Be very careful with the perpetuating above types of descriptions as patternas because they are certainly not the norm. They are not condusive to the practice of good medicine under any circumstances and are far from commonplace in good teaching facilities. When I conduct teaching rounds (I can speak for my partners and my colleagues all of whom are university attending physicians), I am not trying to "blow sunshine up anyone's rear end" or "entertain you" but I am there to present the best teaching and clinical outcomes based on clinical experience and knowledge. This is not an exception but a rule in the best teaching facilities. If you find rounds "drudgery" then do something else that can entertain you as there is nothing about patient care is drudgery if you have the best interests of the patient in mind as either you do the job or you don't get it done.
I am thinking you are misreading my points. Drudgery IS NOT rounds depending upon who is leading them. I've worked in NO less than 8 teaching hosptials, and some of them ivy league or ivy league affiliation, while others were university-based but not ivy-league. Honestly, yes. The one that was not the ivy league was not as open and in my view enlightening--but that is based on rounds on various units. Make no mistake. In the clinical setting, we are often dealing with all kinds of personalities and dynamics, period. Some people are a joy to be on rounds with. We are excited when they lead, b/c we know it's going to be a good time for learning and discussion. NOT SO MUCH for others. Don't assume everyone leading rounds is as great at is as you or some of your colleagues are. It's just not reality. The weekends are a great example of this. It may be viewed as more relaxed, less performing and attention to teaching--but still, IT ALL DEPENDS UPON WHO IS LEADING rounds and who is there.
And such is a separate issue from being on rounds primarily to help get the best plan in motion and get the patient what he or she needs. YES. That is and should be the primary focus.
I can assure you I consistsently strive to have
the best interests of my patients in mind and addressed--on rounds or otherwise. But there is a bit of a tug of war at times, just as I am sensing one now, when people dig their heels in or are inflexibile. Nurses have learned to get what the patient needs in other ways sometimes.
Most of us first and foremost are patient advocates. But to be sure, there are people you have to walk on eggshells with and EVERYONE knows who these people are.
I teach in college as well. There are enough issues of egomania and politics in medicine, healthcare
and education. Personally I find it takes away from the
primary focus, and that is/should be the patient. But we learn to deal with it, b/c the truth is the patient needs us--and we also strive to learn what we can when we can.
We all know which fellows and attendings are really there foremost to help the patient and also impart insight, wisdom, and learning. And I've been fortunate, b/c overall I feel that most of those I've worked with have been great.
Still, there are those that are just a pain in the butt at times. This is true in all fields. But there is also some percentage of people that are in this field to meet some ego need--to somehow be stroked. They may not be in touch with it, but there are times when they are about that.
What's more, I could write a best seller on some of those that put their own pride and ego before the needs of patients and others. Again, not always, thank God, or I would not have stayed in critical care as long as I have. But rest assured, those people are there, and in some ways
they scare me a lot more than those that may not be as bright as others. I find their prioritizing at times close to if not out and out unethical. I have seen it and so have others.
NO, it's not the norm, BUT it does happen. I think in 20 years I can speak to this. I wish it were not so. I have seen some troubling things over the years. I have also seen many good and wonderful things.
But I can't deny those things that are troubling, and they should be addressed and brought out into the light of day. This is part of how we strive to improve and get better. Openness promotes improvement. Denial or suppression promotes decline.
Not everyone in medicine or healthcare is always and every minute involved in going for the ideal or to always make their top priority the patients' health interests. This is true for some nurses, physicians, and other healthcare providers. When this becomes a pattern that I see consistently see--where the health interests of the patients are put on the back burner due to ego issues, sometimes laziness, or for political interest, it is something that IS very tough to tolerate. I wish I have not seen this, but I would be
a bold face liar if I said otherwise.
So, unless I have mistakenly taken what I feel are unfair and negative comments from you, I strongly resent your implications. I find them highly offensive. I
never think I am on rounds to be
"entertained," and the drudgery enters in
when people are just going through the damned motions. That doesn't always happen, but it happens enough, and we all know it. Rounds are not always the same as they are on days during mon-fri work week. That's just not reality, and I can say this, and I have worked in many critical care units.
And it's not just the difference between the ivy league and the one that isn't. There are pediatric cc intensivists that are excellent at putting the patients first and at teaching. One woman I'm thinking of is wonderful and when I have a moment, I leave the cardiac unit and go on rounds with her in the PICU if she isn't covering rounds for both areas at that time. And she takes individual time with people, but she really cares about excellence. I respect her immensely and attend any of her presentations whenever it is feasible for me.
There are others like her as well, but there are those that can't hold a candle to her period. For those that are just going through the motions on rounds, my ears are still up and I'm paying attention. I listen to the plan and contribute where necessary. I ask questions or address concerns based on what is going on with my patient/s. Be
sure of this,however, lest you further misunderstand me. If addressing an important concern annoys someone on or the one leading rounds--such that perhaps maybe they want to use the opportunity to try to make me feel like as azz--I really don't give a damn,
b/c I'm a patient advocate first. If there is something that I need to have clarified or understand, I address it, period. At the same time, I will say that I have found we need to be careful about this.
I'm not going to waste my time and energy getting into some kind of pizzing contests with people. It just leads to unnecessary tension and draining of energy, which I could better use to help my patients. And with some people, they can have quite a stick up their azz and be a pain in the butt. As I have stated, fortunately for me that hasn't been most of my experiences,
but it can happen, and sometimes it happens more that we would like.
In this field one thing is quite true. You must carefully and wisely pick your battles. I've had a egomaniac specialist demand all kinds of idiotic things when I'm in the midst of doing something important, like drawing a vital (not routine) blood gas. His demand was an issue of pride and was no where near a priority--it was based on his pizzing contest with another intensivist. People can at times suck others dry with such lunacy.
I've seen some incredible things in 20 years working in critical care--incredible things indeed--and some of them are just plain idiotic crap. I have also had a CT surgeon yell at me when his patient was dumping 200-300cc/hr out of the chest tubes for many hours and he refused to come in and address what's going on with the patient--after dumping I don't how much blood products into the pt and getting no response from DDVAP or other things, it was totally outrageous.
I had another one tell me to just let the patient on the IABP with an augmented pressue of 50 tell me to go ahead and let the patient code as we were maxed out on Levophed. I thought the rest of the staff and I would kill ourselves trying to keep those patients alive--b/c the truth is,
we literally fought long and hard to keep them alive when a few (vital) others clearly didn't have the same focus as we had. It was an ugly reality, yet there it is.
So when some folks aren't giving it the ole college try on rounds, I am not overly bummed out; b/c I'm there for my patients--and no, I don't shut the hell up like a mouse b/c I am afraid I'll get put down. It may happen--I may get condescended to, but I've gained a lot of respect by standing my ground for my patients when it is necessary to do so. And then there are times that others might mark you on their ****e list b/c you asserted for important things on the behalf of the patients. And then there are times it's a judgment call--but the judgment for me is based on the highest priority needs of the patient. And then there are times when there are many ways to approach a situation, and I'm not going to get in a struggle with someone necessarily over their approach. Again--it requires wisely picking your battles. (Now, thankfully these examples I give are NOT the norm--else, again I would not have stayed in this field, but it did help to move me into pediatrics critical care, where people are often many times more anal-retentive, and for good cause. Also I'm honestly thankful that the two surgeons I referred to are no longer working in the field. You know, I will kill myself to help a surgeon, especially when it is clear he or she is putting the patient first. But when they are practically admitting to me that they don't really give a damn, well, that puts everyone in a horrible place. And I have stood up to that and have taken the heat for it, believe me.)
I have NO idea why you would even suggest such as thing as me desiring
to be entertained, etc.
That is NOT at all what I was talking about. But yes, some people are more about their own ego and insecurity than others, and this is true in life in general. I wish it weren't, but we live in quite an imperfect world.
As an aside, I will say that I learned something from a cardiology unit director. He also showed me that there are times to side step direct confrontation (related to ego arguments and pizzing contests) to get what you need for you patients--that there is more than one way to skin a cat and get what the patient needs. He knew this and nurses have had to learn this for the sake of their patients. And then quite frankly you do the best that is within your realm to do and pray the Serenity Prayer. There are things I cannot control, but I am not negligent in those things that I can control Still, that director did show that you can get things done and not feed into unnecessary conflict and drama. I learned part of why he was the director of that unit that particular day b/c of his skill in this approach. Sometimes running up the middle isn't the way to get the touchdown.
And at the end of the day, it's ultimately about effectively meeting the needs of the patients.
If somehow I took what you are saying the wrong way, I truly apologize; but I feel somehow condescended to and reprimanded for discussing dynamics
that I know exist and that are not necessarily totally rare-to-never dynamics. What is "rare" can be relative and depend on a number of things. But no. I don't throw the baby out with the bathwater. Most of my experiences with others have been great.
It is just that there are those times when you have figure out how to get past some idiotic mentality in order to get the patient what he or she needs. This can be part of the reality shock in healthcare. Denying that it exists is counterproductive in my view.