Friday, March 31, 2006

Why do we round at dawn?

In the realm of medical practice, it's a small thing, but I suspect it's emblematic of what's wrong with the doctor patient relationship. I'm talking about hospital rounds. It varies from specialty to specialty of course, but most doctors make rounds at dawn.

I understand that this is because it's convenient for us as doctors. We see our hospitalized patients before the operating room opens, or before we head to our office. It's not convenient for the patients, though. In fact, it's worse than inconvenient for several reasons:

Hospitalized patients are (by definition) sick. They need rest to heal, yet we wake them up.

The patients are often slightly disoriented because we have just awakened them. In that state they find it difficult to remember what we told them and they forget to ask what questions they may have.

It is dawn so they are very unlikely to have family present. There is no one to help remember and corroborate our instructions. For patients who are very ill or confused, there is no family member present to ask questions, to inquire about the plan of care, or the plans necessary for discharge.
On balance, it's clearly a very bad idea to round at dawn. Why don't we change it?


Anonymous Moof said...

I've always found the early morning rounds rather difficult as a patient. This is also about the time that the nurses are preparing to change shift, and that the outgoing crew is taking care of last minute details: catheter removals, etc. ...

Hospitals are the absolute worst place in the world to try to sleep. There's a constant racket in the hallway, people in and out of your room all night, the lights are always on - which makes it difficult for those of us who need darkness to sleep ... and the worst of all: getting a new middle of the night room-mate - with over 1/2's worth of rote questions besides the hassle of settling them in.

Yes, changing rounds would help a bit ... educating nurses that patients need to sleep during the night might help even more ...

11:41 PM  
Blogger Flea said...

Got a better idea, Amy?

The alternative for me is not rounding.



7:42 PM  
Anonymous Anonymous said...

I hate to say it, but this is yet another point in favor of hospitalists. Perhaps it's time to adopt the British system of the office-based GP and the hospital-based Consultant. Continuity of care is losing out to economics and improved hospital routines.

10:02 PM  
Blogger Flea said...

Why do you hate to say it? Cuz it's money out of our pockets? Come to think of it, that's not a bad reason to hate to say it -

But that's the train that's coming, so we might as well get the heck off the tracks.



8:07 AM  
Blogger Amy Tuteur, MD said...

Do I have a better idea?

It's not a simple problem, so there cannot be a simple solution, but I do have some ideas. First of all, I think we should consider teaching rounds and attending rounds separately.

When it comes to attending rounds, there is really no justification for rounding at dawn. I know it's much easier to do it that way, and it's always been done that way, but hospitalized patients deserve an opportunity to talk with the attending each day at a time when they will be awake and when a family member could be present. In addition, simple courtesy dictates that patients and their families should know when we are going to appear and should not need to wait for hours at a time, or for the entire day, just to have a few moments with us. At a minimum, we should talk to them on the phone at an appointed time if we can't get to the hospital on that day.

There is a certain logic to having one person round for an entire practice. It could be a hospitalist or just somebody assigned to round for that week. That only makes sense, though, if the rounding doctor is actually in charge of the patient's care. The patient deserves to speak with the decision maker, not a random doctor who has access to the decision maker.

Teaching rounds are another story of course, since it is difficult to gather an entire team in the middle of the day, especially in the surgical specialties where various members of the team might be operating. Nonetheless, general surgery could round after breakfast and immediately before the operating room opens, not at 5 AM.

My main point, which all those who have commented have picked up on, is we must take patients into consideration. At the moment, the patients are the last people in the world we consider when determining when to make rounds.

1:20 PM  
Blogger neuroticillinifan said...

I agree that early morning rounds are difficult on the patient and the patient's family. When Hubs was in the hospital, I had to take Son to school before heading up to the hospital meaning at best I could get up there around 8:30 a.m. Inevitably the Dr(s) had already come by, and Hubs, who was in pain and not a morning person anyway, had no clue what they might have said to him, if anything. We had one wonderful Dr who was willing to call me on my cell phone so that I could listen in from wherever I was in my morning routine while he spoke with Hubs. If only we could have persuaded others to do likewise, but they treated our request as though it would be horribly inconvenient to them.

3:03 PM  
Anonymous Sid Schwab said...

as a surgeon, I made rounds at 6am, and indeed often awakened patients (or let them sleep). I also rounded again at noon, and after 6 or 7 pm; at minimum. The need for early rounds is to catch things that happened overnight, to get tests, etc, ordered whose need has arisen, in order to keep the hospitalization short. Our hospital once started dinging us for afternoon discharges, until I pointed out the folly: would they rather I made am rounds only, and delayed discharge til the next day to avoid a ding? The problem isn't early rounds; it's not coming back again later...

If you want to know how I got that habit, read my new book, just published, about surgical training in the 1970s. It's called "Cutting Remarks; insights and recollections of a surgeon." Available at amazon. Shameless, I know; but since some things are universal to all docs, it's a good medical read, I think

12:48 PM  
Anonymous mchebert said...

I round in the evening after clinic, and in the early afternoon, if my clinic schedule permits. Believe it or not, this causes its own set of problems.

Most importantly, I have patients who see other doctors rounding early and feel I am putting them off, or that they are being neglected. They are not important because they are not first. Some patients have the common misconception that doctors who do not emerge bright-eyed at 6 am are not as sharp as the early risers ( the "early to bed, early to rise" ethic).

I don't think there is a way to win. Many patients have watched too many episodes of "ER" and think it is standard of care for a doctor to be hovering around 24 hours a day. It doesn't occur to them that most doctors have clinical responsibilities and can't be there for them all the time.

I caught a snide remark from a patient today because I didn't get to them until 4 pm. What was I doing at 6:30 am? Transferring a patient in respiratory arrest to the ICU. That patient sucked up my morning and I ended up going straight to the clinic without seeing anyone else.

To be honest, it hurts a little when you are going the extra mile for your patients and they still complain you are not doing enough. Luckily these people are in the minority but it only takes a few to make one's life difficult.

1:36 AM  

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