just performing the operations. I think you need to settle down and figure that out before you try and tell your attendings that you're goign to "skip" rounds.

Goodluck

emedpa said:

sweet coffeemaker. I assume it's got the autostart am grind and brew feature but what can it do for ME that I can't get out of my mr coffee automatic?

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The secret is these little miracles:


You put one in the machine, and it brews you a cup of coffee in one minute. It's so easy to use and so fast and so tasty that there's no excuse to not have a nice cup of coffee before 0500 rounds.


Mmmmmm... And the blue lights are so pretty.

Entei said:

The secret is these little miracles:

You put one in the machine, and it brews you a cup of coffee in one minute. It's so easy to use and so fast and so tasty that there's no excuse to not have a nice cup of coffee before 0500 rounds.

Mmmmmm... And the blue lights are so pretty.

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mmmmm

so you're saying yes to home brew and no to wasting money on Dunkin Donuts and/or Starbucks?

cdql said:

mmmmm

so you're saying yes to home brew and no to wasting money on Dunkin Donuts and/or Starbucks?

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Dunkin Donuts coffee is awesome. I would consider that money very well spent. But when I'm home or in a rush, the Keurig makes excellent, very convenient coffee!

Starbucks on the other hand... blech! Drinking Starbucks coffee is, to use Mac's words, the LEAST EFFECTIVE USE OF MY TIME.

Entei said:

Dunkin Donuts coffee is awesome. I would consider that money very well spent. But when I'm home or in a rush, the Keurig makes excellent, very convenient coffee!

Starbucks on the other hand... blech! Drinking Starbucks coffee is, to use Mac's words, the LEAST EFFECTIVE USE OF MY TIME.

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too bitter right?

i find myself dumping 2-3 bags of that brown sugar into my grande cappucino with skim milk to fix that problem

much better!

MacGyver said:

If floor rounds were really as important as you guys say they are, then surg attendings would be present. The fact that they turf 100% of their floor work to others (residents, PAs, NPs) speaks volumes.

Besides, its hard to take it seriously when every single surg resident states over and over again how worthless and crappy floor work is.

The truth is that if surg residents could eliminate floor work completely and give it over 100% to the PAs so they could be in the OR they'd do it in a heartbeat. Be honest with yourself and admit this fundamental truth.

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Many surgery training programs do not have attendings on rounds for a very deliberate reason, as I heard over and over again during interviews. These rounds are the time for the senior residents to "take charge" of a service and start making independent decisions about patient care as opposed to having an attending rattle off what to do while everyone mindlessly scribbles a to-do list. Attendings aren't on rounds because they are boring or useless, they are not there so the chiefs can practice being an attending, which they will be shortly. Most surgery programs tout this policy of independent rounds as a benefit to applicants.

Entei said:

Obvious trolling is ooooooobvious. Mac's just looking for attention. Ignore him.

This thread is now about Keurig coffee makers:

Great invention or greatest invention?

Click to expand...

we have these in the doctor's lounge you mean I can buy one for home?!?!? sweet!

LovelyRita said:

we have these in the doctor's lounge you mean I can buy one for home?!?!? sweet!

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yessirree! their website has home and office style coffee brewers!

cdql said:

yessirree! their website has home and office style coffee brewers!

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Can you afford this miracle machine and coffee cartridges on a resident's salary?

We don't have a fancy coffee machine (or a lounge for that matter), so I carry a cup of the Red Diamond special on my "useless" morning rounds.

I buy my little miracle cartidges from Bed Bath and Beyond. (Don't laugh!) They retail for $9.99 for 18 k-cups, but I get 20% off coupons spammed to my mailbox all the time from BB&B. So it's not THAT bad compared to a couple bucks for coffee from DD or Starbucks. The price of the machine is a different story... but hey, the 20% off coupon applies to that too!

To the OP,

Just wondering what you decided to do. Did you talk to your staffman about skipping rounds or did you discuss ways to make rounds more educational?

Please let us know how your surgery rotation is going.

LovelyRita said:

we have these in the doctor's lounge you mean I can buy one for home?!?!? sweet!

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We have one in The Cancer Institute - supposedly for the patients, but I sneak some Southern Pecan when I can!!

Mac,

I hope by now you realized that skipping on rounds is like skipping on learning... watch the sign out and what the chief tells the intern to do to the patient... starting thinking of why this and not that (e.g. why did they order a PT/PTT/INR for patient A or what is the followup of the pancreatitis or AV fistula patient). I think what you are feeling is the fall behind on reading...

Start reading on the disease management for the different diseases on the floor and see if you are able to second guess the resident orders. Plus on rounds of surgery core rotation you will master changing Vacs, Wet-to-Dries and the basic wound bandaging (is it infected?)

to the OP--once you have that talk with the attendings about skipping rounds to read and stuff, another thing you could do is be the first or second person to leave to OR after the case is done and the attending has left. don't offer to help clean up or waste any time waiting for anesthesia to wake the patient up...um, BORING!...and you could get some good reading done instead of sitting there with the other residents and nurses. they've got plenty of people in the room to help, and since it's not your job, skip all that post-op stuff and just meet them in the recovery room or surgeons's lounge....at your convenience, of course.

within a few days you'll earn such notoriety as being a student unlike any they've ever seen...you'll become so famous that your bold and visionary ideas will be the topic of conversation among the attendings and residents. you will no doubt leave an impression on the surgery department in a way that no one will ever forget, and you most definitely will leave them with something to remember you by...in a very, hmmm...mel gibson and michael richards sort of way, if you catch my drift.

sorry if this sounds like a lecture, but you're a guest on the surgical service and like it or not, the rest of the team deserves your respect and cooperation. if you have the audacity and arrogance to walk right into their "home" and think you can start calling the shots, not only are you in for a painful, traumatic surprise, but you are going to end up sabotaging your entire time on the surgical clerkships (and possibly beyond, as word spreads faster than c. diff in the hospital), and you'll soon find yourself not going to cases at all and instead being told to stay on the floor and help the intern all day, so that he or she can then scrub in on a case or two.

mcindoe said:

...and you'll soon find yourself not going to cases at all and instead being told to stay on the floor and help the intern all day, so that he or she can then scrub in on a case or two.

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That's a really good idea. I will have to remember it for those med students who come through feeling entitled and who rarely help on the floor stuff, can't be found while on call and never have dressing change materials ready/the dressing down on the patients who have been there longer than the student has been on clinical rotations and who, every day, have a dressing change during morning rounds. Really, really good idea...

I like your style Mac.

oh good lord I can't believe all the time wasted on responses, the OP has been a troll for years

emedpa said:

you and I are the only ones who recognize this.....

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I refer you to post #11.

I have a theory. I think Mac and Miste might even be the same person, but I have no way to prove this.

MacGyver said:

I've been getting to the hospital an hour before morning roudns start and getting all the vitals, labs, and new imaging studies recorded in the chart. Then I change all the dressings (nothing complicated, just routine dressing changes). Then I get all the meds (recorded in a separate area) and write them in the daily note. So basically I write the SO part of the note and leave the AP part for the residents to fill out later.

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hmm... in other words, you are doing the job of a 3rd year medical student. I'm glad you finally figured out your role on the team...

MacGyver said:

...So here's my plan. I'm going to talk to the surg attendings directly and just ask them if I can scrub in on cases all morning long, and forget the stupid rounds...

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The troll is strong with you young padawan....

Surgery rounds taking 2.5 hrs? Yeah right.

MacGyver said:

Average 20 patients on service x 7 mins avg per patient (looking up vitals, calculating Is/Os, looking at their medication list, looking up daily lab values in the computer, looking at yesterday's imaging results, changing dressings, repacking wounds if necessary, removing staples if necessary, formulating a plan, talking to the patient, answering their stupid questions)

you do the math

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Dressing changes, removing staples, packing wounds, calculating I/O - the nurses do all of this at every hospital i've ever been at! Do clerks really do this in American hospitals? what a waste of time.

tussy said:

Dressing changes, removing staples, packing wounds, calculating I/O - the nurses do all of this at every hospital i've ever been at! Do clerks really do this in American hospitals? what a waste of time.

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While nurses at academic hospitals commonly won't remove staples, sutures or drains, they can and do at *some* community hospitals I've worked at. In addition, nurses do change dressings and pack wounds, but the surgeons have to see the wound AT SOME POINT IN TIME, so it makes sense for us to do it on morning rounds. If I'm in a real hurry, I'll ask the nurse if she can redress the wound, but most of the time someone from the team does it.

filter07 said:

Surgery rounds taking 2.5 hrs? Yeah right.

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Sure...like Mac notes, if you have a large service, with lots of wounds that have to be undressed, redressed, etc., lots of SICU patients with complicated problems or vascular patients with lots of graft checks, rounds can take that long. Its why we started rounding at 500-530 am to make it to the OR at 730.

I've been on a vascular service before and rounds never took that long. The medical students undressed the wounds before rounds. We had dopplers ready by the bedside with the graft site exposed, ready for checking by the residents. The interns and other junior residents had already checked the relevant images. We had a streamlined system to read vitals and labs, as well as write notes. Rounds started at 6, ended at 7:30. I can understand 2.5 hrs if there is no prerounding at all, but otherwise there's gotta be ways to make rounds more efficient.

filter07 said:

I've been on a vascular service before and rounds never took that long. The medical students undressed the wounds before rounds. We had dopplers ready by the bedside with the graft site exposed, ready for checking by the residents. The interns and other junior residents had already checked the relevant images. We had a streamlined system to read vitals and labs, as well as write notes. Rounds started at 6, ended at 7:30. I can understand 2.5 hrs if there is no prerounding at all, but otherwise there's gotta be ways to make rounds more efficient.

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Many places don't allow pre-rounding now, to cut down on work hours.

And yes, there are ways of making rounds more efficient, and yes, there are med students who are not as organized, helpful or just plain "with it" as you obviously were. I can still hear me mumbling, "its the same &*^& everyday" when the students and interns stood around motionless as if they had never done these rounds before.