When to speak on rounds?

[Sparda29]

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So I started my Internal Medicine rotation yesterday. Most of my responsibilities will be on the patient floor and rounding, with some presentations to residents and whatnot.

So my question, when should I speak? The team I'm on consists of the Attending Physician or Chief Physician, 2-3 residents, 2-3 nurses, social worker, physical therapist, and me. For example, today we were on a patient with MRSA bacteremia. Chief physician asked what the trough level should be? (He knows what it should be, but I think he was asking the team because he likes to teach while he is conducting rounds.)

Is it okay for me to jump in and say the answer or should I wait for the residents to say an incorrect answer first and then correct them? The thing is, this chief physician is always looking at the residents and I'm usually standing next to the chief physician: so I don't really know who he is directing questions to unless he directly asks me a question.

 

[All4MyDaughter]

Where is your preceptor?

 

[Jabberwocky12]

Oh you changed your icon! What's the meaning behind it?

/end thread jack

 

[Sparda29]

Where is your preceptor?

He was there yesterday, wasn't here today. Told us that in the future we will be going on our own to different floors and then reporting back to him.

 

[Sparda29]

Oh you changed your icon! What's the meaning behind it?

/end thread jack

Creepy pasta. I don't know, it just looks funny.

 

[Its Z]

15mcg/ml

 

[Sparda29]

15mcg/ml

Yes, but do I just butt in and say that right after he asks the question or do I wait?

 

[Jabberwocky12]

Creepy pasta. I don't know, it just looks funny.

I was referring to A4MD since it was very recent but your icon has me wondering as well 😛

 

[Its Z]

I would've said "the latest IDSA/ASHP Vancomycin Guidelines and recently published MRSA treatment guidelines strongly recommend 15mcg/ml trough to ensure AUC/MIC ratio of 400." "As you all know...MRSA Bacteremia has a very high mortality and treatment failure...therefore it's imperative we get the levels therapeutic as fast as we can through a loading dose...say 25mg/kg ...then make sure we keep the trough above 15mcg/ml at all times..." "Some studies have show that treatment failure in MRSA bacteremia can be over 50% with either Daptomycin or Vancomycin..."


They'll think you're a showoff....yet this sort of display in knowledge is how you earn the respect and trust from physicians.

 

[Its Z]

you can always start with..."If you'll let me interject..."

 

[Sparda29]

I would've said "the latest IDSA/ASHP Vancomycin Guidelines and recently published MRSA treatment guidelines strongly recommend 15mcg/ml trough to ensure AUC/MIC ratio of 400." "As you all know...MRSA Bacteremia has a very high mortality and treatment failure...therefore it's imperative we get the levels therapeutic as fast as we can through a loading dose...say 25mg/kg ...then make sure we keep the trough above 15mcg/ml at all times..." "Some studies have show that treatment failure in MRSA bacteremia can be over 50% with either Daptomycin or Vancomycin..."


They'll think you're a showoff....yet this sort of display in knowledge is how you earn the respect and trust from physicians.

That's what I'm afraid of. Until they get me some credentials for the computers, I'm at the mercy of the residents for getting me the patient census, med lists, and access to profiles when I'm prerounding.

 

[SpirivaSunrise]

You've got to give a little and take a little. Definitely don't want to be the smartass that answers every single question. But you're a part of the team and if you know the answer...every once in a while you're absolutely entitled to speak up.

I sure as heck wouldn't just be waiting to pounce on the residents when they're wrong though! That isn't going to get you anywhere.

And also remember...sometimes a better angle to take (from a learning perspective for the team anyways), is to ask a challenging, yet appropriate follow-up question that you'd like to learn more about. Just be sure you're timing is right when you do this too.

 

[Its Z]

That's what I'm afraid of. Until they get me some credentials for the computers, I'm at the mercy of the residents for getting me the patient census, med lists, and access to profiles when I'm prerounding.

Why....is everyone who answer the question correctly considered a show off????? This is a learning environment and this is a major part of learning.

 

[Its Z]

That's what I'm afraid of. Until they get me some credentials for the computers, I'm at the mercy of the residents for getting me the patient census, med lists, and access to profiles when I'm prerounding.

That's what you get for going to a diploma mill I guess.

You mean to tell me you don't have the patients already worked up before the round??? You don't have access to patient info??

Geebus... you should know everything there's to know about all your patients before you round. Who's your preceptor??

 

[All4MyDaughter]

I was referring to A4MD since it was very recent but your icon has me wondering as well 😛

I was looking for something a little more undercover... I will change it back eventually.

 

[Sparda29]

That's what you get for going to a diploma mill I guess.

You mean to tell me you don't have the patients already worked up before the round??? You don't have access to patient info??

Geebus... you should know everything there's to know about all your patients before you round. Who's your preceptor??

No fool, I get there a while before rounds start but I need the residents to print out the patient censuses and give me access to the patient profiles.

 

[All4MyDaughter]

I would've said "the latest IDSA/ASHP Vancomycin Guidelines and recently published MRSA treatment guidelines strongly recommend 15mcg/ml trough to ensure AUC/MIC ratio of 400." "As you all know...MRSA Bacteremia has a very high mortality and treatment failure...therefore it's imperative we get the levels therapeutic as fast as we can through a loading dose...say 25mg/kg ...then make sure we keep the trough above 15mcg/ml at all times..." "Some studies have show that treatment failure in MRSA bacteremia can be over 50% with either Daptomycin or Vancomycin..."


They'll think you're a showoff....yet this sort of display in knowledge is how you earn the respect and trust from physicians.

If someone tried to answer that way on rounds at my current site, the attending would cut them off.

 

[All4MyDaughter]

No fool, I get there a while before rounds start but I need the residents to print out the patient censuses and give me access to the patient profiles.

Sounds normal if you just started this rotation. It takes a few days to get credentials at most of the hospitals here as well. Up to a week sometimes if all the students (med, pharm, nursing + interns and residents) are starting at the same time). Many of our sites require some computer and HIPAA training before assigning codes.

 

[Old Timer]

You've got to give a little and take a little. Definitely don't want to be the smartass that answers every single question. But you're a part of the team and if you know the answer...every once in a while you're absolutely entitled to speak up.

I sure as heck wouldn't just be waiting to pounce on the residents when they're wrong though! That isn't going to get you anywhere.

And also remember...sometimes a better angle to take (from a learning perspective for the team anyways), is to ask a challenging, yet appropriate follow-up question that you'd like to learn more about. Just be sure you're timing is right when you do this too.

👍👍👍👍

You should observe the interaction between the attending and the rest of the team. I would prefer the speak up approach as opposed to waiting until the attending calls on you...

 

[nnguyenc]

DAMMIT!!!....I thought the answer was B

 

[Its Z]

No fool, I get there a while before rounds start but I need the residents to print out the patient censuses and give me access to the patient profiles.

Well dummy that's because you got a chitty rotation with a chitty program. You should have been given full access to patient profile. You should work up the patient before the round even a day before and follow all your patients progress. You should know why they're hospitalized, what meds they're on, and what lab values that pertain to medication is what.... and since you're the "Pharmacist/intern" on the team, you should be the expert/intern..... and take ownership and become an integral part of the team... I guess your preceptor didn't explain that to you.

 

[Its Z]

If someone tried to answer that way on rounds at my current site, the attending would cut them off.

That's because your program sucks too...and you probably couldn't answer it that way any ways.

 

[Its Z]

👍👍👍👍

You should observe the interaction between the attending and the rest of the team. I would prefer the speak up approach as opposed to waiting until the attending calls on you...

Yup.

 

[All4MyDaughter]

Well dummy that's because you got a chitty rotation with a chitty program. You should have been given full access to patient profile. You should work up the patient before the round even a day before and follow all your patients progress. You should know why they're hospitalized, what meds they're on, and what lab values that pertain to medication is what.... and since you're the "Pharmacist/intern" on the team, you should be the expert/intern..... and take ownership and become an integral part of the team... I guess your preceptor didn't explain that to you.

He just started. It sounds like he'll have codes in a day or two. I don't think that says anything about the quality of the rotation. I do question the wisdom of his preceptor allowing him to go to rounds solo on his second day, though.

 

[All4MyDaughter]

That's because your program sucks too...and you probably couldn't answer it that way any ways.

Riiiiight. 🙄

 

[Its Z]

He just started. It sounds like he'll have codes in a day or two. I don't think that says anything about the quality of the program. I do question the wisdom of his preceptor allowing him to go to rounds solo on his second day, though.

It says a lot about the program if they're not fully preparing him to be a part of the team. I don't have issues with the preceptor not being there as long as the preceptor fully prepares the student on expectations of the rotation and how to integrate pharmacy student into a Medical Team.

He still think it's the responsibility of the residents to print out the census data....that aint enough. He needs access to full chart.

 

[Its Z]

Riiiiight. 🙄

You're still a student. If an attending can cut off residents, students, and intern, as you expect, then I can cut you off too. You haven't earned your PharmD yet and haven't worked a single day as a pharmacist let alone precept a pharmacy student. You know very little about how medicine rotation should be structured and the entire "rotation experience" at top tiered programs are taught.

 

[All4MyDaughter]

It says a lot about the program if they're not fully preparing him to be a part of the team. I don't have issues with the preceptor not being there as long as the preceptor fully prepares the student on expectations of the rotation and how to integrate pharmacy student into a Medical Team.

He still think it's the responsibility of the residents to print out the census data....that aint enough. He needs access to full chart.

Maybe you need bifocals. He said that he will be getting computer codes and access. Then again, you also accused of him not pre-rounding, when he had already stated that he had been...

 

[Old Timer]

You're still a student. If an attending can cut off residents, students, and intern, as you expect, then I can cut you off too. You haven't earned your PharmD yet and haven't worked a single day as a pharmacist let alone precept a pharmacy student. You know very little about how medicine rotation should be structured and the entire "rotation experience" at top tiered programs are taught.

A little feisty tonight? Maybe some cabin fever since you guys actually have winter this year???

 

[Its Z]

Maybe you need bifocals. He said that he will be getting computer codes and access. Then again, you also accused of him not pre-rounding, when he had already stated that he had been...

why rely on residents? Couldn't preceptor provide the data?? Preceptor has access.

 

[All4MyDaughter]

You're still a student. If an attending can cut off residents, students, and intern, as you expect, then I can cut you off too. You haven't earned your PharmD yet and haven't worked a single day as a pharmacist let alone precept a pharmacy student. You know very little about how medicine rotation should be structured and the entire "rotation experience" at top tiered programs are taught.

And you're still an anonymous windbag on the internet. I can disagree with you all I want. I'd say I know plenty about how inpatient rotations are structured, at least in health care facilities in my area, since I've been doing them for the last year.

The answer you gave was ridiculous. No one talks like that. If the attending asks a question, you answer it and the team discusses it further as necessary. No need to embellish or pontificate.

 

[Its Z]

A little feisty tonight? Maybe some cabin fever since you guys actually have winter this year???

I get that way when students start to act "know it all" ... I don't think you'd appreciate student telling you how you should do your job as a preceptor...

 

[All4MyDaughter]

why rely on residents? Couldn't preceptor provide the data?? Preceptor has access.

I agree that since Sparda has just started this rotation, it would be most appropriate for his preceptor to remain with him and insure that he gets all of the information he needs for rounds. It sounds like the problem here is with the preceptor, not necessarily the rotation site.

 

[Its Z]

And you're still an anonymous windbag on the internet. I can disagree with you all I want. I'd say I know plenty about how inpatient rotations are structured, at least in health care facilities in my area, since I've been doing them for the last year.

The answer you gave was ridiculous. No one talks like that. If the attending asks a question, you answer it and the team discusses it further as necessary. No need to embellish or pontificate.

Yeah...keep believing that...and when you're a practicing pharmacist, let's see how you will appreciate know it all student telling you that you don't know what you're talking about.

 

[Old Timer]

One more thing to think about. I have not been on rounds for almost 30 years. But certain events stick with you forever. We had a patient with sick sinus syndrome. Being this is 1982, patient was on aspirin and dipyridamole. Asked how the aspirin worked as a blood thinner. Residents didn't know, med students didn't know. Then the attending looks at me and I answer. I gave a Z like answer with a little too much detail. He liked my answer so much that asked me to give an in-depth presentation the next day so the team could get up to speed. No internet, no Powerpoint, no word processor..... Moral of the story be firm in your answers, but be humble....

 

[cycloketocaine]

I get that way when students start to act "know it all" ... I don't think you'd appreciate student telling you how you should do your job as a preceptor...

You're getting bitchy. Go get a crown and coke.

Anyway, OU sets up computer access at a site like this a week prior to starting rotation. During my ID rotation, I had full access to patient charts and records from day 1.

 

[Its Z]

One more thing to think about. I have not been on rounds for almost 30 years. But certain events stick with you forever. We had a patient with sick sinus syndrome. Being this is 1982, patient was on aspirin and dipyridamole. Asked how the aspirin worked as a blood thinner. Residents didn't know, med students didn't know. Then the attending looks at me and I answer. I gave a Z like answer with a little too much detail. He liked my answer so much that asked me to give an in-depth presentation the next day so the team could get up to speed. No internet, no Powerpoint, no word processor..... Moral of the story be firm in your answers, but be humble....

Well, I did say 15ug/ml....firm one liner answer. But in a teaching environment, that's not enough. It needs to be discussed further and students, interns, and residents need to understand the rationale behind the number.... It's a great discussion point at the same time has a huge financial and clinical outcomes implications....

 

[Its Z]

Anyway, OU sets up computer access at a site like this a week prior to starting rotation. During my ID rotation, I had full access to patient charts and records from day 1.

Go Legacy Program! Don't you wish you'd given my kind of answer at your residency interview?

 

[All4MyDaughter]

I get that way when students start to act "know it all" ... I don't think you'd appreciate student telling you how you should do your job as a preceptor...

I had two main points:

-I don't think Sparda was ready to be alone on rounds on the second day of his rotation. This seems to be compounded by the fact that he lacks computer access and doesn't know what's expected of him. That's based on my background as an educator (in another field) and trainer. I don't think this point is very controversial at all.

-You answer was over the top for a question that can be answered succinctly. That's my opinion.

Yeah...keep believing that...and when you're a practicing pharmacist, let's see how you will appreciate know it all student telling you that you don't know what you're talking about.

Oh, you are such a baby. Someone disagrees with you and you immediately go to "you're a student, you're a know it all, you don't know chit."

The beautiful thing about this web site is that we're all equal. You're not my preceptor, supervisor, professor, etc. I can have my own opinions and express them and YOU are free to ignore them. That's probably what you should do, since they bother you so much.

 

[Its Z]

The beautiful thing about this web site is that we're all equal.

Here's where you're mistaken. We're not equal. I'm a practitioner who's been doing this for a long time at a very high level at multiple sites across the US. You're a student.

You may be equal to Sparda... but that's about it.

 

[All4MyDaughter]

You're getting bitchy. Go get a crown and coke.

Anyway, OU sets up computer access at a site like this a week prior to starting rotation. During my ID rotation, I had full access to patient charts and records from day 1.

I think that's the ideal setup. I'll have codes on the first day of the rotation I start Monday. We set them up after we selected this site back in 2010. But some of our other sites (the VA and University) never set them up until the student is actually on site.

I've been at facilities that used a "dummy" login for students, but those were smaller hospitals, clinics or other types of practice sites. I would be generic logins are against policy at most major medical centers. I know they are strictly forbidden at the VA (and you can get fired for sharing codes).

 

[All4MyDaughter]

Here's where you're mistaken. We're not equal. I'm a practitioner who's been doing this for a long time at a very high level at multiple sites across the US. You're a student.

You may be equal to Sparda... but that's about it.

Keep thinking what you want to think but the hierarchy you desire doesn't exist on SDN. This isn't the hospital... this is an internet web site. Check the TOS if you don't believe me. 😉

 

[Its Z]

Keep thinking what you want to think but the hierarchy you desire doesn't exist on SDN. This isn't the hospital... this is an internet web site. Check the TOS if you don't believe me. 😉

Right... must be good to know that you think you're equal to some of the idiot posters on here. So, you keep thinking that and hide behind your TOS no one reads.

 

[All4MyDaughter]

Right... must be good to know that you think you're equal to some of the idiot posters on here. So, you keep thinking that and hide behind your TOS no one reads.

And you just keep on thinking you're better than all of us. Whatever makes you happy, sir.

Can't believe you didn't read the TOS. You agreed to it every time you registered. Didn't you ever hear that you shouldn't agree to any agreement you haven't read? 😉

 

[Its Z]

And you just keep on thinking you're better than all of us. Whatever makes you happy, sir.

Obviously you must think that... otherwise you wouldn't have brought it up??

I know and understand this industry more than you and most here. I don't claim to know nuclear pharmacy or retail... but if you think everyone is equal here, then don't read my posts..since you think you're equal and know as much.. as a pharmD candidate.

 

[Its Z]

Can't believe you didn't read the TOS when you registered. You agreed to it every time you registered. Didn't you ever hear that you shouldn't agree to any agreement you haven't read? :winks:

Nope I don't have to agree to it...and look at me, I'm still here. evidently you wasted your time and read it...

 

[All4MyDaughter]

Obviously you must think that... otherwise you wouldn't have brought it up??

I know and understand this industry more than you and most here. I don't claim to know nuclear pharmacy or retail... but if you think everyone is equal here, then don't read my posts..since you think you're equal and know as much.. as a pharmD candidate.

You seem to have very poor reading comprehension for such a smart boy. I never claimed to know as much about pharmacy as any of the more "seasoned" posters on SDN. I only said that we are all equally able to share our opinions and participate in the threads posted on this web site. Which is a fact.

You could take a page from the book of any number of our more accomplished posters and learn how to give advice and share your knowledge without sounding like an arrogant jerk and demeaning others. But the beauty of the anonymous internet is that you get to behave as badly as you want to without any real consequence. Just as you are free to ignore my opinions, I'm free to discount yours because of the odious delivery. 🙂

 

[cycloketocaine]

You seem to have very poor reading comprehension for such a smart boy. I never claimed to know as much about pharmacy as any of the more "seasoned" posters on SDN. I only said that we are all equally able to share our opinions and participate in the threads posted on this web site. Which is a fact.

You could take a page from the book of any number of our more accomplished posters and learn how to give advice and share your knowledge without sounding like an arrogant jerk and demeaning others. But the beauty of the anonymous internet is that you get to behave as badly as you want to without any real consequence. Just as you are free to ignore my opinions, I'm free to discount yours because of the odious delivery. 🙂

Dang lady, you're pulling out some big words, I'm having to use context clues. Lol.

 

[gotdrugs]

As someone who has rounded and been a preceptor for well over 10 years..............

1) For the preceptor to leave a student on rounds by himself and expecting the student to get the patients med profiles etc from the medical residents is complete bull****. If I were those medical residents I would be pissed at that pharmacist for basically dumping his/her student on me. And if this is a pharmacists who 'consistently' works with said residents that is not a good way to build rapport with those physicians. It shows irresponsibility.

2) As far as the whole "succint" vs. "academic" answer..........from my own personal experiences and opinion, it depends on how indepth you should go. Factors include: 1) Knowing your attending 2) Knowing the current situation 3) some other crap

Z has a great point though on the teaching part and even in those situations where it dictates a succint answer on rounds, I follow up with the resident's "off-line" for a more thorough explanation.
To give an absolute answer - you should always just say "15mcg/ml" isn't appropriate.

And on the flipside there will be times if you try to give the more thorough answer you would be cut off.

With experience you learn how to practice effectively.

 

[gotdrugs]

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