Does your program make interns "preround?"

[medicinesux]

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no prerounding? are you serious? what do you think happens each morning?...that all the residents and attendings hold hands and skip down the hallway singing "skip to my lu" as they see patients for the first time together each morning

 

[boston]

no prerounding? are you serious? what do you think happens each morning?...that all the residents and attendings hold hands and skip down the hallway singing "skip to my lu" as they see patients for the first time together each morning

maybe we are all using different terms. to me, seeing the patients as a resident team before the attending is just "rounds" or "work rounds," not prerounding. i think of prerounding as one person on the team seeing the patient first before we see the patient together as a team. attending rounds is a different story all together, usually later in the day, between cases, etc.

 

[SocialistMD]

You could always cry more.

It seems like it's working out for you well on this thread.

:tear:

Still not getting it.

:tear:

Okay, okay. I got it. Wait, I lost it.

 

[Raidergate]

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.

What do you think Polk would say about interns showing up at 7 and tagging along while the Chiefs rounded? 😀

 

[DrDawg]

What do you think Polk would say about interns showing up at 7 and tagging along while the Chiefs rounded? 😀

Polk, I heard he didn't talk to interns, so I'm guessing he did think much of them to begin with.

To all the no individual rounders out there:

Do you guys write notes on people you operated on?
Do you see patient in preop before you operate?

 

[Winged Scapula]

One of the issues, as I see it, is that many of us have trained in different systems where one or the other practices differ for important reasons.

For example, regarding interns developing some independence and formulating plans on pre-rounds. boston mentioned that is developed seeing consults and ED patients. Sounds great, except in my program interns and junior residents did NOT see consults or ED patients, so the only independent evaluation happens on pre-rounds.

For those of you that have night floats, are these residents really engaged enough to see all the patients, and get a real feel for what is going on? I know our residents, in addition to covering their own service and the cross-cover services, also responded to traumas. It was not unusual, especially in the summer, for the residents in house to have not seen any patients all night because they were busy in the trauma bay. Patients with major acute issues would be seen, but for routine visits, checking on vitals, labs, etc. that was NOT being done overnight, and having other residents on the team come in and pre-round was valuable. Our census was much lower than some of the estimates I see here (70 cross cover patients)...I cannot imagine it is possible to see and evaluate that large of a number of patients by ones self overnight.

Many hospitals do not have EMRs which are as advanced as those described...there is no preprinted sheet with labs, vitals, etc. My fellowship hospital was the worst...not only was the system horribly outdated, but there were separate systems for labs, for orders, for vitals, and for rads studies. I had to carry around an index card with all my log in info (because of course it couldn't be the same for each system). It might not be possible to quickly print out these pieces of information for 70, or even 20 patients.

I agree that if Chief rounds simply consists of the Chief hearing the reports and not actually seeing all the patients themselves or just looking at them for "45 seconds" it doesn't make a lot of sense. But I know there was no way we would have gotten done with rounds on the number of patients we had unless the basic information (ie, vitals, events over night, drain output,etc.) was collected before rounds. Otherwise, Chief rounds would have started even earlier than 5:30. I preferred to see all the patients, or at least the vast majority of them with my team. Other Chiefs may be more lackadasical...but as said above, I know some of the junior residents lied about seeing the patients and only students saw them, so I sure as heck wasn't going to let the patient go unseen.

I believe others here when they say it CAN work ...but that may be AT THEIR FACILITY ONLY. Infrastructure and many other variables make it difficult to transfer experiences across programs.

 

[SocialistMD]

For example, regarding interns developing some independence and formulating plans on pre-rounds. boston mentioned that is developed seeing consults and ED patients. Sounds great, except in my program interns and junior residents did NOT see consults or ED patients, so the only independent evaluation happens on pre-rounds.

We are the consult residents as R2s and R3, seeing all ED consults as well as all the in-house surgery consults.

For those of you that have night floats, are these residents really engaged enough to see all the patients, and get a real feel for what is going on? I know our residents, in addition to covering their own service and the cross-cover services, also responded to traumas.

Interns do not respond to traumas; the ED R2 and in-house chief do that. The interns' sole responsibility is the floor and step-down; they round on the patients in the ICU in the morning with the team, but they are not responsible for any decision-making.

Many hospitals do not have EMRs which are as advanced as those described...there is no preprinted sheet with labs, vitals, etc.

While I wouldn't consider our computer system advanced, it is at least mostly integrated and all labs/vitals are on the same system with imaging on another.

I agree that if Chief rounds simply consists of the Chief hearing the reports and not actually seeing all the patients themselves or just looking at them for "45 seconds" it doesn't make a lot of sense.

I agree. To me, it sounds much more dangerous for the patient to allow the evaluation to be done by the intern/med student with just a cursory nod from the chief than to not have the interns pre-round.

I believe others here when they say it CAN work ...but that may be AT THEIR FACILITY ONLY. Infrastructure and many other variables make it difficult to transfer experiences across programs.

And I think that those of us at institutions where it does work understand this. I just get mad when someone who has absolutely no idea about what s/he is talking says it can't work, patients will die, etc... It isn't a part of our system and NISQIP has shown that our outcomes are no worse than any other hospital. I'm not telling anyone it can work at all hospitals, I'm simply saying it does work at ours, thus proving it can work.

 

[Blade28]

My fellowship hospital was the worst...not only was the system horribly outdated, but there were separate systems for labs, for orders, for vitals, and for rads studies. I had to carry around an index card with all my log in info (because of course it couldn't be the same for each system). It might not be possible to quickly print out these pieces of information for 70, or even 20 patients.

I feel your pain.

Come to our county hospital here, where there's a separate computer system for labs, H&P/op note dictations, pharmacy records, and radiology dictations. You have to go downstairs to the CT reading room to view CTs. You have to go to the film room to view x-rays. Vitals, ins and outs, etc. are only recorded by hand on flowsheets.

👎

 

[DoctorMunchkin]

What do you think Polk would say about interns showing up at 7 and tagging along while the Chiefs rounded? 😀

Polk would politely ask the intern "Boy, do you like your momma?"

Intern: "yes, sir, I do"

Polk: " Good, because you are going home to her. You're fired."

One of the many urban legends about Hiram 'fire 'em' Polk.

 

[boston]

To all the no individual rounders out there:

Do you guys write notes on people you operated on?
Do you see patient in preop before you operate?

Yes and yes.

 

[boston]

For example, regarding interns developing some independence and formulating plans on pre-rounds. boston mentioned that is developed seeing consults and ED patients. Sounds great, except in my program interns and junior residents did NOT see consults or ED patients, so the only independent evaluation happens on pre-rounds.

I think this may be the difference. Like socialist, we start seeing consults early - in fact, as interns, on all services -- general surgery, vascular, transplant, peds,...

For those of you that have night floats, are these residents really engaged enough to see all the patients, and get a real feel for what is going on? I know our residents, in addition to covering their own service and the cross-cover services, also responded to traumas.

The R3 and in-house chief respond to traumas here. The interns cover the floor and R2 covers the burn and cardiac ICU.

I believe others here when they say it CAN work ...but that may be AT THEIR FACILITY ONLY. Infrastructure and many other variables make it difficult to transfer experiences across programs.

You are right, WS. It depends on the set up. I think seeing consults early in residency is a good thing.

 

[Winged Scapula]

I find the comments about trauma responses very interesting.

How is it possible to run a trauma, especially a Level 1, without only two residents (PGY3 and Chief, or ED R2 and Chief, depending on program)?

We required all surgical residents in house except those covering the SICU to come to all Level 1 and 2 traumas...that would generally be about 4 residents and the Chief. For the not so infrequent multiple traumas, this would not be enough people...if during the day, there would be plenty of House Staff and attendings to come in. At night, you could count on some of the residents at home to drive in when they heard a multiple trauma response.

I can envision running a trauma with 2 people (Chief included) because I've done it when there are multiples...but it means some things are not getting done in a timely fashion when there are multiple needs at the same time which exceed the number of hands doing them.

 

[Blade28]

It gets worse because any given computer will only have some of these programs on them, meaning that in the morning I have to go from one computer to the other to get all the info for a given patient.

Same here.

God it's painful.

How is it possible to run a trauma, especially a Level 1, without only two residents (PGY3 and Chief, or ED R2 and Chief, depending on program)?

We required all surgical residents in house except those covering the SICU to come to all Level 1 and 2 traumas...that would generally be about 4 residents and the Chief. For the not so infrequent multiple traumas, this would not be enough people...if during the day, there would be plenty of House Staff and attendings to come in. At night, you could count on some of the residents at home to drive in when they heard a multiple trauma response.

Our day trauma team consists of a 1, 2, 4, fellow and attending. The night trauma team is a 1, 3, 4, fellow and attending. In both cases the intern isn't involved in the trauma bay itself - rather, he/she is manning the floor.

We also have 1-2 off-service rotators (from EM) on the team at any given time. There are always 3-5 dedicated PGY-2 residents (G Surg, EM and OMFS) in the SICU during the days, and 1-2 at night. Their backup is the same fellow as before (T/CC).

We seem to have enough to get the job done. Bear in mind we have a ridiculously busy trauma center. There have been plenty of times when I ran a trauma by myself, with minimal assistance from the ER peeps (now granted these were more straight-forward cases, but still). The only time I've heard of people getting called in from home was when the 1996 Olympic Park bombing occurred, and we had 100 blast victims arrive simultaneously.

 

[Raidergate]

Polk would politely ask the intern "Boy, do you like your momma?"

Intern: "yes, sir, I do"

Polk: " Good, because you are going home to her. You're fired."

One of the many urban legends about Hiram 'fire 'em' Polk.

He told me, as a visiting student presenting on walk rounds another of his famous quotes:

"Boy, there's three things in the world I don't understand:

1. Boys liking boys.
2. Ultrasound
3. Whatever the **** it is you're talking about, so why don't you sit down, shut up, and let somebody who knows what they're doing talk about this patient."

He'd also walk into patients' rooms, and the first thing he'd say was a variation of, "Now, just sit there and shut up, we're fixing to talk about you."

Despite all that, if you could get past the way the message was presented, he knows more than anyone I've ever been around. It's crazy. Plus, if you do make it through his (former), program, he'll move heaven and earth to help you get what you want afterward. He's an interesting guy, to say the least.

Back to the original discussion, these people are your patients, as a junior, you should always "preround."

 

[SocialistMD]

I find the comments about trauma responses very interesting.

How is it possible to run a trauma, especially a Level 1, without only two residents (PGY3 and Chief, or ED R2 and Chief, depending on program)?

We required all surgical residents in house except those covering the SICU to come to all Level 1 and 2 traumas...that would generally be about 4 residents and the Chief. For the not so infrequent multiple traumas, this would not be enough people...if during the day, there would be plenty of House Staff and attendings to come in. At night, you could count on some of the residents at home to drive in when they heard a multiple trauma response.

I can envision running a trauma with 2 people (Chief included) because I've done it when there are multiples...but it means some things are not getting done in a timely fashion when there are multiple needs at the same time which exceed the number of hands doing them.

We have an EM residency. The surgery R-2 does the primary survey, the EM-1 does the minor procedures (lines), the EM-3/4 is in charge of the airway and the surgery R-4 runs the trauma (or some variation of the above depending on days or nights). When we have multiple-traumas, we split the groups and recruit more residents as needed.

Did you guys have a level 1 pediatric hospital, or did the pediatric trauma come to the same hospital? We have the chief and the intern/junior resident only for pediatric trauma and things get done in an orderly fashion (although, multiple trauma there is a little more of a flail).

 

[Dr. V]

Dang I wouldn't know what to do with a trauma with all that help.

We have 2 level 1 centers and a level 2.

The trauma service consists of a PGY 4 and 2 at both of the Level I's.

Then for night call at one of the Level I's we have a night float intern that is responsible for all traumas, plus the Sr resident on call (PGY-3-5) and there is a back up Jr in house until late if needed.

At the other Level I and you are the intern you always have a Sr resident on call with you, but the intern covers all traumas with the Sr. If you are PGY2-4 then your call is solo (except when a 4 gets an intern for help).

At the Level II all call is solo, and no interns or chiefs go there at all so it's a strictly PGY2-4 service.

No ER residency and no ER help with traumas except at the level II where the ER doc may help out occasionally.

 

[DoctorMunchkin]

He told me, as a visiting student presenting on walk rounds another of his famous quotes:

"Boy, there's three things in the world I don't understand:

1. Boys liking boys.
2. Ultrasound
3. Whatever the **** it is you're talking about, so why don't you sit down, shut up, and let somebody who knows what they're doing talk about this patient."

He'd also walk into patients' rooms, and the first thing he'd say was a variation of, "Now, just sit there and shut up, we're fixing to talk about you."

Despite all that, if you could get past the way the message was presented, he knows more than anyone I've ever been around. It's crazy. Plus, if you do make it through his (former), program, he'll move heaven and earth to help you get what you want afterward. He's an interesting guy, to say the least.

Back to the original discussion, these people are your patients, as a junior, you should always "preround."

HA!! I have heard that too, directly from his mouth!!

I also got the "DoctorMunchkin, that's the dumbest answer I've ever heard." Then he went to the next person, (who also answered the question incorrectly) "Dr Wombat, that's the dumbest answer I've ever heard." I didn't feel so bad then.

I love on rounds, how he just covers his mouth, instead of putting on a mask. I guess his hand catches more germs than mine. Also heard the sit down and shut up digs at the patient. Love it!! 👍

He is a good guy. Really cares about his residents and the med students. Truly wants you to succeed. He loves his horses, too. I once made a joke about one of his horses going to the glue factory... He didn't laugh nearly has hard as I did.😀

Anyway, to this post, the bottom line is one day you will be the big boss, and you better know how to see your patients efficiently, what is normal and what is ABnormal, and when to be concerned. I think it is difficult to do if you don't have some trial and error on your own.

 

[Winged Scapula]

We have an EM residency. The surgery R-2 does the primary survey, the EM-1 does the minor procedures (lines), the EM-3/4 is in charge of the airway and the surgery R-4 runs the trauma (or some variation of the above depending on days or nights). When we have multiple-traumas, we split the groups and recruit more residents as needed.

That makes more sense. Boston above stated that they run traumas with only two residents: the R-3 and in house Chief.And your previous post stated that traumas were run by the ED R-2 and in-house Chief, thus making it sound like only two people were running the traumas.

We did not have an EM residency when I was in residency, but I understand we do now...we occasionally had some rotators frm the program in York who would come to traumas but were not on the Trauma service. To put it bluntly, their participation seemed to be limited to being first responders to Level 3 traumas, calling the trauma consult and then disappearing without documenting any of their exam findings and assuming the surgery Chief would reassess, document and admit the patient.😡

Did you guys have a level 1 pediatric hospital, or did the pediatric trauma come to the same hospital? We have the chief and the intern/junior resident only for pediatric trauma and things get done in an orderly fashion (although, multiple trauma there is a little more of a flail).

We have a Level 1 Pediatric hospital but all the traumas came to the same hospital (ie, the Pediatric building was on the same campus...they are building a separate Peds ED...I don't know how that will change things, actually having to go to a different section of the campus to respond to Peds traumas, especially when there are multiples, adults and kiddos.

Our plan was:

Level 1 trauma: attending presence required
Trauma Chief Resident
Day: trauma service responds/Peds Surg responds when its a peds trauma in addition (but they tend to be in the OR so the adult service does most of the workl) - this would be two Surgery R-1s, a Surgery R-2, an R4 or R5 and a couple of scattered Anesthesia residents on service and a few PAs.
Night: Trauma Service Chief, all in house surgery residents (generally 4 of them) except SICU, and medical students in house.

Level 2: as above except perhaps not attending

 

[Faebinder]

Prerounding is different for different levels:

Med students: Prerounding was chaotic thing. Med students dont write orders so many times they will see a findings and not know its significance to the management.

Intern: Prerounding was gold. You make your service look good to the chief.

Senior: Preround is a painful thing when you have to do it.

Chief: You probably think everyone should preround to minimize the pains of rounding.

Personal opinion: Preround is crucial for an intern in the surgery world because a good looking service can make you swim and a bad looking service (even if it is not your fault and unavoidable) can make you sink.

 

[Winged Scapula]

HA!! I have heard that too, directly from his mouth!!

I also got the "DoctorMunchkin, that's the dumbest answer I've ever heard." Then he went to the next person, (who also answered the question incorrectly) "Dr Wombat, that's the dumbest answer I've ever heard." I didn't feel so bad then.

My Hiram Polk story:

Med Student rotating there (on Plastics, but interacted with him on the Burns rounds).

Was invited to meet with him.

Brought along my Personal Statement for my application to surgery programs.

He reads it, and flings it back at me across his desk, stating:

"This is not a G-D D--n English Composition class. This is G-D D--n General Surgery. Now go back and cut out all of that flowery stuff in there and tell us why you want to be a surgeon, young lady.

 

[boston]

That makes more sense. Boston above stated that they run traumas with only two residents: the R-3 and in house Chief.And your previous post stated that traumas were run by the ED R-2 and in-house Chief, thus making it sound like only two people were running the traumas.

Ok there is more to it. We are a pediatric level I. We have an ED resident responsible for airway / intubation (unless a trach is needed) and c-spine immobilization. Usually the ED attending is also there. We have 2 ED nurses responsible for peripheral IV access, drawing labs, etc. We have a radiology tech and respiratory tech on hand. As surgery residents, though, we run the trauma. With so much help, sometimes we can run it with just a single surgery resident, if the other person is in the OR.

Once we were spread thin were when 3 traumas (4 victims) arrived at the same time.

Another time, my senior and I did bilateral ED thoracotomies on a chest GSW. We had clamshelled, sowed up the hole in the heart, clamped the hilum, and were doing cardiac massage when the attending arrived and called it. Right then, two more traumas arrived. The second was a GSW to the abdomen that went to the OR (hemodynamic instability) while I was whipstitching the thoracotomies closed. Luckily the third was a blunt trauma that was not serious.

 

[SocialistMD]

To put it bluntly, their participation seemed to be limited to being first responders to Level 3 traumas, calling the trauma consult and then disappearing without documenting any of their exam findings and assuming the surgery Chief would reassess, document and admit the patient.😡

They are better about that here, although there are times where, after we show up and the patient is "stable," they are pretty hard to find.

 

[Winged Scapula]

Ok there is more to it. We are a pediatric level I. We have an ED resident responsible for airway / intubation (unless a trach is needed) and c-spine immobilization. Usually the ED attending is also there. We have 2 ED nurses responsible for peripheral IV access, drawing labs, etc. We have a radiology tech and respiratory tech on hand.

I think that goes without saying...

Most places I am familiar with have either EM or Anesthesia doing the airway, plenty of nurses, RTs, etc. I did not mean that when you said only two residents were there that I assumed they were the only ones in the room! That would surely lead to disaster.😀

As surgery residents, though, we run the trauma. With so much help, sometimes we can run it with just a single surgery resident, if the other person is in the OR.

And sometimes that has to happen. I would find it undesirable to have only two surgery residents there, even with all the other help, for most Level 1 and 2 responses.

We would have one resident (the Chief) running the code..ie, making decisions about what needed to be done, another (usually the intern) doing the Primary and Secondary survey and at least one more to assist the surveyer, do the fem stick, Foley and rectal, well as put in orders, keep track of the findings (we had our own H&P that had to be filled out apart from what the nurse was recording), and admit the patient. For Level 1s, it was helpful to have others available to place chest tubes, central lines, etc.

Once we were spread thin were when 3 traumas (4 victims) arrived at the same time.

Sounds like your hospital was a bit quieter than ours. Our hospital was pretty busy...no Shock Trauma but it was pretty routine to have multiple traumas, both children and adults. Our record during my time there was 11..."we never close to trauma" in the words of our Trauma Chair. Even if it meant straining our resources, stacking patients up in the hallways of the ED.🙄

 

[europeman]

I guess what i'm appreciating from all of this debate about prerounding, is like many of you are saying, the best-method is effectively institutional dependent because of variations in resources, patient loads, coverage, and technology.

I just spoke to one of my medical student colleagues, and at his institution, the residents have PDA's which automatically update patient vitals (the CNA's enter them into a computer, which automatically update to the doctors pda), fluids in/outs, and labs! holy crap! i didn't even know such technology exists!

And their notes are not just a blank sheet of paper (like where I'm at); rather, it's a form sheet with checks and small space for additional text when needed.

Be it as it may, it goes without saying that these systems effectively make for a much more efficient service!


Now how do i figure out how to get pda's at this place!?

 

[Winged Scapula]

Now how do i figure out how to get pda's at this place!?

That's not the problem. You could purchase them out of the department book fund.

The problem is having an EMR which is advanced and new enough to allow the sync.

 

[Blade28]

Now how do i figure out how to get pda's at this place!?

Agree with what Winged Scapula said above - you need to find a program that has a wireless network with constant updates.

Off the top of my head, BID has this - not sure who else.

BTW, this isn't necessarily a good thing - you'll now be expected to immediately respond to any changes in a patient's vitals, labs, etc. since you have 24/7 realtime access. That's both a blessing and a curse. The Sword of Damocles, IMHO.

 

[Pir8DeacDoc]

I think CMC in Charlotte also has this type of vitals/labs PDA system.

 

[Winged Scapula]

I thought I remembered Christiana in Delaware having it as well (and that was a thousand years ago when I interviewed there).

 

[DrDawg]

Access to 24 hour realtime vitals is the ideal. I would guess in reality you only get them as often as the nurse inputs them, as most patients are not on monitors. With nursing ratio's of 1 to 6-8 I bet they don't get recorded until end of shift. Good guess??? We don't have a high tech system here. We use paper.

 

[Cheisu]

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?"

Agreed

 

[SocialistMD]

Agreed

🙄

Better rethink your opinion ESU_MD. If Cheisu thinks it is right then it must be wrong...

 

[Winged Scapula]

🙄

Better rethink your opinion ESU_MD. If Cheisu thinks it is right then it must be wrong...

Aww...give the kid a break.😛

 

[SocialistMD]

Aww...give the kid a break.😛

Hey, I'm just as burnt by it in the scrubs thread...😉