'Reasonable' number of patients for an intern to round on each day?

[-Goose-]

---

Members do not see this ad.

I'm a new intern doing a month of the general surgery trauma service at a busy trauma center and we are having to see and write notes on ~45 (or more) patients by ourselves. We're Q3 and the person on call has to write all the notes, accept new pts, and field floor pages.

I'm surviving, but I'm wondering if this is a unique experience and whether or not people think this is a reasonable think to expect out of an intern.

 

[filter07]

45 is a lot but I've had to do progress notes on about 30-35 pretty consistently on the busier services. I don't think it is unique to do what you described on 45 patients, but I don't think it's common. I don't think I ever had to do 45 notes a day, but my friend at a different program had to do 50+.

Interesting to note that in the Libby Zion case, the intern and senior resident had to take care of 40 patients, and the civil trial jury found the hospital negligent for allowing them to handle such a high number of patients.

http://en.wikipedia.org/wiki/Libby_Zion_law#Civil_trial

 

[Winged Scapula]

Agree that its not unheard of.

Whether its "reasonable" or not is up for debate (hence your question here I would presume).

I think it unreasonable to ask a brand-new July 1st intern to round on and write notes for 45 patients every 3rd day while on call (are you also responsible for responding to traumas in addition to admitting them...this tends to lead to *no* notes being done before am rounds) when you are still figuring out where to park, where the ORs are, etc. What's the plan - you stay and write notes until you are done (ie, even if its 2 pm)? Or are you expected to have the notes done before am rounds?

I think the more senior residents need to help you out until they are sure you have a system in place and that nothing gets missed. New interns are so often overwhelmed that stuff gets missed, some interns consider lying about what's been done, etc. Even then most people, even senior residents or attendings would have trouble *really* taking care of that many patients *well*. There's a reason we have teams.

I think it fraught with possibilities for problems.

 

[SLUser11]

I'm a new intern doing a month of the general surgery trauma service at a busy trauma center and we are having to see and write notes on ~45 (or more) patients by ourselves. We're Q3 and the person on call has to write all the notes, accept new pts, and field floor pages.

I'm surviving, but I'm wondering if this is a unique experience and whether or not people think this is a reasonable think to expect out of an intern.

I think it is simultaneously unreasonable and relatively common.

When you are "writing notes" on that many people, I wonder if you are truly doing the patient management. It would be hard to be the primary caregiver for that many patients....it seems like maybe the intern becomes a note monkey, and the real patient decisions are delegated to someone higher, which I believe is deleterious to our surgical education.

 

[glade]

I personally think that's ridiculous. Even if you aren't doing any patient management (and you're not), what are you learning from writing 45 notes every day? Nothing. You're not even writing real notes and I'd bet you aren't even evaluating the patients. You're just slapping together some idiocy like "uh, patient is, uh, whatever, eff this, continue everything, signed me." And then you tell yourself you saw a patient in five minutes or less and high five your Program Director, who obviously doesn't give two craps about your development whatsoever.

But whatever, I'm sure in the grand scheme of things it doesn't matter. They're just patients, right? 👍

 

[glade]

Oh, and before anyone wants to say anything about it, I've been on services where we've had over fifty patients before. It's fine if:

a) you literally don't give a **** for anything other than your incision/wound and act like the stereotypical surgeon that doesn't pay attention to anything else about the patient; and

b) you don't write notes, meaning you do the management while everyone else has already gotten together all the other info and shoots it at you at your request.

Anyone who claims they're actually taking care of over fifty patients in any real sense of the word is a *****. You can HAVE over fifty patients, but the fact that they make it out of the hospital speaks more to the amazing healing potential of the human body than for any managment skills you have. The fact that any place -- and it's usually a university hospital -- does that to anyone merely reinforces to me that they care less about patients than they do about using residents for cheap labor, which is why I flip them off when they talk about caring for patients. Yeah, kiss me where the sun doesn't shine.

 

[JackADeli]

...intern doing a month of the general surgery trauma service at a busy trauma center and we are having to see and write notes on ~45 (or more) patients by ourselves. ...the person on call has to write all the notes, accept new pts, and field floor pages.

...I'm wondering if this is a unique experience and whether or not people think this is a reasonable think to expect out of an intern.

So, as everyone has said... reasonable is a matter of opinion. Unique? I suspect the interns before you at your institution have been doing it and those before them. So, not likely to be unique. But, none of that equates "reasonable". The real question is "write notes".

You need to ask your seniors and get a feel of what they expect to be written. The rounding note can sometimes be extremely important and other times simply evidence to show the team saw the patient. I can write 75 notes in under 90 minutes if it is simply a survey document. I can take an hour to write two notes if it is a lengthy and thorough document. The other issue is do your attendings round and leave a note too? This again goes to how much you need to write and what level of importance your literary publication carries.

If the INTERN notes on the entire trauma service are viewed as particularly important, primary sources of critical management data... I would not have the post-call intern writing them. In fact, I probably wouldn't have the intern writing any of them if it was at that level of importance. All that said, In general, I would not ask myself about it being reasonable. Rather, I try to figure out what the objective is and then am I achieving that.

...When you are "writing notes" on that many people, I wonder if you are truly doing the patient management...

I would say the answer is "no" and I don't believe that is the point. The new intern is not expected to be doing "primary management". These notes are little more then chart graffiti of...."ziggy was here".

 

[glade]

I can write 75 notes in under 90 minutes if it is simply a survey document.

I still can't figure out how people do that. I knew a guy who would write a note in about one minute. Now, keep in mind it was an absolute crap note and he didn't know anything about the patient and half of what he wrote was wrong. Forget all that. I'm just saying how can someone PHYSICALLY see a patient and write a note in one minute. Your note would have to just be "pt OK, cont care, f**k this place."

 

[deleted50541]

I just finished my first week of internship (q3 100+ hrs, 3 teams of a 4 and a 1) on a busy general surgery service and we're carrying 30+ patients at any given time. Thankfully, my senior and I work well in tandem to see everyone by 6am.

 

[glade]

It hasn't been a week yet, so you must be delerious and hallucinating.

 

[filter07]

I still can't figure out how people do that. I knew a guy who would write a note in about one minute. Now, keep in mind it was an absolute crap note and he didn't know anything about the patient and half of what he wrote was wrong. Forget all that. I'm just saying how can someone PHYSICALLY see a patient and write a note in one minute. Your note would have to just be "pt OK, cont care, f**k this place."

75 in 90 is pretty impressive and I got nowhere close to that speed, but one thing we did was have everyone round at the same time, the 3 or 4 examines patient, chief says plan out loud, and intern scribes both the exam and plan to a note. Also helps if the date, patient name, surgery type, and post op day and such, are pre-populated by hooking up your rounding list or computer system to the progress note. Someone else would have to write plans on the rounding list though, either a med student or the 3 or 4.

When I was an intern we use to have the night person fill out the vitals and labs on the rounding list. So on some services I would make a quick note of the incision or whatever on my rounding list, then at the end of my shift just transfer all the vitals/labs/exam/plan based on my rounding list. Depending on how crappy I write and how focused I am, I could get through maybe 30 in 90 minutes.

Glad I'm not an intern. 🙂

 

[glade]

I took it to mean that he would see a patient and write the note by himself. If it's team rounds, that's a whole different ballgame.

 

[Apollyon]

When I rotated on trauma, the attending one week was Greg Georgiade (if you know him, you know him - and he was on the first season of "MythBusters" - and talked more on that show than I EVER heard him talk in person). His middle initial is "S.", but should have been "E." for "efficient". 20 patients, with real notes, and bedside care, in 40 minutes.

Then again, way back when, when I was a med student, a surgical resident wrote for me the joke - but real - daily note of some surgeons:

VSS
C/D/I, SNT
CCM

 

[SouthernSurgeon]

Then again, way back when, when I was a med student, a surgical resident wrote for me the joke - but real - daily note of some surgeons:

VSS
C/D/I, SNT
CCM

Or the ortho variant:

VSS
LGFD
BSB

 

[glade]

20 patients, with real notes, and bedside care, in 40 minutes.

I could see that if all the patients were in consecutive rooms and there were two per room and 75% of them had no issues. Otherwise, I'm not sure what you mean by "real notes and bedside care." If it's a trauma service and you mean his plans were like "discuss disposition with Ortho" or "transferring to Neurosurg service," I'm not that impressed.

 

[dynx]

I expect an intern in the middle of the year to be able to see 20 or so. Fully worked up, real note and ready to discuss a full plan by 6:15. I think thats all you can really expect a single person to know in detail and even thats stressing it. I've been onservice with 45 patients. You gloss over things and bad things happen. I've never seen anyone...including some really great residents, stay on-top of that many patients (in the detail I think you need to know to take good care of them).

 

[Dr.LeoSpaceman]

I'm a new intern doing a month of the general surgery trauma service at a busy trauma center and we are having to see and write notes on ~45 (or more) patients by ourselves. We're Q3 and the person on call has to write all the notes, accept new pts, and field floor pages.

I'm surviving, but I'm wondering if this is a unique experience and whether or not people think this is a reasonable think to expect out of an intern.

Why does the on-call intern "have to" do all of these things? It sounds like a poor use of the available man power. In my mind, all three of you should be splitting the work. The overnight person should have the vitals/labs, and perhaps have skeltonized the notes, while the other two bang out the notes in the morning. I know the feeling of "But this is the way it's always been done" and "It's a right of passage" type stuff exists when it comes to these matters, but I do find that unreasonable.

 

[BlondeDocteur]

I think if it were any other service than trauma, where so many pts are relatively stable and are just hanging out until their dispo is arranged, it would be impossible. Literally impossible.

As it is... I agree with Glade. It speaks more to the natural course of illness rather than any medical management provided. There's just no way to keep 40+ people straight in your head like that.

It would depend too on how much brevity is permissible, and whether or not you have medicine or other subpsecialty consultants who write orders on your patients and actively manage specific problems versus just giving recs or going at it alone. If that were the case then you could both feel a bit safer about your patients' well-being, and bang out the notes.

I've been writing only 12 or so notes per day, and give myself at least an hour for them. Maybe things will speed up, but for right now I need that much time to gather my thoughts about the patient and write something that might actually be useful to other people taking care of them. Then again, part of the reason I went into GS is because I like medically complex patients and am interested in the management thereof.

 

[Apollyon]

I could see that if all the patients were in consecutive rooms and there were two per room and 75% of them had no issues. Otherwise, I'm not sure what you mean by "real notes and bedside care." If it's a trauma service and you mean his plans were like "discuss disposition with Ortho" or "transferring to Neurosurg service," I'm not that impressed.

I've been writing only 12 or so notes per day, and give myself at least an hour for them.

It was the trauma team - it's not one intern writing notes and doing dressing changes. All the patients were on the same floor, and it was a second-year surgical resident (at Duke) doing the notes, with an intern doing the bedside care. BD - a brand-new intern - is taking 5 minutes per note. I am guessing those are "complete" notes. The notes from the JAR were complete, with a narrative, physical exam, and plan. 2 minutes is not unreasonable. Hell, Duke MICU notes were pre-printed with just fill-in-the-blanks and sign, and they took longer to fill out (and the Duke MICU was, for the very largest part, a glorified floor bed).

 

[glade]

I think you're missing my point. It depends on the patient you're taking care of. Like I said, if you have a service full of healthy 30 - 58 year-olds who have one to two comorbidities like HTN or DM and take one or two meds, sure. You could see them and bang out a note in two minutes, realistically. And if you happen to hit ONE room with some 78 year-old guy who is having delerium, then throw your watch out the window. Now if you have a service full of patients like that, then, yeah, you could continue to relentlessly plow ahead (which I have seen done before), but that wouldn't constitute "managing" the patient in any sense of the word. It's all relative, too. You could have a guy on Trauma who has long bone fractures, head injury, mandibular fractures, etc, but as long as he had no Gen Surg issues, it would take like three seconds to see him.

 

[Apollyon]

Like I said, if you have a service full of healthy 30 - 58 year-olds who have one to two comorbidities like HTN or DM and take one or two meds, sure.

Inner-city trauma floor? Try 16-28 y/o, with either extra ventilation holes, or just broken after MVC or being beaten "for no reason".

Otherwise, I hear you. On transplant or onc/colorectal, not so fast at all.

 

[glade]

Actually, when they're 16 years old, that's ideal. I'd much rather that than have a bunch of rickety 75 year-olds who sneezed and turned all of their bones magically to dust.

 

[JackADeli]

...There's just no way to keep 40+ people straight in your head like that...

Actually, you will be surprised at how many patients you can keep straight in your head after 5 years of training. I was always amazed at my attendings that remembered the patients that went home the day before and followed up on some studies a few days later, while at the same time keep the patients in the hospital in their heads, while at the same time knowing what patients/cases were coming up in a few days..... The list goes on. I was also amazed at my chiefs that seemed to know the entire service without a list and the best ones could even tell you lab values.... without a printout.

But, I now find myself easily doing it, juggling a multitude of past admits, pre-admits, current admits, etc... in my mind with just situational memory tricks. Please do not short change yourself into believing it is impossible. Open your minds and learn. The intern year is tuff. Many have gotten through it before you and many will after you. I do not necessarily support the "dark ages" approaches in the past but do recognize that ~softening the environment may very well rob you of the stimulus/need to tune your mind and capabilities as those that went before you.

 

[dynx]

Actually, you will be surprised at how many patients you can keep straight in your head after 5 years of training. I was always amazed at my attendings that remembered the patients that went home the day before and followed up on some studies a few days later, while at the same time keep the patients in the hospital in their heads, while at the same time knowing what patients/cases were coming up in a few days..... The list goes on. I was also amazed at my chiefs that seemed to know the entire service without a list and the best ones could even tell you lab values.... without a printout.

But, I now find myself easily doing it, juggling a multitude of past admits, pre-admits, current admits, etc... in my mind with just situational memory tricks. Please do not short change yourself into believing it is impossible. Open your minds and learn. The intern year is tuff. Many have gotten through it before you and many will after you. I do not necessarily support the "dark ages" approaches in the past but do recognize that ~softening the environment may very well rob you of the stimulus/need to tune your mind and capabilities as those that went before you.

Oh yeah! well my internet persona ****s rainbows and benches 350...but I don't expect interns in the real world to be able to do that.

 

[BlondeDocteur]

Actually, you will be surprised at how many patients you can keep straight in your head after 5 years of training. I was always amazed at my attendings that remembered the patients that went home the day before and followed up on some studies a few days later, while at the same time keep the patients in the hospital in their heads, while at the same time knowing what patients/cases were coming up in a few days..... The list goes on. I was also amazed at my chiefs that seemed to know the entire service without a list and the best ones could even tell you lab values.... without a printout.

But, I now find myself easily doing it, juggling a multitude of past admits, pre-admits, current admits, etc... in my mind with just situational memory tricks. Please do not short change yourself into believing it is impossible. Open your minds and learn. The intern year is tuff. Many have gotten through it before you and many will after you. I do not necessarily support the "dark ages" approaches in the past but do recognize that ~softening the environment may very well rob you of the stimulus/need to tune your mind and capabilities as those that went before you.

Therein lies the rub, I think.

 

[SLUser11]

On a side note, I'm not a big fan of these "working rounds" with one doc doing the PE, one writing the note, etc. I feel it nearly eliminates patient ownership and resident autonomy. It would be easy for a marginal resident to slip through the cracks, and do multiple rotations without really having to develop a game plan or use independent thought to treat patients.

I know some people disagree, and it usually has a lot to do with where you train and what you've experienced, but I personally enjoy the fact that my interns see the patient, write the note, and develop a plan before I get my grubby hands on the chart.

 

[deleted50541]

It's very difficult to make thorough and efficient rounds on my service. With only two people on-call and tasked with rounding on everyone by 6am when the other four on-call/pre-call residents arrive, our rounds are routinely interrupted.

Just last night, my senior and I were tied up in the ED until 4am with multiple consults (about half were BS) and then had to speed through rounds, writing incredibly short and vague progress notes. It didn't help that my senior had to scrub into an emergency lap appy at 6am and the remaining seniors were at Wednesday conference until 9am.

That left me (the lone post-call intern) to finish rounds and see one last consult on the floor (I kept nodding off while writing the consult). The other two interns got started on other floor work for me or were preparing to cover cases that started at 7:30. We've got to find a better system.

P.S. I'm q2 this week due to a scheduling change.

 

[filter07]

On a side note, I'm not a big fan of these "working rounds" with one doc doing the PE, one writing the note, etc. I feel it nearly eliminates patient ownership and resident autonomy. It would be easy for a marginal resident to slip through the cracks, and do multiple rotations without really having to develop a game plan or use independent thought to treat patients.

I know some people disagree, and it usually has a lot to do with where you train and what you've experienced, but I personally enjoy the fact that my interns see the patient, write the note, and develop a plan before I get my grubby hands on the chart.

I'm at a program that does these work rounds. I agree that it does reduce autonomy and slow down learning. I also tend to think that one can learn a lot through osmosis in the span of several years as long as they have the proper background (med school, keeping up with reading) to absorb the things going on around them. In other words I think we will eventually catch up on the patient management side during residency, although if you compare us at the end of pgy 1 or maybe even 2, we would be behind. I don't have much to back it up, more of a guess than anything. I think in the era of strict work hours and night float, it's hard to get the intern to see patients before 5 or 5:30... unless they can pre-round on a patient per minute and come up with plans for all of them.

 

[SLUser11]

....my senior had to scrub into an emergency lap appy at 6am.....

I found that comment pretty funny for some reason. I guess my vivid imagination is envisioning this:

Attending: "What's that?!? Appendicitis?!? Call the operating room and tell them we have an emergency. And page the chief resident STAT!"

I'm at a program that does these work rounds. I agree that it does reduce autonomy and slow down learning. I also tend to think that one can learn a lot through osmosis in the span of several years as long as they have the proper background (med school, keeping up with reading) to absorb the things going on around them. In other words I think we will eventually catch up on the patient management side during residency, although if you compare us at the end of pgy 1 or maybe even 2, we would be behind. I don't have much to back it up, more of a guess than anything. I think in the era of strict work hours and night float, it's hard to get the intern to see patients before 5 or 5:30... unless they can pre-round on a patient per minute and come up with plans for all of them.

I know that there are several different scenarios that occur, and I can't make blanket statements that universally condemn "work rounds." It just sort of sucks when it's obvious that service is much more important than education. I hate to hear people say that "it's possible with hard work, the appropriate background, and osmosis" to pick up a surgical education. Programs shouldn't just allow an education to occur...they should facilitate that education....

Also, I feel that it takes a full five years to learn to be a really good clinician, especially if you are entrusted with the patient's total care, as many of us are. If the team is consulting medicine for diabetes management, maybe it's not as important.

 

[filter07]

The attendings at the academic centers I've worked at wouldn't know what to do if residents weren't around. It's inevitable that these type of environments tip the balance towards service than education. Maybe if there were a system in place that doesn't require resident work (attendings who still remember how to do all aspects of patient care, midlevel providers), there might be wiggle room for more educational aspects.

That being said, another perspective is, maybe osmosis is ok for the first few years. While I'm sympathetic to your bolded sentence, maybe residents turn out just fine without additional facilitation. At some point in residency, whether as interns or as 3s, 4s, or 5s, we will have to make clinical decisions. Maybe the safest way for the patients, and most efficient for the service/learning ratio is to have the junior levels learn by example for the first few years and make decisions in their later years. Everything is a trade off, and if I were program director, would I make changes to the system in place? I guess that would depend on whether I'm satisfied with the clinical decisions of my graduating chiefs. If I am, how would I justify any changes? Would it really be important that an intern makes great decisions earlier in residency, or am I ok with them running things by with their chief, learning how to communicate with the team, and learning autonomy a bit later on in their training?

My program does provide a lot of education, just not much in the way of bedside teaching. (So the problem isn't widespread apathy towards education as a whole.) Either we don't have the resources appropriately set in place for bedside learning, or we just don't think there's a problem with the current system.

 

[Doc Ivy]

I think it is simultaneously unreasonable and relatively common.

....it seems like maybe the intern becomes a note monkey, and the real patient decisions are delegated to someone higher.

Yes, exactly.

When I was an R3 last year on a very busy trauma service I would routinely round on 55+ floor patients with the 2 interns (the chief would round with the R2s in the ICU)... I think everyone was aware that the intern's job was to spoon feed me information so that I could make decisions that they would carry out, and to write the notes. However after rounds if I wasn't stuck in the ER with traumas, seeing consults or operating I would try to pitch in and write some notes. It was easy for me because I wasn't so overwhelmed and could write a more concise, accurate and meaningful note faster than they could because I wasn't getting mired in the details and could see the forest for the trees.

 

[McDizzy]

As someone who has been there and done that many times over, my advice is to learn everything you can from every patient you see in the most efficient manner possible. These years of your life will be rough, but they will pay off in the end. There were many times in my residency where I felt tired and tortured. I thought it would never end. However, I have learned things in the middle of the night on the edge of exhaustion that have saved patients lives in my current practice.