When to speak on rounds?
Started by Sparda29
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I've been working on this writing piece lately. Academic/medical stuff... have been using the fancy vocabulary for it because the person paying for it likes that stuff. It's bleeding over into my posts, lol.
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I think this is very true. Current attending (ICU) likes his questions answered in a very short, straightforward manner. If he wants to follow up with more detail, he will. Our rounds are extremely long already so excessively wordy answers would not be welcomed by anyone on the team. We round in the morning and do presentations/topic discussions in the afternoon where we get into things a bit further.
My psychiatry attending loved to talk in depth about things with the pharmacy students, but he tended to save it for the end of rounds and he would dismiss the social worker, MHC, nurses, chaplain, etc so they wouldn't have to sit through all the drug talk.
It's all about context and taking cues from your preceptor and the others on your team. At least in my experience.
I didn't demean anyone. I demeaned your diploma mill programs which I have issues with. Don't take it personally, but you did. They don't always provide the best "rotation" experience. I'm not going to sugar coat my delivery here. Take it or leave it. But I've been consistent. Yet students here evolve. WVU was a pompous student yet once he became a pharmacist, you could see him mature as a practitioner. While Rxforlife was a mild student who went crazy as a practitioner. Problem with students is that they don't know what they don't know. With experience and practice, you realize your limitations. But only with experience you gain that insight. You're not there yet as a pharmacist.
You think my response is ridiculous regarding vanco. That shows how little you know how much more you have to go as a pharmacy educator you're not. What I said about vanco is what I would want my students to know and be able to communicate with others.
Everyone may have equal rights to express an opinion. But some opinions are more valuable than others. I've pissed off plenty but I also helped plenty. Unfortunate part of this forum is when you lose valuable members like SDN1977.
Again, let's wait and see how you change once you're a practicing pharmacist.
I've always wondered what happened to her.........she was a wonderful resource.....
Y'all can't even do that right...
She pissed off some students and mods/owner who thought they knew more than her. They banned her ip..
I'm not going to derail Sparda's thread any further because I think it's a great question and worthy of discussing more. This exchange is obscuring that, so I'm done.
I stayed in touch with her... until her daugther got married... I need to email her.
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Getting back to the original question, having been the senior resident on inpatient service on many occasions (that includes pharmacy students and pharmacy residents), the answer depends on the purpose of the question. In this case, it seems the attending is trying to gauge the knowledge of the interns, to see what trough level to look for, and when to draw trough. If Sparta29 were to answer right away, esp as a brand new pharmacy student, it would have serve no purpose. The interns may or maynot know the answer but the attending will never know. And being told the answer would not necessarily mean the interns will remember the answer for future reference. To talk about MIC, if not referring to culture sensitivity, would have been TMI. If there is a drug drug interactions you are concern about, or dosage change that you recommend, present those during the team discussion, usually right after the intern finish presenting the assessment and plan. Usually this is when the attending or senior resident or nursing chimes in.
Since this is your first experience, watch how the team dynamics work, and you will get a sense of when to answer, or even who the question is directed towards.
Since this is your first experience, watch how the team dynamics work, and you will get a sense of when to answer, or even who the question is directed towards.
👍 Thanks for sharing your perspective.
I've seen two different times of rounds at my current facility. On Medicine rounds we sat in the team room and discussed each patient at length. That's when we'd bring up things like you mentioned above (interactions, dose changes, etc). Then we'd all go around to each patient room and see the patients with very little discussion. On ICU rounds we just go room to room and discuss everything as we go. It takes a LOT longer but there is still somehow less time to discuss. I see my preceptor discussing things one-on-one with the attendings more frequently on this team.
I'm guessing this is just an "attending preference" thing or is it some sort of standard protocol (Medicine vs. ICU) that I'm not aware of?
ICU rounds are longer because typically the patients are more complicated.
Intensivists are some of the (if not the) most efficient physicians out there when you take into consideration everything they have to do and the acuity level of the patients they are taking care of.
This isn't a knock to any other physician out there that may be reading, it's just from my observations.
Intensivists are some of the (if not the) most efficient physicians out there when you take into consideration everything they have to do and the acuity level of the patients they are taking care of.
This isn't a knock to any other physician out there that may be reading, it's just from my observations.
The reason why my preceptor doesn't get me that information is because I arrive 2 hours before the preceptor, who arrives 1/2 hour before rounds start (less traffic driving around at 6AM as opposed to 8AM), and I like getting out at 2-3PM vs 5PM.
BTW, my site is also a LIU site. They're taking 2 of our students while taking 1 LIU student.
BTW, my site is also a LIU site. They're taking 2 of our students while taking 1 LIU student.
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I have to say, ICU rounds are fascinating, long or not. There's just so much going on with the patients. Our attending has a great sense of humor and that makes it go by faster. Last week, our team got yelled at by a (very) famous surgeon who thought we were being "too loud" and "laughing too much" and "jumping around in the halls" on rounds. After he finished his rant and stomped away, our attending started bowing and saying the Latin mass to his retreating back. Then we really WERE laughing!
I go back on Medicine next month, but at a different hospital, so it will be interesting to see the differences between facilities, attendings, etc.
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It's attending preference. The two type of rounds that you just described are sitdown rounds and bedside rounds. Usually if the patients are in one location, bedside rounds are preferred since you can involve the nurses, patient, and family members in the discussion. If the patients are all over the place, and time is limited, then sitdown rounds might be more practical.
One thing I would tell Sparta29 is that patient care is very dynamic, and things can happen quickly, esp in the afternoon and night. The plan discussed on rounds may change significantly depending on new information or status change. Antibiotics may be changed, imaging studies may alter plans or even alter diagnosis. Your COPD exacerbation may have developed NSTEMI and be on betablockers, ASA, maybe even integrellin drip and/or heparin drip. May have gone to the cath lab and be on plavix s/p stents. Your mrsa bacteremia may be infective endocarditis, epidural abscess, osteomyelitis, etc. Things change and as a pharmacy student you may be kept out of the loop, esp if you are not with the team in the afternoon.
One thing I would tell Sparta29 is that patient care is very dynamic, and things can happen quickly, esp in the afternoon and night. The plan discussed on rounds may change significantly depending on new information or status change. Antibiotics may be changed, imaging studies may alter plans or even alter diagnosis. Your COPD exacerbation may have developed NSTEMI and be on betablockers, ASA, maybe even integrellin drip and/or heparin drip. May have gone to the cath lab and be on plavix s/p stents. Your mrsa bacteremia may be infective endocarditis, epidural abscess, osteomyelitis, etc. Things change and as a pharmacy student you may be kept out of the loop, esp if you are not with the team in the afternoon.
That's why after rounds end (11AM), I go work on projects for a few hours and then come back to the floor to update info on the patients I'm following.
Take a day or two to get a feel for the dynamics of the team so you know when to speak up and when to shut up. Each team is different and each question is different (is it the first question or the tenth and everyone but you has already answered one, for example; or everyone is looking down hoping someone else will answer it vs everyone is jumping right at it).
I personally always let the med students/residents answer the pimping questions during rounds since that's who these are usually meant for, and besides I never cared for being a walking, talking trivia book, filled with information one can easily look up. Instead, I would bring up issues I have identified while preparing for rounds and/or jump in the follow-up discussion. I happen to prefer "why" and "what if" to "what" and "how". I never liked/aspired to work in a hospital, so I tried to find something interesting about it since I had to complete two acute care rotations to graduate...🙂 I did ICU and transplant, as those allowed for more interesting things than other rotations. The most interesting thing about ICU to me was how virtually every patient was a chapter out of a book on what not to do. The most interesting part about transplant was doing discharge counseling.
I personally always let the med students/residents answer the pimping questions during rounds since that's who these are usually meant for, and besides I never cared for being a walking, talking trivia book, filled with information one can easily look up. Instead, I would bring up issues I have identified while preparing for rounds and/or jump in the follow-up discussion. I happen to prefer "why" and "what if" to "what" and "how". I never liked/aspired to work in a hospital, so I tried to find something interesting about it since I had to complete two acute care rotations to graduate...🙂 I did ICU and transplant, as those allowed for more interesting things than other rotations. The most interesting thing about ICU to me was how virtually every patient was a chapter out of a book on what not to do. The most interesting part about transplant was doing discharge counseling.
I do sometimes feel like everything good/interesting happens at night when I'm not there. I have yet to be able to observe a code and we have had some really interesting ones. If I were not pregnant and able to move faster I could go with my team to Express Team calls but I'm too slow in my current condition. 🙁
It's a lot more fun on tv.
So I've heard. But we have had at least one code that was so dramatic/badass/crazy that the entire hospital was abuzz about it for a good 36 to 48 hours. It involved rib-cracking CPR and two surgery residents cutting the patient open on the floor. The patient lived and was sitting up eating the next day.
I'm on my 5th hospital rotation and have yet to witness a code. I have one more inpatient rotation to go though.
I have only witnessed one, and if I could "unwitness" it I would. The patient didn't make it, so that probably goes a long way towards shaping my perception of the event.
A good friend of mine at another school is a P4 and on his FIRST DAY at his FIRST ROTATION a random dude in the hospital collapsed in front of him while he was counseling a patient. He attempted CPR but the patient died within minutes!
I had never seen a code until my 3rd month of residency. I was in the CCU for rounds in the morning, and a patient coded. Revived, back to rounds, code, revived. Go back to rounds when a half hour later another patient coded. They called her after 15 minutes of CPR. Right then the first patient coded again, and the team ran over to that room. The patient was revived again. The family then decided no further interventions if he was to code again, and he passed later that day. It was expected for the one patient and not really a surprise for the other, but it was a (somewhat controlled) chaotic morning.
Joint Commission was in the hospital across the hall during the whole thing.
I work at a hospital, but I haven't been to a code yet. We have techs who go with the pharmacist but I'm not entirely sure what the point of having a tech there is. I feel like I'd be totally useless at this point.
Our techs stand outside the room to get anything that is not in the crash cart.
I have been to/seen some scary codes alongside a pharmacist. And like mentioned above, if I could "unwitness" it, I would.
We have a pharmacist who came from retail that would grab an intern or tech when she was going up for a code. She just wasnt very comfortable with making drips on the spot since she hadn't had it since school. She doesn't do it anymore..I think it was more of a learning too many things at once thing.
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to answer your question honestly...i think it's really attending dependent. but generally don't be that guy. be modest. i like old timer's example...you wanna keep your head down, but speak up appropriately if there is a real question or issue. also remember that there is a difference between knowing the name of something, and actually knowing something. for example most students would say ideal vanco trough for HCAP is 15-20 if asked. but you really need to take it to the next level like Z does, with examples such as high failure rate with MRSA PNA, vanco is a slow bacericidal killer, need better penetration in the lungs thus higher level, need to load critically ill pts, etc...
additionally, if i were to do my genmed all over again, i'd probably review baseline primary lit + review mechanisms, as well as doses. everyone at my diploma mill said don't memorize doses you can look them up but i think that is the biggest load of BS ever.
lol
additionally, if i were to do my genmed all over again, i'd probably review baseline primary lit + review mechanisms, as well as doses. everyone at my diploma mill said don't memorize doses you can look them up but i think that is the biggest load of BS ever.
lol
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Truthfully, I would not leave any student to round alone on his/her first week of the rotation. I've had some students who were very capable and could have handled it, but I've also had a few who were completely clueless. No student of mine gets to round alone before I have a chance to get to know them and assess their abilities.
As far as when to answer a question: if you have a really good, in-depth answer, go ahead and speak up. Give a few answers like this every day, then let the residents do the rest of the talking - the MD is probably more concerned with teaching them than anyone else.
Do the kids have skool today?
No...been out for 3 days... I was suppose to make a site visit in your neck of the woods..but hell no, I aint going outside.
Yes!! It finally worked!
I just figured it out. Hence my elation in the next post.
My neck of the woods like Tulsa or my neck of the woods like Oklahoma?
Oh not that far up... right around the border. That's far enough and close enough to OK.
Oh, psha. That's not my neck of the woods.......
My daughter used to say that 2 years ago... just caught on up there huh?
I've rounded on many different teams, so here's my .02.
If you are on rounds with first/second year residents, keep your mouth shut until the treatment plan is being worked out. They are still in the learning phase of basic diagnosis and are being overwhelmed with info, so don't add to it. The team I've been on the last year or so consists of a couple of attendings, several first and second year family med residents, sometimes dietary, pulmonologist, etc. depending on the patient. A lot of the time, the residents are kinda "deer in headlights". I usually go over things with them before rounds and help with their tx plan, it's easier to explain your thoughts, and they REALLY appreciate it.
Pt care is first though, so if I feel anything is missed after the treatment plan, or if the resident doesn't agree with my thoughts, I bring it up to the attending after the presentation is complete. Never interrupt a resident or medical student's pt presentation, not only unprofessional, also rude as hell IMO.
I used to round with the renal team some, it's more easy going IMO. I get along with everybody on my current team, but when you are rounding with an attending and a couple of fellows, the "teaching" aspect isn't as strict, just more easy going and you can discuss more openly during the presentation.
I guess my rule is, everybody is there to learn, but pt care comes first. If you need something addressed for pt care, do it. If you address something to make someone else look bad (in front of everybody), you lose respect real quick. It's best to deal with mistakes one on one.
If you are on rounds with first/second year residents, keep your mouth shut until the treatment plan is being worked out. They are still in the learning phase of basic diagnosis and are being overwhelmed with info, so don't add to it. The team I've been on the last year or so consists of a couple of attendings, several first and second year family med residents, sometimes dietary, pulmonologist, etc. depending on the patient. A lot of the time, the residents are kinda "deer in headlights". I usually go over things with them before rounds and help with their tx plan, it's easier to explain your thoughts, and they REALLY appreciate it.
Pt care is first though, so if I feel anything is missed after the treatment plan, or if the resident doesn't agree with my thoughts, I bring it up to the attending after the presentation is complete. Never interrupt a resident or medical student's pt presentation, not only unprofessional, also rude as hell IMO.
I used to round with the renal team some, it's more easy going IMO. I get along with everybody on my current team, but when you are rounding with an attending and a couple of fellows, the "teaching" aspect isn't as strict, just more easy going and you can discuss more openly during the presentation.
I guess my rule is, everybody is there to learn, but pt care comes first. If you need something addressed for pt care, do it. If you address something to make someone else look bad (in front of everybody), you lose respect real quick. It's best to deal with mistakes one on one.
So, basically, contribute as much as possible without being a tool about it. Noted.
That's a good point. I seriously doubt most of the retail pharmacists I've worked with would be as comfortable making an IV as a decent IV tech.
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lol this is the dumbest thing I've read here in a while and if you did this in real life everyone would think you were a *****. just fyi
I would take this approach. You have to remember the Attending physician is there for the residents and not you. Your preceptor is supposed to be the one pimping you. You are a part of the team and there is nothing wrong with you speaking up from time to time, but wait until the team knows that you know you shiz. Trust me, the residents will be picking your brains everyday. The first time you spout out some BS, will be the last time you spout out anything. Also, it would be best to have a short and direct response. The attending doesn't always care how you got your answer and if he does, he will ask. The less you give, the more chances you have of answer the net question he will ask. Look up an article published in JAMA called "The Art of Pimping". You don't want go shooting your whole wad off with your first response.
We read and discussed "The Art of Pimping" in our pre-APPE course during our last classroom quarter before rotations. 👍
Did a full SOAP on a patient today, took me an hour because the charts are all handwritten and disorganized. As I was wrapping up my work getting everything put away to leave for the day, I hear the nurse at the monitors go "Oh... the patient in ICU Isolation 2 just flatlined, call the family to inform."
Patient was DNR/DNI.
Should I just toss this workup out or are workups on patients who end up dying allowed?
Patient was DNR/DNI.
Should I just toss this workup out or are workups on patients who end up dying allowed?
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