"I hate rounding."

[AmoryBlaine]

Going to continue my attempt at starting controversial threads.

I get sort of annoyed when I hear people say that part of the reason they went into EM was that they hated rounding. Here are some points of dicussion.

1. No one likes rounding except the academic attending, he or she only likes it because it is their chance to discuss things they know alot about and teach. The residents in IM are likely as bored as you would be. If you were given the chance to have a captive audience and some time with which to exploit it you would likely be as verbose as the attending.

1.5. People don't go into internal medicine because they like to round. They go into it because they like problem solving and inpatient work. It sets up this false dichotomy that I think does a disservice to students trying to plan their future specialty.

1.75. If EM people were as immune to this verbosity as they would like to believe they are then lectures by EM faculty/presentations by EM residents would take 10 minutes.

2. When rounds go long (be they on the floor or the unit) it is usually because the patients are complex and sick. All this nonsense about hour long discussions of potassium homeostasis is mostly urban legend. I am not saying it never happens, I am saying that if you have 10 sick patients on your service you cannot make good plans for them in an hour.

3. Everyone that I know in IM is getting killed during residency, ditto the hospitalists. We admit admit admit because we see such complex people in the dept. My friends on IM are up all night on their calls putting in orders, moving the meat in their own way. Believe me, there is very little sitting around debating BUN values.

4. Finally if there be any IM people reading this forum let me say thank God that you are out there. We (EM) pride ourselves on being able to work quickly, stabilize critical patients, and deal with a variety of complaints. But when we get something we can't figure out we usually don't crack a book or put our thinking caps on, we usually just shrug and page those boring, methodical internists!

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[jbar]

I'd posit that one of the reasons that some of these specialties are up all night "moving the meat" is that when you spend 5 hours rounding, it doesn't leave much time for doing actual work. I understand spending some time on an interesting case, but it seems that a lot of teams go into that level of detail on every patient even if there isn't much instructive going on.

 

[xaelia]

My IM months last year spent a minimum amount of time rounding. We put in orders, senior residents ran the list with the attending, got out as early as possible barring our long call days. There was a direct correlation between how hard/fast you worked to the amount of time you spent at the hospital. It was as bearable as it could be.

I just hate clinic, chasing labs and diagnostic studies, following-up consults, long-term longitudinal planning etc. for sick people. The "go see your regular doctor in (1)(3)(5)(10) days for (follow-up)(suture removal)" is as much as I can handle.

Oh yeah, and medication reconcilliation. Bane of my existence on inpatient.

 

[GeneralVeers]

Rounding was useful when it actually taught something. I believe it was valuable on new patients coming in, or patients that destabilized. It was not useful to discuss EVERY DAY the treatment for DKA, alcohol withdrawal, Ranson's criteria or other minutia on patients that had been there for days/weeks. The 5 hours of rounds could easily have been boiled down to 1 hour if only the most interesting cases were discussed.

Also, I would love to have had EM lectures only 10 minutes long in residency. I tried to keep mine down to 30 minutes (which was the minimum I could get away with). The whole point of lecture should to be reinforce key concepts and ideas, not regurgitate all [/RIGHT]of Tintinalli into Powerpoint form.

 

[DrMom]

4. Finally if there be any IM people reading this forum let me say thank God that you are out there. We (EM) pride ourselves on being able to work quickly, stabilize critical patients, and deal with a variety of complaints. But when we get something we can't figure out we usually don't crack a book or put our thinking caps on, we usually just shrug and page those boring, methodical internists!

Absolutely! I'm grateful for everyone in those specialties that I personally didn't like. I think that there is value to every specialty & truly don't understand those who bash other specialties.

(btw: I *really* did experience a 20+ minute monolog on Na+ testing methods as an MS1 on my first exposure to IM. Burned me permanently. )

I just hate clinic, chasing labs and diagnostic studies, following-up consults, long-term longitudinal planning etc. for sick people.

I think this is a decent summary of my thoughts. I much prefer to see new patients each shift rather than managing the same ones for days in a row.

 

[nymbarra]

Keep these posts coming, Amory...

I agree, the "I hate rounding" sentiment does more for our collective identity in EM than it does accurately reflect IM.

Another reason (or at least phrased differently) rounding takes so much time is that for each floor or ICU team there are 2-4 interns each carrying 5-15 patients. Their presentations for each patient may be short but multiply by the total number and you get long rounds. Also, they usually present on all active issues, not just the most acute issues like we do in the ED.

It's also important to realize that this all changes after residency. If you're a non-academic or community hospitalist or subspecialist, I imagine you work like the Flash so that you can get out on time.

 

[vtucci]

Going to continue my attempt at starting controversial threads.

I get sort of annoyed when I hear people say that part of the reason they went into EM was that they hated rounding. Here are some points of dicussion.

1. No one likes rounding except the academic attending, he or she only likes it because it is their chance to discuss things they know alot about and teach. The residents in IM are likely as bored as you would be. If you were given the chance to have a captive audience and some time with which to exploit it you would likely be as verbose as the attending.

1.5. People don't go into internal medicine because they like to round. They go into it because they like problem solving and inpatient work. It sets up this false dichotomy that I think does a disservice to students trying to plan their future specialty.

1.75. If EM people were as immune to this verbosity as they would like to believe they are then lectures by EM faculty/presentations by EM residents would take 10 minutes.

2. When rounds go long (be they on the floor or the unit) it is usually because the patients are complex and sick. All this nonsense about hour long discussions of potassium homeostasis is mostly urban legend. I am not saying it never happens, I am saying that if you have 10 sick patients on your service you cannot make good plans for them in an hour.

3. Everyone that I know in IM is getting killed during residency, ditto the hospitalists. We admit admit admit because we see such complex people in the dept. My friends on IM are up all night on their calls putting in orders, moving the meat in their own way. Believe me, there is very little sitting around debating BUN values.

4. Finally if there be any IM people reading this forum let me say thank God that you are out there. We (EM) pride ourselves on being able to work quickly, stabilize critical patients, and deal with a variety of complaints. But when we get something we can't figure out we usually don't crack a book or put our thinking caps on, we usually just shrug and page those boring, methodical internists!

Thank you Amory. I saw another post this morning by an OP, 4th year med student no less, who was considering EM because they hated rounding and hated surgery. Growl.

 

[WallowaWanderer]

Amory,

It seems like most of your "controversial" (your description) posts focus on people choosing EM for the wrong reasons. Why are you so concerned about other people's decision trees? I think it is difficult to really probe someone's motivations for choosing a certain specialty. For some it is difficult to eloquently explain why they chose a certain field because it is more complex that a pro/con list. You really have to know that person you are judging well. I know I joke around all the time saying I went into EM so I could wear pajamas to work and not have to do follow up, but obviously that's not why I picked the field. I wonder if you are maybe just not getting the full story from your colleagues.

On another point, I disagree with you that noone likes rounding and it shouldn't be used to characterize the specialty of internal medicine. Different personalities may be more able to tolerate extensive rounding, whereas other peronalites (surgeons, EM docs) would rather be in the OR or seeing another patient. Something like this may seem of little consequence, but in conjunction with many other things, quite important in selecting a specialty. If you don't like being in the OR, you shouldn't be a surgeon. If you don't like office practice, you shouldn't be a PCP. And if you are miserable rounding I would be cautious about selecting the one specialty that rounds the most.

Just my thoughts.

 

[DrQuinn]

I picked EM because i hate rounding. Well, hated it. I don't do rounds anymore.

 

[AmoryBlaine]

Amory,

It seems like most of your "controversial" (your description) posts focus on people choosing EM for the wrong reasons. Why are you so concerned about other people's decision trees? I think it is difficult to really probe someone's motivations for choosing a certain specialty. For some it is difficult to eloquently explain why they chose a certain field because it is more complex that a pro/con list. You really have to know that person you are judging well. I know I joke around all the time saying I went into EM so I could wear pajamas to work and not have to do follow up, but obviously that's not why I picked the field. I wonder if you are maybe just not getting the full story from your colleagues.

On another point, I disagree with you that noone likes rounding and it shouldn't be used to characterize the specialty of internal medicine. Different personalities may be more able to tolerate extensive rounding, whereas other peronalites (surgeons, EM docs) would rather be in the OR or seeing another patient. Something like this may seem of little consequence, but in conjunction with many other things, quite important in selecting a specialty. If you don't like being in the OR, you shouldn't be a surgeon. If you don't like office practice, you shouldn't be a PCP. And if you are miserable rounding I would be cautious about selecting the one specialty that rounds the most.

Just my thoughts.

All good points.

I know that people joke and obviously no one choses a field based on the clothes they get to wear at work. I am largely trying to create some discussion of how real the stereotype of 1 hour discussions of BUN are. I'm "concerned" about other people's decision trees to the extent that I am interested in the process of specialty selection and the haphazard process by which it sometimes occurs.

 

[GeneralVeers]

I picked EM because i hate rounding. Well, hated it. I don't do rounds anymore.

Ditto the hating as well. We're just a bunch of haters.

It comes down to learning style. I learn by doing, not by listening to a pedantic attending drone on for 2 hours about hyponatremia.

 

[deleted109597]

I am largely trying to create some discussion of how real the stereotype of 1 hour discussions of BUN are.

BUN, I've never had an hour. However, I did have to stand for an hour once while an attending sat down with his feet propped up in the NICU talking about ECMO. I had 2 hours of sit down rounds about hypokalemia (maybe she has Bartter syndrome! Medicine hard-on). I spent a noon conference with the cardiology fellows arguing with each other about 1 EKG and what it meant. So yeah, I'm over that.

 

[Spaceman Spiff]

Going to continue my attempt at starting controversial threads.

2. When rounds go long (be they on the floor or the unit) it is usually because the patients are complex and sick. All this nonsense about hour long discussions of potassium homeostasis is mostly urban legend. I am not saying it never happens, I am saying that if you have 10 sick patients on your service you cannot make good plans for them in an hour.

I've never seen plans made DURING rounds. Usually the interns and residents (and med students) are busting ass BEFORE rounds coming up with the plan and writing the note. Which then gets picked apart and modified during rounds.

I've had 5 hour rounds on Medicine, which totally sucked. We started at 9a and got done at 2p. My feet were killing me from standing relatively still for so long!


EM folks are hands-on, like surgeons. Which is why the surgery rounds were always much more pleasant for me. Quick and to the point. If someone didn't need to be discussed we wouldn't spend more than a few seconds on them, then move on to the next.

 

[pdp2001]

i second that, i loved my medicine attendings - but seriously, the best ones were the most efficient. i had one that rounded for a grand total of....SEVEN HOURS TOTAL in a day. running the list turned into 2 hour sit-down rounds. it was torture. but that's not why i picked EM. i'm ok with efficient rounds. i'm ok with with f/u and consults and chasing labs. i'm not ok with seeing the same patient with the same problem that's not getting better for the 8th day in a row. and having a good 10+ patients like that a day...gives me the heebie-jeebies just thinking about it.

 

[SoCuteMD]

I hate rounding. I'm going into EM. I love EM.

 

[pinipig523]

There's a place for everything. Even though I don't like rounding perse, I feel that it's a necessary evil and it's the only way to really pump out plans and get that bit of learning in also. Everything is different as a student vs a resident, things that bored me as a student no longer do because I have a lot more at stake with the patient.

Same thing with rounding.

Though I do tire quickly and a 3-4 hour rounding session blows through my threshold by quite a bit.

 

[Hard24Get]

Amory,

It seems like most of your "controversial" (your description) posts focus on people choosing EM for the wrong reasons. Why are you so concerned about other people's decision trees? I think it is difficult to really probe someone's motivations for choosing a certain specialty. For some it is difficult to eloquently explain why they chose a certain field because it is more complex that a pro/con list. You really have to know that person you are judging well. I know I joke around all the time saying I went into EM so I could wear pajamas to work and not have to do follow up, but obviously that's not why I picked the field. I wonder if you are maybe just not getting the full story from your colleagues.

On another point, I disagree with you that noone likes rounding and it shouldn't be used to characterize the specialty of internal medicine. Different personalities may be more able to tolerate extensive rounding, whereas other peronalites (surgeons, EM docs) would rather be in the OR or seeing another patient. Something like this may seem of little consequence, but in conjunction with many other things, quite important in selecting a specialty. If you don't like being in the OR, you shouldn't be a surgeon. If you don't like office practice, you shouldn't be a PCP. And if you are miserable rounding I would be cautious about selecting the one specialty that rounds the most.

Just my thoughts.

Totally agree with you. There are tons of pat answers to why people make ay decision. And when most people say they don't like rounding they mean they don't like meaningless rounding. These are usually the same people who don't like inefficiency in general. I guess Amory was fortunate enough to go to a med school where only important topics were discussed during round, like "why is this patient's liver failing and what can we do about it", rather than the attending waxing philosophical about some lab test or another. It's true I haven't gotten an hour on electrolytes at one time but if you add up the irrelevant or historical dribble that comes up during medicine rounds o a given day with certain attendings it is at least that much, ad it stands in the way of progress. And there are some residents that are just as into it as the attending is; those destined to be the next time-wasting attending. A lot of medicine people don't want a frantic pace, they want time to just sit there and relax (n=about 15), which is why they hate the ED. I don't look down on IM or any other field, but I do hate inefficient rounds, which is one of the reasons I love EM, and I'm not sure why Amory feels the need to judge me or anyone else for that.

 

[deleted6669]

I also hate rounds.
we have an obs service run by the emergency dept staff with 12 beds that also gets some cross coverage occassionally from the medicine staff.
when em faculty round in the morning it takes an hr for all 12 pts.
when IM faculty rounds on the same pts(already completely worked up) the next day it takes 4 hrs.
my personal beef is the IM attendings who whine about how busy they are but take 2 hrs to admit a simple pt from the ed who is already completely worked up. the guy needs a bed outside of the ed, not another complete H+P.....how hard is it to admit an otherwise healthy 24 yr old with pneumonia and dehydration....come on now.....

 

[traumamonkey]

just thought i'd chime in

1. yes, i HATE rounding. especially the hours of useless banter that is somehow considered educational. and there are places where electrolyte rounds go on for an hour in a dark room
2. not a big fan of clinic either. some folks argue that the ED is like clinic all the time, but they apparently haven't lived through VA neurology clinic.
3. hate dressing up at work. yes, i will admit that being able to wear scrubs every day is a draw--i do not have the wardrobe to do derm.
4. HATE call. i know no one really enjoys being on call for 30 hours, but i will be very happy when i never have to do that again.

at my program we actually do have 5 minute lectures. not the ones during conference, but the morning teaching before sign out is actually 5 minutes of high yield stuff.

now, the fact that i'm a hater is not the main reason i chose EM, and there are certainly things about our specialty that aren't perfect, but it does give me some satisfaction to know that once i'm done with training i will not have to round again!

 

[deleted6669]

until your ed finds that it is financially rewarding to open their own 24 hr ed obs unit then you get into the rotation of having to do progress notes on these folks as well as admit and d/c them from the unit....but fear not, most of these folks aren't all thjat sick....cellulitis, asthma exacerbation, trauma obs, etc so 5 min evals for admit, progress, and d/c......still better than being a hospitalist.....

 

[AmoryBlaine]

Totally agree with you. There are tons of pat answers to why people make ay decision. And when most people say they don't like rounding they mean they don't like meaningless rounding. These are usually the same people who don't like inefficiency in general. I guess Amory was fortunate enough to go to a med school where only important topics were discussed during round, like "why is this patient's liver failing and what can we do about it", rather than the attending waxing philosophical about some lab test or another. It's true I haven't gotten an hour on electrolytes at one time but if you add up the irrelevant or historical dribble that comes up during medicine rounds o a given day with certain attendings it is at least that much, ad it stands in the way of progress. And there are some residents that are just as into it as the attending is; those destined to be the next time-wasting attending. A lot of medicine people don't want a frantic pace, they want time to just sit there and relax (n=about 15), which is why they hate the ED. I don't look down on IM or any other field, but I do hate inefficient rounds, which is one of the reasons I love EM, and I'm not sure why Amory feels the need to judge me or anyone else for that.

Pray re-read my original post and find the text where I "judged" anyone.

 

[cali-ob]

I too really hate rounding! Cant stand it. some our attendings do sitting rounds where we just sit in the conference room and discuss. Better on the feet, but much harder to stay awake. The one nice thing about FP where I am at is that everyone is so laid back...I basically just break away after I present my patients, and go do my work. They really don't mind if we don't stick around to hear each other present.....that makes it so much better. I get to call my consults early, and put orders in early so basically I'm usually done with "work rounds" before noon every day.

 

[brc12]

my personal beef is the IM attendings who whine about how busy they are but take 2 hrs to admit a simple pt from the ed who is already completely worked up. the guy needs a bed outside of the ed, not another complete H+P.....how hard is it to admit an otherwise healthy 24 yr old with pneumonia and dehydration....come on now.....

Not really sure what you mean here. Do you mean already completely worked up by an EM attending? I'm sorry, but any patient I or any other IM attending would go see for admission, a full H+P is mandatory. (Apart from just providing diligent medical care, medicalegally you need to do your own H+P if you are evaluating a patient.) And your example is terrible. An "otherwise healthy" 24 year old with pneumonia would either be sick as hell, or would be treated as an outpatient with oral antibiotics.
I agree though, 2 hours would be a bit long for someone without a laundry list of medical problems.

 

[domer621]

Not really sure what you mean here. Do you mean already completely worked up by an EM attending? I'm sorry, but any patient I or any other IM attending would go see for admission, a full H+P is mandatory. (Apart from just providing diligent medical care, medicalegally you need to do your own H+P if you are evaluating a patient.) And your example is terrible. An "otherwise healthy" 24 year old with pneumonia would either be sick as hell, or would be treated as an outpatient with oral antibiotics.

Agreed. An interesting statement for a guy who has been in the ED for 21 years.

 

[deleted6669]

my example was pneumonia AND DEHYDRATION if you check my original post.....aka an overnight obs pt for hydration and a few doses of iv abx.....

 

[Hard24Get]

Pray re-read my original post and find the text where I "judged" anyone.

I guess what I meant is why you find the need to "get sort of annoyed" is unclear to me. Moreover, I am grumpy because I am on medicine wards right now, having different experiences than your claims, and like to come on the EM forum for escape, not to read your 455th post on how wonderful and smart IM folks are.

And speak for yourself about "we usually don't crack a book or put our thinking caps on, we usually just shrug and page those boring, methodical internists". Completely untrue for all EM docs I know, if you think that way maybe you chose the wrong specialty.