1
What are rounds?
Rounds are a medical team’s daily evaluation of each patient cared for on a clinical service. This includes an organized assessment of the patient’s diagnoses and pathologic condition as well as a formulation of a management plan.
2
List the different types of rounds
There are various types of rounds, and they can be very different from each other. There are work rounds, teaching rounds, table rounds, and grand rounds. The attending on each service will decide on a day-to-day basis which types of rounds will occur.
3
What are work rounds?
Work rounds are the most time-efficient form of rounding. They involve presenting the patient’s pertinent history in a very short and efficient manner (for example, only overnight events or pertinent positive and negative aspects), reviewing the task list for each patient, and creating a plan of management for the day. The emphasis is on efficiency. These rounds are usually performed while walking around the hospital to each patient’s room, discussing each patient’s case outside the patient’s door. After discussing the patient, the team will enter the room to discuss the plan with the patient.
4
Describe teaching rounds
Teaching rounds are significantly different from work rounds. Generally they will involve a formal and complete patient presentation, which will be followed by several teaching points. There may be a formal teaching session before/after rounding, or each patient can become an individual teaching session. Many attendings will conduct this teaching session in the Socratic method by asking the medical students a variety of questions. This is also known as “pimping.” These rounds are extremely educational but can take much more time.
5
What are table rounds?
Table rounds are a combination of work and teaching rounds. The team is seated around a table and discusses each patient, their interesting clinical findings, and any teaching points. These rounds do not involve walking or direct patient interaction. Patients are presented as if the team were in front of his or her door, but the team does not actually attend rounds as a whole. Instead, the senior resident and attending will “walk round” or the attending will go see the patient on his or her own.
6
Explain the concept of grand rounds
Grand rounds are usually once-weekly gatherings of everyone within a specialty, including faculty, residents, or visiting professors. During these sessions, particularly interesting patients or areas of departmental research are commonly presented. These sessions can be thought of as hospital-wide teaching rounds. Each patient presentation is developed with the intention of educating the audience on a clinical topic.
Grand rounds can also be called a different name, depending on the clinical service. For example, the surgical equivalent can be called Death and Complications (D&C) or Morbidity and Mortality (M&M). These types of rounds are generally used to discuss patients with adverse outcomes or interesting features. The goal is to spark discussion about either what went wrong and why, or what approaches would work better to avoid similar complications.
7
What components of the medical team are present for rounds?
The medical team is composed of several different components with a hierarchical level of authority that is displayed in Figure 6-1 . The attending is at the top and has the authority for all final decisions. The senior resident is the clinical team’s leader for the hands-on portion of the clinical care. He or she makes the day-to-day decisions and presents them to the attending. It is the senior resident’s job to know all of the patients and to manage the residents/interns. On surgical services you may have rounds with only the senior resident. The senior resident can be viewed as an “attending in training.” All non-senior residents are referred to simply as residents. However, a first-year resident is called an intern. Residents and interns have responsibility for their own patients and spend a significant amount of time working directly with medical students.
A fourth-year medical student may have the role of a sub-intern (Sub-I) or acting intern (AI) depending on the terminology of the medical institution. Sub-Is have responsibility for their own patients and present directly to the senior residents and attending. They are treated as if they were at an intern level. The third-year medical student has the least authority on the team as they are relatively new to hospital processes. Depending on the service, there may be no to several third-year medical students.
Another type of resident is a chief resident. A chief resident in medicine is one or more of the senior residents who have been chosen to take on additional clinical, teaching, and administrative responsibilities. They generally are not present on rounds with a specific medical team, but rather serve as administrative managers for the entire body of residents for each clinical service. In addition, there may be other members of the team including pharmacists, physician assistants, and nursing staff who may attend rounds with the team.
A chief resident in surgery is one of the senior residents who has additional administrative and clinical tasks in addition to their usual workload. The difference between chief residents in medicine and surgery is that surgery chief residents are not spending an additional year of residency compared with other residents as in medicine.
8
Explain what “assigned to a patient” means
Medical students are assigned to a patient with interns or residents. This means that the medical student co-manages the patient with the intern or resident. The student’s role often involves obtaining the history, performing the physical examination, presenting the patient, and writing daily progress notes on the patient. The medical student is also expected to stay up to date with each patient’s diagnostic studies, laboratory values, and daily medications. Because medical students have fewer patients and therefore more time to spend per patient, they are considered a valuable resource by interns who manage a much larger patient load.
9
Why do medical students work with interns/residents?
The important reason is for patient care. Medical students are in the process of learning new clinical knowledge. Therefore, interns and residents must direct and guide a medical student’s patient management. As a medical student’s clinical experience accrues, interns/residents will allow for more autonomy. Ideally, as a sub-I (or AI), a medical student will manage patients on his or her own with only minor direction from the senior resident, akin to the interns.
10
What is the relationship between an intern and a medical student?
Interns are a valuable resource for medical students. Because of their relatively recent completion of medical school, they are able to remember what it was like to be a medical student. Thus, they can offer advice and guidance on the basis of these experiences.
Some residents can be somewhat protective of their time, but with a little bit of coaching the medical student can become a time-saving asset. If gently reminded, their teaching will enhance the medical students’ education and also save them time with their daily work. For example, teaching a medical student how to write admission orders will save an intern time for each patient admitted.
11
What kinds of things can interns teach medical students?
Some of the main lessons are the same skills that residents are working on themselves. Some basic examples include writing admission orders, reading chest x-rays, and interpreting electrocardiograms (ECGs). This is not to say that medical students should not read about these topics on their own, but they can supplement their reading with interns’ teaching time.
12
What time do rounds start?
The start of rounds is based on the attending’s preference and can be service dependent. For example, surgery rounds tend to start early (and go quickly) because the surgeons need to get to the operating room by the time the first procedure is scheduled to begin. Medicine-oriented services such as internal medicine, pediatrics, neurology, family medicine, and psychiatry rounds tend to start later because there are no operating room procedures pending for the day. Rounds may also start earlier if the patient load is high or start later if there are only a few patients on the service. Fairly typical starting times for rounds are 5:30 to 6:30 am for surgical rounds and 7 to 8 am for medicine-oriented services.
13
What time do medical students need to arrive at the hospital?
As a medical student (and even as an intern), you will typically need to arrive before the start of rounds. All patients will need “pre-rounding.” Initially, pre-rounding will take more time until the routine has become more natural. Generally, allow for at least 15 to 20 minutes per patient at first. Depending on the service, the amount of detail to be collected on pre-rounds will vary significantly. Surgical services typically require far less time for pre-rounding than medicine services.
14
Describe pre-rounding
Pre-rounding occurs before rounds and involves collecting patient information such as overnight events from overnight residents or nurses, preparing to present the patient in front of the team, and formulating a medical management plan.
15
Name the different parts of pre-rounding
The six components of pre-rounding are displayed in Table 6-1 .
| 1. Vital signs: read the flowsheet, record vital signs | 2. Talk to the patient | 3. Physical examination | 4. Laboratory results | 5. Check overnight orders and MAR | 6. Talk to nursing staff |
| Tmax, Tcurrent: Highest temperature overnight, what the temperature is now. Heart Rate: Get the range and be sure to note outliers (e.g., an episode of supraventricular tachycardia in the middle of a night with otherwise normal sinus rhythm). Blood pressure: Obtain the range for systolic and diastolic and note outliers. Respiratory rate: Obtain the range and note outliers. SpO 2 : Oxygen saturation. Write down the percentage, and how much oxygen the patient is getting and by what means. Example: RA, 2 L by NC, 60% FM. Inputs/Outputs: Especially important for surgical patients, and patients you are trying to diurese. Inputs are IV fluids, PO intake, etc. Outputs are UOP, chest tube output, etc. | Did anything happen overnight?
| Does not need to be complete, unless there is a specific need.HEENT, heart, lungs, abdomen, and extremities is usually sufficient. Example:
| Check am and pm laboratory results, and have these ready for your presentation. Keep them organized and record them sequentially. Example:
| Look back over the orders that were written by the overnight cover team and which medications the patient received. Examples:
| Often overlooked, nurses are a great resource. They have been with the patient all night and can tell you valuable information that you may have missed. Examples:
|
16
Explain the purpose of pre-rounding
The purpose is to collect information early enough so that you have time to process the information before rounds. The next step after pre-rounding is to organize the information you have collected, both for a progress note and the presentation. Sometimes there is time to complete part of the note before rounds, or to at least skeletonize it. Either way, there should be some effort made to organize the information collected about the patient’s last 24 hours so that it can be presented in a coherent fashion. Many medical students find it helpful if the resident can discuss the patient with them during pre-rounds. This way there are no surprises for the team, and the student looks well-prepared and knowledgeable during rounds.
17
Describe skeletonizing a note
This is a quick process in which a scaffold is created for the daily progress note that can later be filled in. The scaffold should be consistent for each day and patient. After pre-rounding, you will have already collected several components of the note and can write them out: the subjective (S: how the patient did overnight and interval events), the objective (O: vital signs, physical examination, laboratory results, and imaging/procedures), the assessment (A), and the plan (P). Writing these out will help with preparing to present the patient.
18
What makes a good patient presentation?
A good patient presentation is organized and succinct and delivers all of the pertinent information necessary to make a decision about the plan for the day. Achieving excellence in presenting patients may take a lot of practice. An outline of how to deliver a good patient presentation is displayed in Table 6-2 .
