Monday, October 22, 2007

Hospital Rounds: Inefficiency By Design

I should preface this post by noting that my experiences are shaded by working at a public hospital that does not yet have electronic medical records. I am not complaining about my workload in particular, but rather the structure in which everyone in the health care field operates in when 'rounding' on patients in the hospital.

A Typical Morning

On many services, mornings are scheduled around some kind of morning conference. For this example, I will assume that I am on internal medicine, Morning Report is at 8:30 AM, and I have three patients to see. The attending wants to round after Morning Report at 9:30. This all sounds reasonable enough, right? However, here is what really happens. The residents, reasonably enough, want to discuss the patients prior to attending rounds, so we have prerounds/work rounds, typically at 7:30 AM, before morning report. I allocate about 30 minutes per patient (15 minutes for looking up results from the previous night, 10 min to see the patient, and 5 min transit time), so this forces me to arrive at 6 AM to see my 3 patients prior to work rounds.

Now, if I were able to utilize that time fully to understand everything that had happened with my patient the previous night and discuss problems thoroughly with my team, that would be great. But no. Instead, I waste most of that 1.5 hours hunting down charts that are being shared by up to 10 individuals who are caring for the patient (nurses, respiratory techs, other techs, consult teams, etc). When I finally find the chart, I have to hunt all over the place for vitals, medications, etc, which may or may not be filed under the correct tabs. Then, I have to read notes other people have left, but there are two problems here. First, everyone is forced to regurgitate the same basic info about the patient, so you have to skim through all of it just to get to the relevant stuff. Second, HANDWRITING: some people just refuse to write legible notes, thereby defeating the purpose of leaving a note. In that 90 minutes, I sadly only get 30 minutes max to actually see how my patients are doing, let alone think and discuss the issues they have.

Why 'Rounds'?

Why do medical students round? There are many ways to teach and practice medicine. There is no inherent need to 'round' in order to care for patients. My history may be a little bit rough, but I believe the idea of rounding in American medical education can be attributed to Sir William Osler and the program he began at Johns Hopkins. Physicians had rounded prior to that, but my understanding was that Osler was the first to integrate medical students and education into this system. And, for decades, the system succeeded and many learned medicine at the bedside. And, I must admit, I learn a fair amount on rounds. However, it is ironic that while the buzz in medicine is all about 21st century technologies and practices, we are still stuck in a 19th century work flow pattern. Remember, when Osler rounded, there were no X-rays to interpret, no EKGs, no other fancy studies. Heck, they barely had blood pressure cuffs. Rounding was an appropriate way to pattern work for the 19th century hospital, but rounds are no match for the information overload that each patient now presents.

A Modest Proposal

Well, perhaps several mini-proposals. Rounds should change to keep up with the advances in medicine. First, there is no excuse for having paper charts in the year 2007. It just makes no sense when nearly all the data that goes into charts is generated by some piece of electronics. Second, why must I see my patient 3 times each morning, yet not really examine them because each time I am in a rush to get to the next set of rounds and/or conference? The med student pre-pre-rounds and pre-rounds should be combined. The obvious criticism is that the med student would not be as exposed to the data and would not be required to think on their own. This is easily avoided by simply ensuring that the residents allow the medical students to examine the patients first and to "lead" the rounds for their own patients. By doing so, the students will have more opportunities to ask questions and have their physical exams directly observed by their interns and residents who can help them do a better job. Lastly, and maybe this is just because I'm not a morning person, can't we just combine Morning Report with noon conference? The "break" at 8:30 seems nice, but all it is really doing is extending the day in a particularly inefficient way by breaking everyone's work flow. Anyway, that's my two cents.


  1. I completely agree with you. There are so many built-in inefficiencies in the teaching-hospital setting that it's almost MI-inducing to think about them.

    I think that part of the reason for inefficiency and multiple meetings is an insistence on the APPEARANCE of rigor -- the program WANTS you to show up early, to spend a ton of time at work, and to not have much time at home to study. Many attendings and program directors (esp. the old guard) hate the concept of spoonfeeding information to students (which technology would easily do -- imagine showing up to work and having every updated piece of information about the patient at hand without flipping through a chaotic chart). I haven't fully worked out the sociopsychological reasons for med school's insistence on rigor for the sake of rigor, but I'm convinced at this point that it does exist, and that it's ridiculous.

    For a while now, I've been thinking that I could learn much more efficiently by spending half of each rotation at home studying & perhaps watching taped interviews of patients with "core" problems, while spending the other half on the wards, but this idea is complete heresy to the status quo. On most rotations, I'm forced to spend an unholy amount of time on the wards, during which I learn quite little. Btw, the process of writing labs & vitals down every day does NOT help in memorization of normal ranges! At all! Only memorization of normal ranges aids the memorization of normal ranges ;).

    Your classmate

  2. The intensity or rigor of rotations is generally directly correlated with the amount of time you spend on them and inversely correlated with how much you learn.

    This sets up quasi-zero-sum games in which students who are in the know gun (often surreptitiously) for low-intensity services, while those who play by the rules occasionally get completely shafted by the system (forced to spend insane amounts of time on the wards and thereby not mastering the rotation at all).



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