Tuesday, November 19, 2013
Ward rounds ... does style matter?
Over the past few weeks I have had several discussions about the style of ward attending rounds. Medical educators who I respect greatly have argued strongly that they have the best way to do rounds. The more variations that they report, the more I am convinced that we have many ways to skin that cat.
When we started our ward attending round research over 10 years ago, we wanted to discover something about the style of rounds. We discovered a great deal, but nothing about the style of rounds. We learned the characteristics and domains of successful rounds.
Quoting from our recent letter to the editor of JAMA: “We learned that successful attending rounds required a multidimensional skill set comprised of 5 distinct domains: learning atmosphere, clinical teaching, teaching style, communicating expectations, and team management. As Wachter and Verghese explained, current work hour restrictions and hospital expectations create a demand for team management skills, one of our domains. This domain includes timeliness, efficiency, and accommodating absences required for administrative demands.”
“While team management is an important domain, it did not outweigh clinical teaching, learning atmosphere, teaching style, or communicating expectations. Trainees valued teaching. They rated ‘sharing of attending’s thought processes’ as the top attribute for successful rounds. They also valued bedside teaching and role modeling. These less precise attributes of clinical wisdom trumped the teaching of evidence-based literature. Students and residents felt they could read books and medical literature, but they wanted and needed attending physicians to demonstrate clinical reasoning, patient communication, physical examination skills, and professional physician behavior.”
There are many successful styles of attending rounds. We should not debate the proper structure of rounds. We should understand that our personalities influence how we like to run rounds. Learners care less about structure than they do about sharing ones thought processes, having some bedside teaching and role-modeling.
I encourage all ward attending physicians to develop their own structure and style for making rounds. Structure and style are less important than content. Our job is to use rounds to insure superb care for our patients and give our learners the opportunity to gain expertise. We should understand that our learners need us to provide role-modeling, not just through words, but also through observation. How we interact with patients matters. That we make certain that patients understand what is happening in the seemingly hostile atmosphere of a hospital matters. That we share our thought processes matters. And these activities trump style and structure.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
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