Why can't more attendings do table rounds?

[ZincFingers]

Table rounds rock. It's where everyone gathers at a conference table and knocks out all the cases there, with someone working a computer terminal to pull up lab values, maybe if you're lucky with a projector. If an attending does it like this you've struck gold, because you know how most people do rounds. March off to the first patient room. The student stumbles through his presentation, the intern listens waiting to pounce in and make the student look like an idiot. The resident stands there nodding. The attending pimps. They chew over some ridiculously minor detail for 15 minutes. The attending goes in and chats with the family for 15 minutes. The attending's buddy walks by and they chat for another 10. Then spend 5 herding the group to the next pt a few floors down -- and then you can't start because the intern is off answering a page involving a K+ of 3.4 so the attending decides to chat with someone on the phone, even as the intern is coming back, so that's another 10 minutes gone.

And even when a case is being discussed, everyone else not immediately with the pt -- the other student, the other intern, the NP, the pharmacist, the pharm student, the "nurse clinical coordinator" and other assorted hangers-on -- sort of check out... "That game last night sucked. If only they had been more careful about the fouls. Man, that pharm student is kinda hot. I wonder if she's got a boyfriend. Wait, what am I talking about. Every chick in this dump has a boyfriend, it's required, otherwise security won't let them in. What's with security here anyway... never around when your 250lb pt goes psycho, but always there to ticket you when you double park for 5 minutes. If I had my way-- oh CRAP he's looking at me. Ummm... what were the ARDS criteria again???"

Table rounds, on the other hand... rock. They just kick ass. Every case, every day, becomes an interactive learning session. You have to stay awake because everybody participates... but more than that, you WANT to participate. No marching around. You don't learn more about CHF simply by being in proximity of a pt with CHF. You learn by interactive question-answer sessions. The whole thing is over after an hour. The attending then goes off on his own to visit with pts and sign notes on his own schedule while the residents have time to handle the details of hospital life and K calls. If there is a case so cool that people benefit by actually visiting the pt, you do that after rounds... there is never more than 1 or 2 cases like this at a time anyway.

And being able to eat breakfast during rounds... how cool is that?!?

C'mon, attendings. Table rounds. You know you want to. 👍

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[Doctor Bagel]

Love table rounds! We only did them when we were short on time, but one of the IM attendings apparently does them all the time. Lucky people who get to work with him. You still get all the learning without the pain.

 

[Droopy Snoopy]

You don't learn more about CHF simply by being in proximity of a pt with CHF.

Tru dat.

 

[SouthernSurgeon]

Yeah sure, if all table rounds were like what you described, maybe I'd like them.

But what about when you're post-call, and your table rounds take 6 hours (with a break for morning report!!) because your attending is obsessed with pharmacology and repeatedly makes the intern google which cyp interaction is at play in this particular patient's drug regimens.

Or what about when the neurology team sits in b/c one of your patient has a seizure disorder, and the agony of staring at EEGs only ends after the neuro attending finally tells the neuro fellow that he needs to hurry up.

I find it much easier to fall asleep in table rounds; I don't put as much effort into my presentations b/c all the info is right there on the table in front of me; and I generally get more bored.

 

[MeowMix]

the best of all worlds is a residency with this kind of rounds, lasting 1 hr each a.m.. This is my life, and I love it.

 

[LadyWolverine]

One of my IM attendings started the morning off with table rounds (complete with copies of journal articles passed to all of us that we then had to present the next morning during table rounds) and presentations + pimping of students and residents for 1-2 hours. After which we would get up and then do walk rounds for the next 3+ hours, which entailed even more pimping. (The interns were grilled just as badly, if not worse, than the med students.) Yet, somehow, we managed never to run out of new subjects to cover.

Table rounds just never seemed to save us from actual walk rounds...

 

[alphaholic06]

the best of all worlds is a residency with this kind of rounds, lasting 1 hr each a.m.. This is my life, and I love it.

Where are you in residency?

 

[DarthNeurology]

Table are good as it is easier to have a more serious discussion around a table and you don't have the distractors on the floors. Education would hurt though if even less time is spent with patients, so I think at least minimal walk rounds are good. New hospitals are being built with privacy areas near each room with computers so you can talk about a patient in there, and then go into the room. Best of both worlds maybe.

Some institutions have started having table rounds because it is a JHACO or OSHA rule that you can't discuss a patient's private medical information i.e. HIV, in a hallway where it could be overheard by anyone, i.e. family, friends or just people in the community.

 

[BigRedBeta]

Like anything, it's always going to depend on who the attending is. Good attendings are good attendings, whether they sit or stand.

I do find it interesting the love of table rounds because as a future peds resident, I was discouraged by places that didn't do family-centered rounds. It wasn't like a deal breaker for me on any particular location, but it was one of those things I considered.

 

[45408]

Yeah, the walking rounds we had when I was on peds were PAINFUL. We'd have to co-round with other specialties, who ran on their own schedule, and we'd get caught up with family members who had lots of questions for the intern that the entire team didn't really need to hear. We once had a 20 minute discussion about some guy's poop. Seriously. It did not need to be that protracted. Guys, let's give him the suppository and see how it works, okay?

Walking rounds were fine on surgery, because that was the only time the attending actually saw the patient, and it was usually wham-bam from one room to the next. And there was actually a legitimate need to look in on the patient, whereas most of my peds patients were yup, still there, still on the ventilator, just like the past 3 weeks.

 

[cyclohexanol]

One of my IM attendings started the morning off with table rounds (complete with copies of journal articles passed to all of us that we then had to present the next morning during table rounds) and presentations + pimping of students and residents for 1-2 hours. After which we would get up and then do walk rounds for the next 3+ hours, which entailed even more pimping. (The interns were grilled just as badly, if not worse, than the med students.) Yet, somehow, we managed never to run out of new subjects to cover.

Table rounds just never seemed to save us from actual walk rounds...

Same 👎

 

[78222]

You don't learn physical exam taking skills by sitting at a table. I thought sit down rounds sounded great until I had an attending that did them and I wanted to pull my hair out.

 

[Thanatos]

Yeah, the walking rounds we had when I was on peds were PAINFUL. We'd have to co-round with other specialties, who ran on their own schedule, and we'd get caught up with family members who had lots of questions for the intern that the entire team didn't really need to hear. We once had a 20 minute discussion about some guy's poop. Seriously. It did not need to be that protracted. Guys, let's give him the suppository and see how it works, okay?

This was exactly my peds experience....and it sucked. We talked once for half an hour about which arm to put the IV in with the concerned family of yet another kid with RSV comfortably sleeping, saturating at 94%. I spent an hour standing outside a patients room one time while the whole team kept cringing about which one of them was going to scrape a rash on a toddlers arm to send cells to the lab. They wouldn't let me do it or I could have saved us all 59-ish minutes.

Walking rounds were fine on surgery, because that was the only time the attending actually saw the patient, and it was usually wham-bam from one room to the next. And there was actually a legitimate need to look in on the patient, whereas most of my peds patients were yup, still there, still on the ventilator, just like the past 3 weeks.

All rounds should be done like surgery rounds. I knew long, drawn out rounds were useless when on services like neuro, peds, and IM our weekend rounds only took an hour (as opposed to 8 on weekdays) and patients managed to survive anyway. That always cracked me up.....everybody was like "okay its saturday lets cut the bs and just get stuff done."

 

[LadyWolverine]

All rounds should be done like surgery rounds. I knew long, drawn out rounds were useless when on services like neuro, peds, and IM our weekend rounds only took an hour (as opposed to 8 on weekdays) and patients managed to survive anyway. That always cracked me up.....everybody was like "okay its saturday lets cut the bs and just get stuff done."

Remember, though, that the "BS" is actual learning time. So, it's not *complete* BS. Especially when you're a med student and paying for the time you're on rounds and in the attending's presence.

And as for learning physical exam skills during walk rounds - while I completely agree, and this is what SHOULD BE happening during medical school and residency, very little of this actually goes on during rounds. Most of the time is spent talking to patients and other consultants, putting in orders, talking about articles and studies and treatment plans, etc. I only had one attending during my IM rotation who actually taught us physical exam skills on walk rounds. Oddly enough, it was the same guy who gave us all those articles and drilled us every day. I learned more on that one-month rotation than I did during my first 6 months of med school.

 

[PeepshowJohnny]

All rounds should be done like surgery rounds. I knew long, drawn out rounds were useless when on services like neuro, peds, and IM our weekend rounds only took an hour (as opposed to 8 on weekdays) and patients managed to survive anyway. That always cracked me up.....everybody was like "okay its saturday lets cut the bs and just get stuff done."

Well, the point is supposed to be that on medicine, the rounds are the teaching (Hence, teaching rounds) while on surgery, the learning is done in the OR.

However, the problem is, I don't think a lot of internal medicine people understand that there's diminishing returns after rounds go so long. First patient: Little old lady with BRPR. Okay let's talk about management of GI bleeders, common things, uncommon, pearls etc. That's a huge freaking topic. So we tackle that. And then we get to some dude who's got hypertensive nephropathy. Oh, let's talk about ALL the different kinds of nephritic and nephrotic syndromes and what tests we'd order and which diagnoses are favored with which risk factors. We're wrapping up...but then someone said Amyloidosis so now we've got to talk about it for 10 minutes! Okay, got that nailed down. Next guy is someone with MRSA cellulitis. Oh! Let's talk about community acquired vs. hospital acquired and the PVL antigen and all that jazz...

It drags on and on and on and after the first patient, you just don't want to tackle these huge subjects anymore. Teaching rounds are great in small doses where you actually get to retain and make connections, the "Drinking from a fire hose" teaching style just burns students out.

 

[Keg]

This is how I'll do it when I'm an attending. Table round with H/P or SOAP presentations, get a plan together, then take the students/interested residents around and gravity round for interesting/important physical findings. Just me.

 

[45408]

You don't learn physical exam taking skills by sitting at a table. I thought sit down rounds sounded great until I had an attending that did them and I wanted to pull my hair out.

You also don't learn physical exam skills by standing outside the patient's room. Noting an interesting physical finding is always worthwhile, but if the patient doesn't have one, or if we're not going to take note of it, it doesn't help me to stand by their room while we wax eloquent about stool.

 

[45408]

Remember, though, that the "BS" is actual learning time. So, it's not *complete* BS. Especially when you're a med student and paying for the time you're on rounds and in the attending's presence.

I had some attendings who used the time to teach, and I really appreciated that. I had one really tough attending who was very nitpicky on medicine, but he spent a LOT of time with us teaching us things. His style took a while to get used to, but I really felt like he took our education very seriously.

On the flipside, listening to the basic chem, CBC, VBG, I/Os, vitals, vent settings, PICC line status, TPN components, blah blah blah blah - on 20+ patients whom I'm not necessarily familiar with = damn near worthless. I perk up when there are teaching points. I zone out when we're discussing which arm to put the IV in, when it's completely irrelevant to the patient's care.

 

[LadyWolverine]

On the flipside, listening to the basic chem, CBC, VBG, I/Os, vitals, vent settings, PICC line status, TPN components, blah blah blah blah - on 20+ patients whom I'm not necessarily familiar with = damn near worthless. I perk up when there are teaching points. I zone out when we're discussing which arm to put the IV in, when it's completely irrelevant to the patient's care.

Agreed 110%. Unfortunately, there's just no smoother way to do it. If one student followed just a one or two residents and one attending, can you imagine how much faster you'd learn?? You'd be a pro in a fraction of the time - at presenting, at coming up with A&Ps, at ordering efficiently, at physical exam. You'd know all of the patients on your service and actually get something out of rounds, and the more tedious parts of rounds would move quicker because you'd know what to say and what to leave out. That's how the old-school docs used to learn.

Instead, today on IM we have these ridiculous gaggles/cluster-Fs called "teams" comprised of 3-4 MS3s, 2 sub-Is, 3 interns, 2 residents, 2 pharm students, 2 NPs, random RNs, and a partridge in a pear tree that follow the lone attending around from room to room in phalanx formation, who when perfectly aligned manage to completely block out the light of the sun. No wonder people don't learn much and start spacing out while Joe Schmo MS3 stumbles through his second patient presentation this morning - there's TOO MANY FRICKIN PEOPLE. The attending doesn't want to stop and discuss a topic with a group this large, nor does he/she want to barge into patients' rooms with this many people in tow.

1-on-1 education is severely lacking in medicine, and would really make the whole process so much more efficient. Also, I don't understand why, on the first day of a new rotation, the interns/residents don't sit down with the new students and take a few minutes to show them, as a group, how to use the computer system/where to find vitals and labs/how to use the paging system or call a consult/how H&Ps, progress notes, and discharge summaries should be written on their particular service/how to dictate/blah blah blah. It would make the transition to a new hospital/service/rotation SO MUCH EASIER for EVERYONE involved - the housestaff would benefit because the med studs would hit the ground running and pick up a decent share of the scut/actual work without having to bug the interns/residents all the time when they don't know how to do or where to find something. It takes a little bit of a time investment on the first day, but it just seems like it would be so much more efficient as opposed to leaving the med student to try to figure it out for themselves or keep asking the housestaff. Yet this has been my experience on more than one rotation.

 

[maceo]

Some institutions have started having table rounds because it is a JHACO or OSHA rule that you can't discuss a patient's private medical information i.e. HIV, in a hallway where it could be overheard by anyone, i.e. family, friends or just people in the community.

thats fu c king beautiful you mean all this time during rounds we were violating hippa regs. Now they have to retrofit hospitals to include seperate rooms where physicians can speak freely. geez. that will help curb health care costs.. How about when docs talk to the patient and there is another patient in the other bed? is this violationg hippa.. things are getting out of control

 

[SouthernSurgeon]

Instead, today on IM we have these ridiculous gaggles/cluster-Fs called "teams" comprised of 3-4 MS3s, 2 sub-Is, 3 interns, 2 residents, 2 pharm students, 2 NPs, random RNs, and a partridge in a pear tree that follow the lone attending around from room to room in phalanx formation, who when perfectly aligned manage to completely block out the light of the sun. No wonder people don't learn much and start spacing out while Joe Schmo MS3 stumbles through his second patient presentation this morning - there's TOO MANY FRICKIN PEOPLE. The attending doesn't want to stop and discuss a topic with a group this large, nor does he/she want to barge into patients' rooms with this many people in tow.

Really? That sounds crazy. I think I've been lucky - I have been the only med student (3rd or 4th year) on all of my teams since November. We never have NPs with us - occasionally we'll have a pharmD (and the obligatory pharm student trailing). The floor nurses steer clear of rounds. So it's usually just me, 2 residents, maybe a fellow, and the attending.

Even when I've had other med students on teams with me, it's just 2 of us - the only time I've ever had more than that was on OB when we have like 6-8 students at a time on L&D.

 

[nlax30]

Interesting to hear about the differences and what ya'll like/dislike about rounds.

Come June my first 2 rotations are IM and at this particular location they do table rounds each morning so hopefully it'll be interesting.

 

[LadyWolverine]

Really? That sounds crazy. I think I've been lucky - I have been the only med student (3rd or 4th year) on all of my teams since November. We never have NPs with us - occasionally we'll have a pharmD (and the obligatory pharm student trailing). The floor nurses steer clear of rounds. So it's usually just me, 2 residents, maybe a fellow, and the attending.

Even when I've had other med students on teams with me, it's just 2 of us - the only time I've ever had more than that was on OB when we have like 6-8 students at a time on L&D.

OK, so perhaps I exaggerated a tiny bit. But seriously, most of my "rounding" rotations have had extremely large groups that become almost unruly and unmanageable, especially when resident X's pager is going off, sub-I Y is trying to put in orders for labs but needs cosigning, and attending Z has to stop and answer the trauma phone. To better outline my experiences thus far:

On my neurology rotation (consult service at the VA hospital), there were FIVE MS3s, an MS4 on an elective, a psych intern, a 4th year psych resident, and the senior neuro resident. The attending would come and table round with us and teach/pimp for 1-2 hours, depending on the number of patients on our service, which was usually only 2-3 new consults each day. We then would walk round only on new patients, which took 10 mins per patient, with little focus on physical exam skills and minimal teaching by the attending. None of the housestaff ever prerounded with us. The senior resident would talk to us about neuro topics during "down time" (which was frequent), which I found helpful. We then had clinic in the afternoons 3 times a week, which was an absolute madhouse.

On inpatient IM month 1 (smaller community hospital affiliated with my univ), there were 2 MS3s, 2 interns, and the senior. This was the month with the drill sargeant attending I mentioned earlier. I thought that this was a manageable size for a team. Still, the housestaff never had time to preround with us in the morning, despite several pleas from me and the other student. The attending (who, I swear, is more machine than man as he was also attending concurrently for the ID service yet never missed a beat with either team) spent tons of time with us during morning rounds, gave us lots of great reading material, and focused heavily on both physical exam skills and cost-awareness (e.g. when ordering tests, labs, and images). We table- and walk-rounded on EVERY patient on our service EVERY morning, both new and old.

On inpatient IM month 2 (large univ hospital), there were 3 MS3s, a sub-I, 2-3 interns, the senior, the PharmD and 1-2 pharm students, 1-2 NPs, social workers, case managers, and someone's cousin Bob present at table rounds in the morning. Usually the SWs and CMs would break off afterwards, and the rest of us would walk-round to see only the new patients for 10 minutes a piece. I can count on one hand the number of times our senior prerounded with us - usually we were lucky if the senior showed up more than 15 minutes before the attending did. I hated this service and it has forever soured IM for me. The group was definitely too large.

On trauma surg (also at same large univ hospital), there were 4 MS3s, 2 sub-Is, 3-7 residents at any given time (from EM, surg, or anesthesia), one fellow, 2 NPs, random RNs, and sometimes an extra attending. These teams were completely unruly and made for a pretty hectic experience in the mornings. There was definitely a "too many cooks in the kitchen" phenomenon. Nobody prerounded with us students, although the residents were amenable to a quick "check in" in the morning just to discuss Mr. so-and-so's latest CT results. Although these were surgery rounds, they still took forever because 1. they were really complicated trauma patients, and 2. there were 20+ patients on our service at any given time.

___________________________________________
Overall, with the exception of my IM month #1 experience, I've had very little in the way of teaching on rounds. I must say that I'm rather disappointed - I expected more out of medical school. The teams are just too big, everyone's jockeying for the interesting patients/procedures, there's no time for one-on-one sessions with the attendings while examining patients, and the housestaff seems mostly uninterested in teaching, often because they themselves are too busy with their own work. There's plenty of scut that needs to get done in the morning, followed by rounds that are less about teaching and more about getting all the notes done/plans squared away/orders in ASAP, followed by an afternoon full of even more scut.

This is why I love the OR.

 

[45408]

Agreed 110%. Unfortunately, there's just no smoother way to do it. If one student followed just a one or two residents and one attending, can you imagine how much faster you'd learn?? You'd be a pro in a fraction of the time - at presenting, at coming up with A&Ps, at ordering efficiently, at physical exam. You'd know all of the patients on your service and actually get something out of rounds, and the more tedious parts of rounds would move quicker because you'd know what to say and what to leave out. That's how the old-school docs used to learn.

Eh, I think it is possible. My intern on peds always had short succinct presentations that cut to the chase. I tried to do the same, and other students were pretty good. Two of the other interns and the sub-I.....not so much. Their presentations dragged, horribly. They had very little filter on what was important and what wasn't. One "slightly loose stool" isn't worth mentioning. A one hour stretch with "a little less urine output" in a day full of urine really doesn't matter! That's just what drove me nuts.

Instead, today on IM we have these ridiculous gaggles/cluster-Fs called "teams" comprised of 3-4 MS3s, 2 sub-Is, 3 interns, 2 residents, 2 pharm students, 2 NPs, random RNs, and a partridge in a pear tree that follow the lone attending around from room to room in phalanx formation, who when perfectly aligned manage to completely block out the light of the sun. No wonder people don't learn much and start spacing out while Joe Schmo MS3 stumbles through his second patient presentation this morning - there's TOO MANY FRICKIN PEOPLE. The attending doesn't want to stop and discuss a topic with a group this large, nor does he/she want to barge into patients' rooms with this many people in tow.

LOL, you forgot the parents and the boyfriend/girlfriend and the patient's nurse. That was the case with my peds rotation, and everything took forever. We had a huge posse on trauma surgery too, but it was quick and dirty.

1-on-1 education is severely lacking in medicine, and would really make the whole process so much more efficient. Also, I don't understand why, on the first day of a new rotation, the interns/residents don't sit down with the new students and take a few minutes to show them, as a group, how to use the computer system/where to find vitals and labs/how to use the paging system or call a consult/how H&Ps, progress notes, and discharge summaries should be written on their particular service/how to dictate/blah blah blah. It would make the transition to a new hospital/service/rotation SO MUCH EASIER for EVERYONE involved - the housestaff would benefit because the med studs would hit the ground running and pick up a decent share of the scut/actual work without having to bug the interns/residents all the time when they don't know how to do or where to find something. It takes a little bit of a time investment on the first day, but it just seems like it would be so much more efficient as opposed to leaving the med student to try to figure it out for themselves or keep asking the housestaff. Yet this has been my experience on more than one rotation.

Yeah, the M4s are often good at that. I had a great intro to trauma surgery from the M4s who were just finishing the month, and it really smoothed things out.

 

[45408]

On trauma surg (also at same large univ hospital), there were 4 MS3s, 2 sub-Is, 3-7 residents at any given time (from EM, surg, or anesthesia), one fellow, 2 NPs, random RNs, and sometimes an extra attending. These teams were completely unruly and made for a pretty hectic experience in the mornings. There was definitely a "too many cooks in the kitchen" phenomenon. Nobody prerounded with us students, although the residents were amenable to a quick "check in" in the morning just to discuss Mr. so-and-so's latest CT results. Although these were surgery rounds, they still took forever because 1. they were really complicated trauma patients, and 2. there were 20+ patients on our service at any given time.

Ours worked out well - we ALL pre-rounded in the morning (everyone but the NPs and the attending), so if I had questions about the patients, the residents and chiefs were right there. Our traumas weren't as complicated, because they stayed in the SICU initially if they were really bad (and there was a separate SICU team). We usually had 35 patients.

Actual rounds included: 1 attending, 1 chief, 2 seniors, 2 juniors, 2 surgery interns, 2 other interns (usually ortho and EM), 1 M4, 3 M3s, 3 NPs, and that was usually it. Still, 17 people

 

[SouthernSurgeon]

Ours worked out well - we ALL pre-rounded in the morning (everyone but the NPs and the attending), so if I had questions about the patients, the residents and chiefs were right there. Our traumas weren't as complicated, because they stayed in the SICU initially if they were really bad (and there was a separate SICU team). We usually had 35 patients.

Actual rounds included: 1 attending, 1 chief, 2 seniors, 2 juniors, 2 surgery interns, 2 other interns (usually ortho and EM), 1 M4, 3 M3s, 3 NPs, and that was usually it. Still, 17 people

I forgot about trauma rounds...I think those are universally crazy. Ours included:
1 attending, (1 fellow - often absent), 1 chief, 2 juniors, 1-2 interns, 2 NPs, ICU floor nurses for each patient, charge nurse, RT, PharmD, Dietician, and assorted med/nursing/pharm/RT students.

 

[LadyWolverine]

OK, so I guess trauma is crazy everywhere 🙂 I was amazed every morning that stuff actually got DONE and we somehow made it to the TRU/OR on time.

 

[Dral]

You don't learn physical exam taking skills by sitting at a table. I thought sit down rounds sounded great until I had an attending that did them and I wanted to pull my hair out.

A lot of attendings just do their abbreviated PE and don't bother to teach bedside that much anyway. My IM attendings would take students to patient rooms after sit down rounds if there was an interesting patient to see, while the interns/residents got to break off and start their work for the day. We got table rounds, students still learned PEs, housestaff didn't have to sit through stuff they already know.

It's the best of both worlds.

 

[lilnoelle]

Wow... I'm glad that my IM rounding team is relatively small compared to most of you. We have the attending, one junior, two interns, two MS3s, one MS4, a PharmD and two pharm students. Our service is also capped at 16, which has been just about perfect. We do a quick "table rounds" with the caseworker and social worker right before rounds - usually takes <10 minutes and is a very informal summation of what various patients need from the CW/SW team.
Our attendings switch out every two weeks, so I've had the opportunity to work with two attendings this month and the length/efficiency/teaching at rounds varied immensely. My first attending believed in teaching (a lot) during rounds and he also spent quite a bit of time with each patient during rounds and so therefore rounds were LONG. It was a very good experience, but eventually got old. Even weekend rounds lasted forever.
My current attending likes speed rounds, but it doesn't mean she skimps on detail. She wants a very succinct, smooth, easy to understand presentation that has a complete assessment and plan. A poorly thought out or incomplete assessment and plan recieves a lot of criticism from her. She expects us to know our stuff and is likely to want an explanation for any plan that doesn't explain itself.
We are usually done with rounds by noon. Its pretty nice because now we have the afternoon to do everything else that needs done, where with the previous attending, people had to excuse themselves from rounds to write discharge summaries, do procedures, etc or they had to stay that much later.

Oh.... and I'm VERY glad that our PharmD/students round with us. They are very valuable on rounds.

 

[ZincFingers]

Also, lilnoelle, your senior resident kicks ass too. 😉

 

[SouthernSurgeon]

Wow... I'm glad that my IM rounding team is relatively small compared to most of you. We have the attending, one junior, two interns, two MS3s, one MS4, a PharmD and two pharm students. Our service is also capped at 16, which has been just about perfect. We do a quick "table rounds" with the caseworker and social worker right before rounds - usually takes <10 minutes and is a very informal summation of what various patients need from the CW/SW team.
Our attendings switch out every two weeks, so I've had the opportunity to work with two attendings this month and the length/efficiency/teaching at rounds varied immensely. My first attending believed in teaching (a lot) during rounds and he also spent quite a bit of time with each patient during rounds and so therefore rounds were LONG. It was a very good experience, but eventually got old. Even weekend rounds lasted forever.
My current attending likes speed rounds, but it doesn't mean she skimps on detail. She wants a very succinct, smooth, easy to understand presentation that has a complete assessment and plan. A poorly thought out or incomplete assessment and plan recieves a lot of criticism from her. She expects us to know our stuff and is likely to want an explanation for any plan that doesn't explain itself.
We are usually done with rounds by noon. Its pretty nice because now we have the afternoon to do everything else that needs done, where with the previous attending, people had to excuse themselves from rounds to write discharge summaries, do procedures, etc or they had to stay that much later.

Oh.... and I'm VERY glad that our PharmD/students round with us. They are very valuable on rounds.

Speed rounds = done by noon??? yikes. To me speed rounds would mean done by 9 at the latest...

 

[lilnoelle]

Speed rounds = done by noon??? yikes. To me speed rounds would mean done by 9 at the latest...

We start around 9:30.

 

[lilnoelle]

Also, lilnoelle, your senior resident kicks ass too. 😉

Now I'm wondering who I'm talking to....

 

[SouthernSurgeon]

We start around 9:30.

Ahh, that'd do it. Our rounds usually started at 7:30 or earlier (dang interventional cardiologists) on IM.

 

[Old_Mil]

Table rounds, on the other hand... rock. They just kick ass. Every case, every day, becomes an interactive learning session. You have to stay awake because everybody participates... but more than that, you WANT to participate. No marching around. You don't learn more about CHF simply by being in proximity of a pt with CHF. You learn by interactive question-answer sessions. The whole thing is over after an hour. The attending then goes off on his own to visit with pts and sign notes on his own schedule while the residents have time to handle the details of hospital life and K calls. If there is a case so cool that people benefit by actually visiting the pt, you do that after rounds... there is never more than 1 or 2 cases like this at a time anyway.

And being able to eat breakfast during rounds... how cool is that?!?

C'mon, attendings. Table rounds. You know you want to. 👍

Yeah they do. I actually ran into one IM attending during 3rd year who did table rounds like this. It was the single best learning experience of all my clinical years. Not sure why it's not more commonly done.

 

[ZincFingers]

One of my attendings during my IM sub-i did this... that's how I fell in love with the practice. The daily drudgery took just a few minutes per case (besides the occasional should-he-go-to-the-unit? situation), and the rest went to teaching. And this guy knew his stuff. Best IM education I got outside of the unit.

 

[vtucci]

My team on my AI in medicine included the attending, one senior, two interns, one MSIV and two MSIIIs. We would do table rounds and then gravity rounds. Sometimes the attending would just see the new admits and any other interesting cases with the team and students, making sure to point out any interesting physical exam findings to the students. Our attending used table rounds for student teaching and white board information-- high yield information to be supplement with appropriate physical exam findings when available.

I agree that traditional rounds walking through the hospital often violates patient privacy. The long drawn out process that some attendings use lose students (when you consider that the average attention span is 50 minutes max) and discourage students from entering internal medicine. I have heard from many of my colleagues entering various specialties that one of the top reasons that they would not enter medicine was the endless rounding and inefficiency.

 

[BigRedBeta]

I didn't know how excruciating rounds could be until I came to Australia...where as a US M4 I was not only older than my intern and second year resident, but probably knew a good chunk more than they did as well...

Honestly, most unorganized rounding structure I've ever seen, though I'm not sure if it was just my service or all the other services too. We started at 8:30 with the equivalent of a fellow (they call them registrars) leading ward rounds. No one had seen the patient prior to any of us stepping in the room...and no one even bothered to write down lab values or other test results (this was a cardiology rotation in the CCU, so every patient had multiple EKG's, most had ECHO's and angiograms as well). So we'd see the patient, the fellow would examine them, either the resident or intern would act as a scribe for them, the registrar would ask a question about some lab value which neither intern or resident knew the answer to, there would be a scramble to find the data, maybe the patient would get to hear what the plan was, and then we'd leave the room - only to have the intern and resident spend the next 30 minutes doing all the "work rounds" type of stuff that needed to get done while the registrar looked up lab values for the next patient and the students sat around doing nothing. Then the attending (they call them consultants) would show up unannounced at a different time each day, usually when we were on patient 5 of 10, want to start rounding at the beginning and we'd go through nearly the same identicle process, except that the down time between patients was used either to pimp the medical students or for the consultant to call the babysitter or their spouse. Occasionally the consultant would have to leave while we were on patient 8 of 10 (having already rerounded on patients 1-5) to go do a cath or EP study, and then we'd have to wait until they came back to finish.

I honestly thought about coming into pre-round, on my own, on half of the patients each day simply so it would give me something to do and would make rounds go faster, but I was afraid it would make my residents and registrar look bad. As it was, I constantly was made fun of for having to work 80 hours a week next year - in Australia the interns contracts are for 38 hours a week and then they start getting overtime pay.