Do EM docs do rounds?

[TheDudeMD]

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MS-III here, roughly 99% sure I will do EM, based on my limited experience so far. One thing I've disliked so far in my rotations are these overly structured and formal rounds in a conference room that last an hour+. The residents on my OB/GYN rotation literally spend 60% of their time on the floor freakin out about prepping for their rounds presentations, stabbing one another in the back, crying about how the attending chewed their ass out during their last presentation, updating their rounding lists to follow pedantic syntax lest they be tarred/feathered by chief resident, plotting against one another, etc.

It's boring as hell, a massive time-waster, and I've literally seen several residents drop what they're doing (i.e. walk out of a 5cm dilated patient's room) because they need to dash to a flippin computer to alphabetize the patient list before evening rounds starts in 5 minutes. And the rounds themselves seem to consist of a lot of phallus-waving by the attendings and chief residents. It's a silly sh*tshow we go through twice a day just to update everyone on the patients' status, which really shouldn't take that long.

Question: WILL THIS BE MY LIFE AS AN EM RESIDENT/DOC? Thanks. Any insight is much appreciated, I readily admit to my lack of experience and appreciate pointers.

Edit: just wanted to prophylactically say I searched the forums and google for an answer, couldn't find anything definitive.

 

[EM_Rebuilder]

MS-III here, roughly 99% sure I will do EM, based on my limited experience so far. One thing I've disliked so far in my rotations are these overly structured and formal rounds in a conference room that last an hour+. The residents on my OB/GYN rotation literally spend 60% of their time on the floor freakin out about prepping for their rounds presentations, stabbing one another in the back, crying about how the attending chewed their ass out during their last presentation, updating their rounding lists to follow pedantic syntax lest they be tarred/feathered by chief resident, plotting against one another, etc.

It's boring as hell, a massive time-waster, and I've literally seen several residents drop what they're doing (i.e. walk out of a 5cm dilated patient's room) because they need to dash to a flippin computer to alphabetize the patient list before evening rounds starts in 5 minutes. And the rounds themselves seem to consist of a lot of phallus-waving by the attendings and chief residents. It's a silly sh*tshow we go through twice a day just to update everyone on the patients' status, which really shouldn't take that long.

Question: WILL THIS BE MY LIFE AS AN EM RESIDENT/DOC? Thanks. Any insight is much appreciated, I readily admit to my lack of experience and appreciate pointers.

Edit: just wanted to prophylactically say I searched the forums and google for an answer, couldn't find anything definitive.

I round often... But its in my head, while looking at the electronic room board.

You do not round in the traditional sense.

You just go see patients... and then follow them up; and juggle 1-10+ at a time.

 

[NYEMMED]

MS-III here, roughly 99% sure I will do EM, based on my limited experience so far. One thing I've disliked so far in my rotations are these overly structured and formal rounds in a conference room that last an hour+. The residents on my OB/GYN rotation literally spend 60% of their time on the floor freakin out about prepping for their rounds presentations, stabbing one another in the back, crying about how the attending chewed their ass out during their last presentation, updating their rounding lists to follow pedantic syntax lest they be tarred/feathered by chief resident, plotting against one another, etc.

It's boring as hell, a massive time-waster, and I've literally seen several residents drop what they're doing (i.e. walk out of a 5cm dilated patient's room) because they need to dash to a flippin computer to alphabetize the patient list before evening rounds starts in 5 minutes. And the rounds themselves seem to consist of a lot of phallus-waving by the attendings and chief residents. It's a silly sh*tshow we go through twice a day just to update everyone on the patients' status, which really shouldn't take that long.

Question: WILL THIS BE MY LIFE AS AN EM RESIDENT/DOC? Thanks. Any insight is much appreciated, I readily admit to my lack of experience and appreciate pointers.

Edit: just wanted to prophylactically say I searched the forums and google for an answer, couldn't find anything definitive.

It depends on the program... No matter which field you will go into you will have to sign out to another doc at some point.

For EM ive noticed most programs do teaching rounds. You walk over as a group to an interesting case and discuss it. There may be lectures given by residents or students also depending on the program.

As far as formal sit down and run the patient list.... Not in EM, we do not have service patient lists to run...

 

[illegallysmooth]

During my rotation at Emory, we did an informal rounds during shift change. It was not like IM rounds. Very short and to the point. So you may find this at some programs. Most places, however, just have a sign-out conversation with whoever's comng on.

 

[TheDudeMD]

Thank you to the 3 replies. It's the formal, sit down in a room for an hour-type rounds that I'm finding out is incompatible with my personality. I love informal, to-the-point discussions during patient hand-offs though, so I'm not anti-social or anything. Just a little sick of pretenses and time-wasting while stuff needs to get done.

 

[RustedFox]

Thank you to the 3 replies. It's the formal, sit down in a room for an hour-type rounds that I'm finding out is incompatible with my personality. I love informal, to-the-point discussions during patient hand-offs though, so I'm not anti-social or anything. Just a little sick of pretenses and time-wasting while stuff needs to get done.

Right-on the head with this'n.

I used to think that I wanted to do IM so badly, then I actually did an IM rotation as an MS3. "Internal medicine" became "Eternal medicine."

 

[TheDudeMD]

Right-on the head with this'n.

I used to think that I wanted to do IM so badly, then I actually did an IM rotation as an MS3. "Internal medicine" became "Eternal medicine."

Ok glad it's not something wrong with me.

 

[Raryn]

Right-on the head with this'n.

I used to think that I wanted to do IM so badly, then I actually did an IM rotation as an MS3. "Internal medicine" became "Eternal medicine."

Versus those of us who do IM choose to do it because we enjoy the discussions of what is going on with our patients and formally thinking/going through the plan.

I thought for the first 2.5 years of medical school I wanted to do EM, but after my IM clerkships decided I liked finding out the actual results of my actions and what happened to my patients.

It's all just personal preferences though, theres nothing more or less right about either philosophy.

 

[TheDudeMD]

Versus those of us who do IM choose to do it because we enjoy the discussions of what is going on with our patients and formally thinking/going through the plan.

I thought for the first 2.5 years of medical school I wanted to do EM, but after my IM clerkships decided I liked finding out the actual results of my actions and what happened to my patients.

It's all just personal preferences though, theres nothing more or less right about either philosophy.

I actually don't mind this either. I love discussions with colleagues where we debate in a friendly manner what's going on with the patient. Maybe the particular programs I've rotated with have just twisted it into something else? Our rounds consist of "sit down, shut up, don't speak until it's your turn to present patient" and if you have something to contribute, wait until after the hour of rounds is over to say something. Lots and lots of awkward silence and passive-aggressive stares between residents and attendings. Maybe it's the culture here.

I'm from a PBL school where we were encouraged to talk out of turn, have a thick skin, and allow pertinent facts to take precedence over formalities/traditions--maybe this is just culture-clash for me.

 

[Raryn]

I actually don't mind this either. I love discussions with colleagues where we debate in a friendly manner what's going on with the patient. Maybe the particular programs I've rotated with have just twisted it into something else? Our rounds consist of "sit down, shut up, don't speak until it's your turn to present patient" and if you have something to contribute, wait until after the hour of rounds is over to say something. Lots and lots of awkward silence and passive-aggressive stares between residents and attendings. Maybe it's the culture here.

I'm from a PBL school where we were encouraged to talk out of turn, have a thick skin, and allow pertinent facts to take precedence over formalities/traditions--maybe this is just culture-clash for me.

That is not typical of rounds for any inpatient specialty that I know of. At least in my medicine program and the one at my medical school, we'd discuss the patients, possibly debate management, and everyone from the JMS up could participate.

 

[TheDudeMD]

That is not typical of rounds for any inpatient specialty that I know of. At least in my medicine program and the one at my medical school, we'd discuss the patients, possibly debate management, and everyone from the JMS up could participate.

So glad to hear this. Was beginning to suspect the profession just operated like this.

 

[EM2013]

One thing I have found very helpful so far in my intern year is q1-2 hr walking rounds with the attending. It literally takes 5-10 minutes and really helps us to keep focused on what's going on / what still needs to be done for the patient. Really helps when you are juggling multiple patients because it's real easy to forget about one and let a 3 hr stay turn into a 5-8 hr stay.

 

[TheDudeMD]

One thing I have found very helpful so far in my intern year is q1-2 hr walking rounds with the attending. It literally takes 5-10 minutes and really helps us to keep focused on what's going on / what still needs to be done for the patient. Really helps when you are juggling multiple patients because it's real easy to forget about one and let a 3 hr stay turn into a 5-8 hr stay.

This sounds much more efficient. It should be off-the-cuff, informal, ALWAYS walking rounds (sitting rounds are a terrible idea IMHO), favoring short/frequent discussion over long/infrequent.

I'm starting to realize that as you increase formality in these kinds of settings, you also increase CYA-behavior in people. This includes lying about details ("yes, of course I went into the patient's room") and conveniently leaving out details that might make you look bad in front of others. As soon as it becomes about winning points with attendings and chiefs instead of empirical facts on the patient, rounds become counterproductive.

And sitting rounds are beyond stupid IMHO. (Again I'm admittedly speaking from very little experience compared to you guys. I'm open to having my mind changed.)

Attendings who make decisions based on computer print-outs + presentations by brown-nosing residents looking to one-up each other, without even LOOKING at the patient...wow that grinds my gears. I know it's easy to judge, being a naive 3rd year without much skin in the game, but I know I don't want to choose a specialty where this culture is normalized. When I become an attending someday, there's no way in hell I'm going to just NOT look at the patient. (Done with rant, apologies for sidelining the discussion.)

My next rotation is IM, hopefully it'll be an improvement compared to my current experience.

 

[Evil_Abed]

This sounds much more efficient. It should be off-the-cuff, informal, ALWAYS walking rounds (sitting rounds are a terrible idea IMHO), favoring short/frequent discussion over long/infrequent.

I'm starting to realize that as you increase formality in these kinds of settings, you also increase CYA-behavior in people. This includes lying about details ("yes, of course I went into the patient's room") and conveniently leaving out details that might make you look bad in front of others. As soon as it becomes about winning points with attendings and chiefs instead of empirical facts on the patient, rounds become counterproductive.

And sitting rounds are beyond stupid IMHO. (Again I'm admittedly speaking from very little experience compared to you guys. I'm open to having my mind changed.)

Attendings who make decisions based on computer print-outs + presentations by brown-nosing residents looking to one-up each other, without even LOOKING at the patient...wow that grinds my gears. I know it's easy to judge, being a naive 3rd year without much skin in the game, but I know I don't want to choose a specialty where this culture is normalized. When I become an attending someday, there's no way in hell I'm going to just NOT look at the patient. (Done with rant, apologies for sidelining the discussion.)

My next rotation is IM, hopefully it'll be an improvement compared to my current experience.

😕

Sitting rounds at the hospitals I rotate at means that we discuss the patients in a conference room and then we physically round on them instead of presenting right outside each patient's room and clogging up the hallways. Haven't ran into any attendings who don't examine their patients -- sometimes, they round by themselves or with the senior resident later on, but I've never seen one just blindly trust the med students' and residents' assessment/plan. So far, I've absolutely loved sitting rounds and have learned a TON of medical management this way.

Also, if the residents and attendings at your institution are focused on one-upping each other and making up information, that's really a problem with your institution and not representative of an entire specialty. Hopefully, you'll have a better experience on your next service.

 

[deleted547339]

I see no problem whatsoever with brief, sitting rounds in EM. My attendings always see every one of my patients (at least as interns) after we see them and put in orders. They know all of my patients, but aren't necessarily following each one as closely as I am. About once an hour, we'll go through a brief "rounds" and I'll say what's going on in each room, e.g. bed 1 - CT done, pending read then dispo; bed 2 - just got off the phone with medicine, they're admitted and going upstairs, bed 3 - called ortho, they're in a case - they'll be down to see them as soon as they're out.....etc. We generally do this every 1-2h and it only takes about 1-2 minutes. Generally the attending helps speed up dispo by saying "you really don't need to wait for X, Y or Z to come back; it's OK to go ahead and call medicine now" or "that CT read is taking a while, I'll call rads" or whatever.

As said above, I find this is a good way to not lose track of patients when you're busy (i.e. out of sight, out of mind), keep your attending in the loop and speed up dispo.

 

[TheDudeMD]

I see no problem whatsoever with brief, sitting rounds in EM. My attendings always see every one of my patients (at least as interns) after we see them and put in orders. They know all of my patients, but aren't necessarily following each one as closely as I am. About once an hour, we'll go through a brief "rounds" and I'll say what's going on in each room, e.g. bed 1 - CT done, pending read then dispo; bed 2 - just got off the phone with medicine, they're admitted and going upstairs, bed 3 - called ortho, they're in a case - they'll be down to see them as soon as they're out.....etc. We generally do this every 1-2h and it only takes about 1-2 minutes. Generally the attending helps speed up dispo by saying "you really don't need to wait for X, Y or Z to come back; it's OK to go ahead and call medicine now" or "that CT read is taking a while, I'll call rads" or whatever.

As said above, I find this is a good way to not lose track of patients when you're busy (i.e. out of sight, out of mind), keep your attending in the loop and speed up dispo.

Yeah this sounds ideal. Thanks for the detail. My mind's at ease if most programs are like this.

Edit: hang on, what's "dispo"? Short for disposition? If so, not sure exactly what you mean by speeding up disposition...

 

[deleted547339]

Yeah this sounds ideal. Thanks for the detail. My mind's at ease if most programs are like this.

Edit: hang on, what's "dispo"? Short for disposition? If so, not sure exactly what you mean by speeding up disposition...

dispo = disposition = where the patient is going. Discharged vs. Admitted and to what service.

 

[TheDudeMD]

dispo = disposition = where the patient is going. Discharged vs. Admitted and to what service.

Ah, gotcha. Thanks!

 

[JediZero]

OP, your program sounds terrifying. Are your other rotations like this? This sounds like a very toxic environment, and I hope it's limited to the OB/GYN program...

 

[Siggy]

So I just got done with my first EM rotation. As mentioned earlier, there was a "formal" rounds at hand off. Basically we walked through the pods and the trauma bay and got a brief synopsis of the patient (CHF exacerbation, BNP ____, admitted to IM with short orders [ED admitting orders, pending admission team orders]). If the patient wasn't admitted yet, then what the oncoming crew needed to follow up with.

As the shift went on, we'd often as a group or individually just run through the rooms in our pod (bed 1 admitted, bed 2 admitted, bed 3 pending CT read, bed 4 pending initial labs, etc) just so that we can keep track of everything.

 

[southerndoc]

We have "huddles" with the charge nurse for overview of the department. We encourage face-to-face sign out of patients in front of the patient during shift change (if we choose to sign out the patient). Most of us usually stay over an hour to finish things up instead of signing it out (we're FFS).

 

[TheDudeMD]

We have "huddles" with the charge nurse for overview of the department. We encourage face-to-face sign out of patients in front of the patient during shift change (if we choose to sign out the patient). Most of us usually stay over an hour to finish things up instead of signing it out (we're FFS).

Nice. Glad to keep hearing everyone say that EM keeps it goal-directed and practical.

FFS = face to face sign out?

Edit: FFS = Fee for service 🙂

Showing my noob-colors.

 

[southerndoc]

FFS = face to face sign out?

Fee for service. Meaning we get paid by the patient, acuity, procedures, etc. instead of by the hour (although we get an hourly bonus/shift differential).

Signing out something simple like following up a repeat K in someone getting IV fluids who was slightly dehydrated and hypokalemic will usually get the original doc payment. If it's complicated like following up an abdominal CT, consulting the surgeon, etc., then the person who got sign out is the one who gets paid.

 

[TheDudeMD]

Fee for service. Meaning we get paid by the patient, acuity, procedures, etc. instead of by the hour (although we get an hourly bonus/shift differential).

Signing out something simple like following up a repeat K in someone getting IV fluids who was slightly dehydrated and hypokalemic will usually get the original doc payment. If it's complicated like following up an abdominal CT, consulting the surgeon, etc., then the person who got sign out is the one who gets paid.

Got it. Thanks!

This isn't the norm for EM, is it? Interesting. I remember a medical finance class I took a couple years ago saying that the drawback of FFS is that it theoretically incentivizes docs to order more stuff. But then on the flip side, a capitated system (I wonder if traditional hourly EM wage system would be considered capitation?) incentivizes the doc to do less, potentially encouraging a do-nothing approach.

My understanding is patients like the "order everything you can, don't undertreat me" aspect of FFS, but then expect the prices of a capitation system.

And from the clinician's POV, I have no idea which is better. And admittedly, everything I know about this was from MBA courses, not from a medical point of view. So I'm sure there's a MBA-oriented bias.

I digress, this is a whole other topic I'll search the EM forums for. Interesting though!

 

[Angry Birds]

We do "lightning rounds", which goes something like this:

The patient in Room 2b is pending CT scan of the belly and Surgery consult.
Room 3 is the one I just told you about. He's ready for discharge as soon as you see him.
Room 8 is the CHF exacerbation, currently on BiPAP. I think we can start him on antibiotics just in case there is a pneumonia component. I'll also call the ICU to evaluate him.
Room 9 is a new one, let me tell you about him...

etc.
etc.

 

[TheDudeMD]

We do "lightning rounds", which goes something like this:

The patient in Room 2b is pending CT scan of the belly and Surgery consult.
Room 3 is the one I just told you about. He's ready for discharge as soon as you see him.
Room 8 is the CHF exacerbation, currently on BiPAP. I think we can start him on antibiotics just in case there is a pneumonia component. I'll also call the ICU to evaluate him.
Room 9 is a new one, let me tell you about him...

etc.
etc.

Is this for each shift sign off, or prn several times throughout the shift? I like the idea of lightning rounds.

 

[Rendar5]

That's an attending asking the EM resident to review the board with him which would happen in-shift. A sign out would be "Room 9's pending a CT scan, dispo per scan. Room 8 needs to be admitted for a COPD exacerbation. I'm getting a CTA to rule out PE and if it's negative call his PMD, if it's positive, put him in the ICU. Room 10 is just weak and dizzy 29yo woman. just waiting on labs that were sent out. If they're good she can go hom."

 

[Angry Birds]

That's an attending asking the EM resident to review the board with him which would happen in-shift.

Yeah I guess this isn't really rounds, lol.

 

[Daiphon]

Only time I do rounds is post-shift, preferably with someone else buying. d=)

Sent from my DROID BIONIC using Tapatalk

 

[RPedigo]

At our program, in the adult ED we have formal sit-down rounds together inside the doc box where each patient is signed out by the leaving team with a brief and pertinent story, a summary of their ED course, and what is pending. Then the attending/senior will do some teaching or give their input on the case, and then we will move on. That way there is teaching done that is based on each patient and is relevant to the care of the patient at hand.

An example would be: "Mr. ____ is admitted to surgery for acute cholecystitis. He is a 30 year old male with a history of intermittent right upper quadrant pain, now constant today and associated with fevers, nausea, and vomiting. He has no medical problems or allergies. His initial vital signs were remarkable for tachycardia to 120 and a fever to 102 but has since been afebrile with stable vitals. His exam has a positive Murphy's sign and is otherwise unremarkable. His labs are remarkable for a white count of 18 with 10% bands and his LFTs are normal. His ultrasound demonstrated a gallbladder wall thickness of 5mm, pericholecystic fluid, and numerous gallstones but a normal common bile duct. He has gotten 2L of fluids, is NPO on maintenance fluids, and got ondansetron, morphine, acetaminophen, ceftriaxone, and metronidazole." Then if there are more junior students or it is the beginning of the year (since gallbladder disease is pretty common where I work and we would beat it to death if we went over it each time) the attending or senior might talk for a couple of minutes about the spectrum of gallbladder disease, the differential diagnosis, ultrasound findings, and management in an interactive way involving medical students, interns, and junior residents as participants. Then they would move onto the next patient until every patient from the old team is signed out.

During a shift, every hour or two I will "run the list" with my attending and tell them quick updates on each patient, what labs are pending/back, what consults have occurred, and what the patient is awaiting before they can be dispo'd.

 

[la gringa]

At our program, in the adult ED we have formal sit-down rounds together inside the doc box where each patient is signed out by the leaving team with a brief and pertinent story, a summary of their ED course, and what is pending. Then the attending/senior will do some teaching or give their input on the case, and then we will move on. That way there is teaching done that is based on each patient and is relevant to the care of the patient at hand.

An example would be: "Mr. ____ is admitted to surgery for acute cholecystitis. He is a 30 year old male with a history of intermittent right upper quadrant pain, now constant today and associated with fevers, nausea, and vomiting. He has no medical problems or allergies. His initial vital signs were remarkable for tachycardia to 120 and a fever to 102 but has since been afebrile with stable vitals. His exam has a positive Murphy's sign and is otherwise unremarkable. His labs are remarkable for a white count of 18 with 10% bands and his LFTs are normal. His ultrasound demonstrated a gallbladder wall thickness of 5mm, pericholecystic fluid, and numerous gallstones but a normal common bile duct. He has gotten 2L of fluids, is NPO on maintenance fluids, and got ondansetron, morphine, acetaminophen, ceftriaxone, and metronidazole." Then if there are more junior students or it is the beginning of the year (since gallbladder disease is pretty common where I work and we would beat it to death if we went over it each time) the attending or senior might talk for a couple of minutes about the spectrum of gallbladder disease, the differential diagnosis, ultrasound findings, and management in an interactive way involving medical students, interns, and junior residents as participants. Then they would move onto the next patient until every patient from the old team is signed out.

During a shift, every hour or two I will "run the list" with my attending and tell them quick updates on each patient, what labs are pending/back, what consults have occurred, and what the patient is awaiting before they can be dispo'd.

if we did that where i was a resident, sign out would have taken over an hour. we were often signing over gosh, at least 20, up to 40 beds at a time.

ours was more like:
Mr __ is admitted to surgery for cholecystitis. got abx, needs X or Y. [does or does not] have a bed. if has bed "waiting for transport".
NEXT PATIENT...

 

[TooMuchResearch]

if we did that where i was a resident, sign out would have taken over an hour. we were often signing over gosh, at least 20, up to 40 beds at a time.

ours was more like:
Mr __ is admitted to surgery for cholecystitis. got abx, needs X or Y. [does or does not] have a bed. if has bed "waiting for transport".
NEXT PATIENT...

I like that model for two reasons: 1. Lots of good teaching. 2. Gives others on the team a chance to ask questions/ challenge the presumed diagnosis. I dislike it because the department would stop moving for an hour at every sign out...

 

[RPedigo]

if we did that where i was a resident, sign out would have taken over an hour. we were often signing over gosh, at least 20, up to 40 beds at a time.

Our rounds do take (up to) an hour. There are two teams in the main ED at any given time, so all critically-ill and trauma patients will be taken by the other team for that 40 minutes to 1 hour of rounds. I think it's important for teaching and for patient care to do this, because then there's built-in learning and assessment of whether the patient's diagnosis is indeed accurate and their care was optimal. Of course, outside of a teaching program this would not be a good idea.

I like that model for two reasons: 1. Lots of good teaching. 2. Gives others on the team a chance to ask questions/ challenge the presumed diagnosis. I dislike it because the department would stop moving for an hour at every sign out...

I agree with your points. However, the department doesn't stop moving because there's another team as well. Basically the way our shifts are structured is (for instance) the swing shift for the A team will come in at 3:30 P.M. and pick up a few new patients and get treatments and diagnostic tests ordered for them. Then at 4:00 P.M. we round for up to 1 hour (4:00 P.M. to 5:00 P.M.) and get sign out on all the patients and transition their care. Once rounds are finished, the labs for the patients we saw at 3:30 P.M. are typically back and they can be dispo'd.

The swing B team comes in at 4:30 P.M. and will pick up a few patients, etc. to round at 5:00 P.M.. That way, there's always a team who can see critically-ill people and if they are not critically ill can at least write pain medications and screening labs on them. From 4:00 P.M. until 4:30 P.M. seeing critically-ill patients and traumas will fall onto the morning B team because they will round with the swing B team at 5:00 P.M. and the swing B team is not there yet. For the morning B team the 4:30 P.M. to 5:00 P.M. timeframe is meant to wrap up as many dispos as possible and finish all your charting and get everything organized for rounds.

I think this approach works really, really well from a patient care and education standpoint. All of our faculty are highly interested in teaching and are generally excellent instructors, so it's nice to get some high-quality teaching that's pertinent to a case at hand every single shift. It's true that instead of rounds I could see a few more patients, but I think that the benefit of the instruction heavily outweighs the additional couple of patients I'd see on my shift from an educational standpoint. If our ED were lower acuity I think it would be less helpful, but we typically have very sick patients so there's often good teaching and management pearls on almost everyone that makes it back to the adult ED.