ACGME Increases Shift Length For Interns

The American Council of Graduate Medical Education, or ACGME, recently announced that it was reversing course and lengthening the longest shift an intern can work in a hospital from 16 to 24 hours. The ACGME governs the structure of all accredited residency training in the United States, so this change will have broad-ranging effects. While PGY-2 residents and above were already allowed to work these longer shifts, interns had been protected from them since 2010. Here are various summary articles:

• ACGME Statement
• NPR
• Business Insider

However, since 2010, concerns have arisen that the shortened shift actually detracts from intern training as they are required to hand off patients frequently in order to abide by the 16-hour restriction. Often times, a complex patient may require care past the 16 hour mark, which the trainee could not participate in while still complying with the rule.

Another concern was the hand-offs themselves. Especially in July, interns are still learning how to manage patients on a very basic level. Asking them to hand off a complex patient to another intern at the same early training stage is a recipe for error, since clinically relevant information may be omitted or underplayed, leading to errors in the provision of care.

Ostensibly, the ACGME attributes its change to the following reasons:

In keeping with this philosophy, the changes are supported by testimony from a wide range of physician specialty educators and intended to:

• place greater emphasis on patient safety and quality improvement;

• more comprehensively address physician well-being;

• strengthen expectations around team-based care; and,

• create flexibility for programs to schedule clinical and educational work hours within the maximums currently utilized in the US.

These revisions were developed as part of the ACGME’s periodic review of all program requirements to ensure that professional preparation of physicians adequately addresses the evolving and growing needs of patients. 

The trade-off though is a return to the era of the over-worked, fatigued intern. Historically, residency was a brutal training process with no restrictions. The first attempt to curb work hours was set in motion by the death of Libby Zion, an 18 year old girl who was under the care of minimally supervised, overworked trainees. Her father Sidney's anger at her death led to the ACGME instituting its first series of work hour reforms. Even those changes were slow to come around: the commission formed after Zion's death recommended changes including an 80 hour work week restriction in 1989; the ACGME instituted those changes in 2003, fourteen years later.

There have been several minor revisions since 2003, including the move to the 16 hour intern limit in 2010. The debate will continue over striking the appropriate balance between clinical exposure and the physician's personal health. As a medical student, you should inquire with prospective training programs about how they plan to manage the change, as well as ask current program trainees how the program actually functions. In more demanding specialties, such as neurosurgery or orthopedics, there are many programs that have trainees working longer than the hours they actually log. Ultimately, the ACGME is not an enforcing body and cannot assess whether each resident actually works the number of hours they say they do, so it is up to you to ensure the training program you join matches your expectations.

Regardless of whether you join a relaxed program or a stressful one, your best bet to make sure you are as prepared as possible to handle patients clinically on your own. Despite different specialties, intern experiences have a lot of overlap. The following resources below should help you be better prepared for the first day when you round by yourself as a full MD:

• Pocket Medicine by Marc S. Sabatine
  A handy guide that easily fits into a white coat pocket, Pocket Medicine has long been essential reading for interns, especially those on medicine wards. This small book is chock full of practical tips and broad differentials for common clinic findings.
  
  
  
  
• First Aid for the Wards by Tao Le, Vikas Bhushan, et al.
  From the authors of First Aid for USMLE Step 1, the bible of Step 1 prep, comes this book about rotation-specific advice. While intended for MS3 students, it still contains lots of useful information for interns, especially those who will rotate among various specialties, such as transitional interns.
  
  
  
  
• Intern by Sandeep Jauhar
  While not a technical guide like the two prior books, this memoir by Dr. Jauhar gives a good sense of what it feels like to be an intern, especially the sense of disorientation one may feel at times.
  
  

Good luck! If you are or recently were an intern, what was your experience like? What do you think of the proposed changes?

Books For Third Year Medical Students

We previously covered books for first year medical students and second year medical students. The section on books for USMLE was important enough to merit its own post. But, as third years, you are through with Step 1, you are through with basic sciences, and you're geared up for the clinics. Alas, day 1 comes and goes and you realize: there is still a ton to learn! Where do you go to find all that information?

The books described here are meant to give you a high yield, high impact approach to each core clerkship you take. Ideally, for each clerkship, try to read one book throughly and use one book for case reviews / questions. Here is a break down of the books you should get, rotation by rotation:

Family Medicine

Family Medicine is generally a nice rotation, with students primarily rotating in outpatient clinics. If you have already done pediatrics and internal medicine, family medicine covers many of the same topics, but in the outpatient setting. Preventative care is also much more emphasized. Blueprints Family Medicine does an excellent job of covering the major topics and preparing you for the shelf exam.

Internal Medicine

As discussed in the post on Books for the Internal Medicine Rotation, the three books above are all you need. Pocket Medicine will get you through the wards on a day-to-day basis while the other two are what you need to power through on your nights and weekends to ace the internal medicine shelf exam.

Neurology

Neurology should be on the relatively lighter side of the clerkships, especially if you have taken internal medicine already. Since there are relatively few therapeutics, focus on learning how to differentiate major disease patterns.

Ob/Gyn

My recollection of OB/Gyn is somewhat fuzzy as I took it during fourth year just as interviews were starting up. The major challenge in OB/Gyn as I recall was learning the skills as well as knowing how to work up various conditions (such as an abnormal pap smear). For OB, just remember: almost always the treatment is - deliver the baby!

Pediatrics

Pediatrics is generally a fun rotation (babies!). The books you should get for pediatrics are much like the other rotations. Conceptually, again there is some overlap with internal medicine, but there is much more of an emphasis on congenital and infectious disorders.

Psychiatry

All you need is the book above - First Aid for the Psychiatry Clerkship, Third Edition. 'Nuff said.


Surgery

Surgery can be a challenging rotation for many students. Not only is there the typical fund of knowledge of disease that needs to be learned, but also anatomy needs to be refreshed as well as technical skills acquired. Many students ask - what books could possibly prepare me for the surgery shelf exam? Studying for the surgery shelf exam will be a constant challenge. If you can wait, pre-order the latest edition of Essentials of General Surgery, so that you can get it right when it is published in October 2012. For the NMS, make sure you get the casebook, not the full surgery review.

Wards

Some topics come up routinely on wards, no matter what service you are on. First Aid for the Wards: Fourth Edition is a great book to cover all those topics that might otherwise fall through the cracks.

Hopefully the books listed above will prove as valuable to you as they have to me - best of luck out there in the wilds of the wards!

Updated 2015-12-25

What Is The First Night On-Call Like?

This common question is answered by an internal medicine intern's experiences on her first night. The text below is a repost of the entry "First Night On-Call", first published on the blog Life In A Q4 World.

October 7, 2010 - In our residency program, like in most others in internal medicine around the country, life revolves around a “q4” call schedule; that is, overnight 30-hour “on call” shifts every 4th night. As an intern, a first-year resident, our “on call” day starts at 8 AM, and we stay overnight in the hospital admitting patients and cross-covering for the other teams who aren’t in the hospital overnight until 2 PM the next day (i.e. 30 hours.) If we’re lucky, we can sleep for an hour or two, but usually cross-covering for 30-40 patients means getting paged constantly about every fever, request for sleeping pill or pain medication, or anything else that goes wrong in the middle of the night, and the little sleep you do get is interrupted and unsatisfying (not to mention the fact that we share a call room with the other intern on call who’s concurrently getting paged about her own separate patients.)

Anyways, the first night on call is sort of a rite of passage for interns, i.e. it will suck, but we survive it, and once that’s over with, the next 6 calls until the end of our one-month rotation (for a total of 7 calls per month) are usually not as bad, or at least not as shocking to the system. My first night on call as an intern was actually in the intensive care unit (ICU), which is generally a bit more stressful than the internal medicine wards, because the patients who are admitted to the ICU (the “unit”) are sicker than those admitted to the wards (the “floor”.) So while I was expecting that first night on call to be overwhelming, stressful, and exhausting, I was not expecting the very first patient I would admit that night to be one of the strangest and saddest cases in our residency program’s history.

She was a 23-year-old girl who came to the ER for shortness of breath, not an uncommon complaint. Her symptoms were way out of proportion to her physical exam or chest X-ray, which looked not quite normal but not like a horrible pneumonia or collapsed lung either. No matter how much oxygen we gave her through a mask, she continued to have more and more trouble breathing, and the oxygen saturation level in her blood continued to get lower and lower—not a good sign. By the time the ER doctors called us, the ICU team, about her, they already had the intubation tray set up and were planning to intubate her (put a tube down her airway so that she could be mechanically ventilated) in the ER. Given the rapid progression of her symptoms, they were able to get very little history from her, but it seemed that she had been completely healthy previously, and had not recently had any cough, fevers, or sick contacts. We gave her everything we could think of—a slew of antibiotics, antifungals, and antivirals to treat her for possible pneumonia or an early-in-the-season H1N1-type flu, all to no avail. We got a CT of her chest, thinking she may have had a massive pulmonary embolism, but that was not the case either, although like the chest X-ray, the CT wasn’t completely normal—it showed some collections of junk in her lungs, sort of like a pneumonia but not quite consistent with the classic pneumonia picture. In the ICU, she continued to deteriorate right before our eyes, her heart and kidneys started failing so that her blood pressure continued to be dangerously low even with maximum vasopressor medications and her kidneys had stopped making urine. Her husband and family members who were there with her could not give any more information about what had happened—she had been completely fine earlier that morning. The only other finding we got from examining her was that she had two cotton balls on her buttocks, covering what looked like recent injection sites. Neither her husband nor her family members could tell us what those were from—she had a couple tattoos on her legs but not recently and not on her butt.

Finally, after tracking down several of her friends on the phone, it was confirmed that she had gotten silicone injections in both her buttocks earlier that afternoon. At that point, we realized what had happened, or at least had a working theory—the injections had gone into her blood vessels and migrated into her lungs, basically turning her lungs into a solid chunk of rubber. This phenomenon apparently had been reported before, though extremely rarely of course, and was known in the literature as “silicone embolism syndrome”, which we spent the next 2 hours on Google trying to find case reports for. We looked for reports on how other hospitals had treated cases of suspected silicone embolism, only to find that basically nothing worked—it was just supportive care and waiting to see if the lungs would recover on their own, which they usually didn’t. One case report said steroids seemed to help, so we gave her a huge dose, but to no avail. She continued to worsen, and finally as the renal team was starting emergent hemodialysis on her to try to save her failing kidneys, her heart stopped beating and could not be restarted despite over an hour of CPR. She was 23 years old, had a husband and two small children, and had been completely healthy 12 hours ago before she decided to have cosmetic silicone injections in her butt.

The other wrinkle in the story was that the injections were performed illegally by an unlicensed doctor from Mexico who had been traveling around the LA area with his two Mexican assistants advertising these cosmetic butt injections. They had just been released from jail a few weeks prior, and had been posting flyers in the area, surreptitiously advertising these services for a mere $800 per injection. We were informed of this around 3 AM when a team of at least five members of the LAPD came in and started questioning us, informing us they were searching for this doctor and his two assistants, who were being charged with fraud and what it seemed like would soon be involuntary manslaughter as well. At that time we were all too stressed and exhausted to fully take in the horrible irony and moral injustice of it all—paying over $800 to die of complications from a cosmetic procedure, something that seemed almost too typical to witness in Los Angeles, especially within my first two months of moving here from Chicago. As I was writing the death summary for the patient the next day, thinking about how it would probably show up in court someday, the sadness and unfairness of it all did start to sink in some more, but I wasn’t as devastated or fraught with nightmares as I had feared I’d be. My first reaction was actually to email the story to all of my friends so that they would never get butt injections. Maybe medical school had prepared me better than I thought for psychological and emotional strains of residency.

Check out the blog Life In A Q4 World for more insights from a resident in a categorical internal medicine program in Southern California. Share your passion by publishing your writing on Scrub Notes today!

Books For Internal Medicine Core Clerkship / Rotation And Shelf Exam

Along with the surgery rotation, the internal medicine rotation is arguably the most important rotation you will take during your clinical training in medical school. Of course, if you choose to specialize or go into another primary care field like pediatrics, those rotations will count a great deal. However, every student will be greatly benefited by doing well in medicine and surgery. The grade you receive on this rotation is on par with your surgery grade and second only to the USMLE Step 1 score in terms of factors that residency program directors evaluate. Your grade will likely be a mix of clinical evaluation and your shelf exam score. However, since the evaluations tend to average out to the same values, the shelf exam is what separates the great students from the good ones.

To do well on the rotation requires the usual medical student qualities of diligence and compassion, but the three main things to know are: know your patient, know your physiology, and know your pharmacology. If you know those three things and study hard, you will succeed. But, how does a medical student acquire all that knowledge in short period of time? The key is studying good resources efficiently. Here are my recommendations:


Books For Internal Medicine Core Clerkship / Rotation

Step-Up to Medicine
by Agabegi / Agabegi

This review book covers major areas within medicine by organ system. It is well-organized and easy to read, with many tips and mnemonics detailed in the margins. I also found the flow charts helpful for thinking through certain conditions, such as what to do for a hypoxic patient.

Case Files Internal Medicine
by Toy et al.

If you are familiar with the Case Files series, then you know that these books are a good way to get up to speed on any clerkship. They are quick to read, but really help you understand the basic concepts and cases within a specialty. Read this book right before your rotation starts or during the first week. The book contains 60 cases of common diagnoses within internal medicine, specifically a patient vignette, followed by a description of the workup, background on the diagnosis, and review questions.

Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine
by Sabatine

While on the wards themselves, you cannot refer to a full reference book for information. That's where Pocket Medicine comes in. The guide is a fairly comprehensive reference that fits in the pocket of your white coat. While it does not go into detail about pathophysiology of disease, it has a lot of information about clinical guidelines, relevant trials, and most importantly, how to manage common medical problems, from congestive heart failure to hyperkalemia to lower GI bleeding.

If you can master the content in these three books, you will do well on your internal medicine rotation. And, as always, remember to keep your differential broad and your therapeutic options broader.

Related Posts:

• Books For Pediatrics Core Clerkship / Rotation and Shelf Exam
• Books For Surgery Core Clerkship / Rotation and Shelf Exam
• The Benefits of First Aid For The Wards

Updated 2015-12-18

7 Quick Stories From Medicine Wards

My first month of internship is coming to an end. I did a month of medicine wards. The hours are long, but it's been interesting. Here are a few quick tidbits from my month:

• One patient was a little too happy that I attempted to say hello to her in her own language. As I began to examine her with my gloved hands and stethoscope, I said "Hello" in her language. She suddenly lit up, grabbed both my hands with her own, said "Hello!!!" and proceeded to kiss my gloved hands. Sadly, I think this was actually more sanitary than had she kissed my bare hands.


• Constipated patients get used to people asking them about their bowel movements. However, a select few get a little too worked up about their situation. One patient was so happy that he finally had a BM, he very generously saved it for me to examine when I returned the next day. Thanks, buddy.


• Nurse: Doctor! The patient is in extreme pain! 10/10! I think we should really give him something for his pain
  Doctor: I just went to see the patient, who I am covering for another doctor. He is sleeping soundly and snoring.
  Nurse: Yes, but when he wakes up, he will be in extreme pain!
  Doctor: ...


• One time, a fellow intern admitted a patient, who soon after admission had a code blue. In this case, the code blue was because the patient had stopped breathing. This could happen to any patient, but it was funny to hear the intern remark "But he was satting 100% on room air when I left..."


• Patient's reason for admission: I ate a bad plum and then vomitted, but I feel better now
  The hospital's reason for admission: rule out heart attack
  ... what?


• In general, a quick assessment of mental status is to ask the patient their name, their location, and the date. If they know all three, they are "alert and oriented times 3". However, it's sad when I examine a patient and realize they are more alert and oriented than I am, especially about what day it is.


• Me: I spoke with Jennifer, the nurse
  Unit clerk: Which Jennifer?
  Me: Uhhh... the one I just spoke with?
  Clerk: We have 4 nurses named Jennifer on this floor: Jennifer C, Jennifer T, Jennifer P and Jennifer J

Thanks to the 200 or so readers who have been following me regularly. For the other thousands of you who stop by briefly, why not hang around a bit more? Click on the big blue button at the top right to subscribe =)

10 Tips To Survive Wards

Wards often cause much consternation for medical students, interns, and residents. This post will be half humorous, half serious, but hopefully all helpful. These are going to be practical tips about your workflow. If you're worried more about looking good on rounds, might I suggest First Aid for the Wards. You might also want to check out:

• Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine
  
• 250 Biggest Mistakes 3rd Year Medical Students Make And How to Avoid Them
• First Aid Radiology for the Wards

Anyway, without further adieu, here is my list:

1. Do no harm. Heh, gotta pay tribute to Hippocrates, no?
   
2. Buy one of those clipboard/organizer deals. Unless your hospital has a full EMR, you will be filling out forms. A clipboard with storage lets you carry around forms so you don't have to hunt for them on each unit where they will be inevitably hidden a different, illogical location.
3. Find out where the good/clean restrooms are. I remember hearing this on the interview trail and thinking it a joke, but it is so so true.
4. Same goes for figuring out where to get food quickly and cheaply.
5. Sometimes people get all worked up on keeping notecards with every single lab value their patient has had. This is a giant waste of time. All you need are the latest labs, and perhaps the previous values for labs that come back abnormal. If someone asks you a sodium level from a week ago, they are being unreasonable and should look it up themselves.
6. Figure out how to round in a path that makes sense. Start with the sickest patient, but then walk around in a logical way.
7. Keep snacks in your pockets. You will need them at some point. I recommend Quaker Chewy Granola Bars
8. Do as complete an exam as you can during your initial H&P, and then do as little as possible while still addressing the patient's major issues during each follow up. There's no point in not checking pulses initially, but then doing fully neuro exams everyday, unless you're specifically asked to do so.
9. Use the time when you page or return a page and are put on hold to do other mindless things, like collect labs.
10. Don't stress too much. Things could be worse - at least you're not the one who is sick in the hospital, right?

Thanks to the 200+ readers who follow this blog regularly. Start following today by clicking the large blue button at the top right :-)

Most Stressful Medical Specialty?

Stress is hard thing to judge within a medical specialty. Various factors play a role in creating stress, from the patients and procedures themselves, to one's work environment and career path. I'm not sure how to weight all these factors, but here's the sense I've gotten from the specialties I've been exposed to. 

5 Most Stressful Medical Specialties

1. General Surgery - perhaps I'm biased by the training, but I think given the career, it seems like a lot of stress, considering the income and hours down the road.

2. OB/Gyn - the training is hard, the hours are long, the liability high, and there's relatively less 'control' / predictability over how patients will do from what I've seen. 

3. Internal Medicine - again, just biased by what I see the residents go through. 

4. Surgical Subspecialties - stressful to train, but I think it gets easier in the career itself.

5. Emergency Medicine - while the career is good, I think the fact that these are 'emergencies' is stress inducing on its own, plus who wants to do overnight shifts when they're 60?

As for the least stressful medical specialty, I don't think you can wrong with the old "ROAD" mnemonic (radiology, ophthalmology, anesthesia, and dermatology). Some people would also throw pathology (heh, PATH / ROAD, get it?) and emergency medicine in there as well. While all are competitive to train for, I think the lifestyle down the road more than makes up for it, leading to less stress overall.

What do you think? Perhaps there are stressful specialties that I just haven't been exposed to?  

Concierge Health Care Service

Concierge health care service is a relatively new concept. The idea is basically one in which the physician cuts out of the middleman and only accepts patients who pay for their care directly, without using insurance. Here is one doctor's concierge healthcare experience (via KevinMD):

This post from about a year ago explored the reasons why my friend and personal physician -- internist Bill Lent, MD -- decided to convert his internal medicine practice to a concierge practice in which he limited his practice to 600 patients who pay $1,500 per year to retain his services. Inasmuch as I am blessed with good health, the only time I see Bill in most years is for my annual physical, which was this past week. As always, it was good to catch up with him and hear his thoughts about the first year of a concierge practice.

In short, Bill's experience has been overwhelmingly positive. The funds generated through his patients' retainer payments have relieved Bill of the financial pressure that had been mounting over the past decade to increase patient visits as Medicare and private medical insurers systematically reduced the amount paid to doctors for such visits. Released from that pressure, Bill is now able to spend more time with each patient, which Bill believes provides the patient with better quality service. The response from Bill's patients has been uniformly positive.

Although Bill's workload has been reduced from the standpoint that he no longer feels compelled to see more and more patients to maintain revenue levels in the face of reduced insurance payments, Bill has had to spend quite a bit of time over the past year in the process of computerizing his patients records. Part of the deal for patients in signing up for the concierge service is that their records are digitized so that the patient, Bill or any other doctor who the patient retains can review the records from anywhere via the Web. That perk has required a considerable expenditure of effort over the past year in digitizing those records, but now that the process is largely complete, Bill will spend far less time in future years as he simply amends a patient's computerized record with each visit.

There have been a number of pleasant surprises in Bill's first year of the concierge practice. For example, Bill was initially concerned that a number of his less affluent patients would opt not to participate because of the retainer payment. Surprisingly, however, his patient base has remained quite diverse from a socioeconomic standpoint -- even a large number of his elderly patients on Medicare elected to participate despite the fact that Medicare doesn't cover any of the retainer payment.

Keep reading for some more interesting observations about the practice. I'm not sure how I feel about the concierge idea yet, but it seems like it has some merit depending on the type of patient the PCP sees. Your thoughts? Comment below!

Don't miss a post! Subscribe to Scrub Notes by email or in a reader!

Into The Night... Call

Since I have night call tonight, I found the following post (registration required) to be appropriate:

Below is a list of things that will help get you through the night:
1. Toothbrush: Nothing is worse than presenting a morning case with bad breath. Don't fret over toothpaste, as you can often find small tubes that are provided to patients. Be sure to make friends with your nurse, as he or she will gladly direct you to the stash of patient hygiene products (including toothbrushes if you forgot one).
2. Study guide: It never hurts to bring along a review or question book when you take overnight call. You may find yourself with hours and hours of spare time to study.
3. Medications: If you take scheduled medications, do not forget to bring an extra supply. You may have been told that you will be home post-call by noon, but anticipate delays and avoid feeling sick because you have skipped a dose.
4. Dollar bills: I cannot stress this enough. Most hospital cafeterias close by midnight. With an erratic schedule, you may not have time to grab dinner. Therefore, your only option may be vending machines which, as you know, only take change or dollar bills. There is nothing better than a Snickers bar and Mountain Dew at 3 am!
5. Phone charger: Hospitals get poor mobile phone reception. Bring your charger so that you can focus on dying patients, not your dying cell phone.
6. Snacks: If you are health-conscious or enjoy frequent small, healthy meals, then don't forget to pack something that you will enjoy during your shift.
7. Backpack: It goes without saying that you will need a bag of some kind. My advice is to choose a subdued, dark-colored, and easily hidden bag for your things. Ladies, avoid large, fancy purses; they are easily spotted and oftentimes go missing.
8. Lock: Some clerkships will provide you with lockers. Be sure to lock up (or hide) your valuables.
9. ID: Do not forget your medical school or hospital ID. Hospitals operate very differently at night, and without ID, you will find yourself locked out of many wards, offices, and surgical suites with no one around to help you. Scary!
10. Warm clothes: Hospitals get notoriously cold at night. Bring your favorite college alumni sweatshirt and show off your pedigree while keeping warm!

I am not sure how busy other people are during call, but I don't think I have ever stayed overnight at the hospital while on call, unless it was a night shift. Then again, I've never been on a call where I wasn't busy all the time. So yea, the list sounds good, but I have no need for a toothbrush or a study guide. An extra pair of scrubs? Now that's something I like having around.

Updated 2015-12-13

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.