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The hospitalist teacher

Bedside rounding combines medical education and patient care

By Clifford W. Zwillich, MACP, and Mel L. Anderson, FACP

From the August ACP Hospitalist, copyright © 2008 by the American College of Physicians

Sidebar: On Rounds

It wasn’t so long ago that residents managed the day-to-day care of patients while teaching attendings supervised rounds once or twice a week. With the rise of the hospitalist model in academic departments, more hospitalists are now primarily responsible for overseeing daily patient care, teaching, and serving as professional role models—all while being viewed as “the attending physician” by patients, families, payers and administrators. How can a hospitalist best direct the care of roughly five new and 10 follow-up patients daily and communicate with patients and families, all while effectively teaching students and housestaff?

At the University of Colorado/Denver VA Medical Center, we’ve experimented with models aimed at balancing these various roles. Our current model, which has evolved since 1997, involves daily bedside rounds on each patient. We believe this format optimizes the interests of patient care, teaching and efficiency. Each of our teams includes an attending physician, a second-year resident, two interns, two third-year medical students, and often a fourth-year medical student/sub-intern.

Here’s how the process works:

• Prerounding. Housestaff and students see their patients before daily attending rounds and gather specific information needed for clinical decision making: history, physical examination, laboratory, and ancillary data (see chart, “On Rounds”). Of importance, we require each trainee to construct an independent daily assessment and plan as a result of prerounding. This encourages learners to interpret the data and to make intellectual commitments regarding possible changes in diagnosis or management. This process can be richly educational.
• Team rounds. At a designated time each day and with the entire team at the patient’s bedside, the student or resident gives a five-minute, patient-focused presentation following specific protocols for new and follow-up patients (see chart). This uninterrupted presentation always concludes with the student’s or resident’s assessment of the patient’s condition, which tests reasoning skills, and plan of treatment, which tests clinical decision-making. During the presentation, the attending hospitalist verifies some of the physical findings while also observing the communication skills of the trainee, always acknowledging when a job is well done. With the patient’s consent, we invite family members to be present during these combined work and teaching rounds.
• Q&A. In stepwise fashion, the student, intern, and supervising resident respond to questions from the attending hospitalist, which are aimed at clarifying the data and analyzing the clinical assessment. By directing questions from junior to senior team members, the attending hospitalist tests their medical knowledge and reasoning. The hospitalist is simultaneously teaching and modifying the assessment and daily plan for his or her patient. A pivotal precondition of such questioning is the establishment of a safe learning environment.
• Wrap-up. Before leaving the patient’s bedside, the team and patient should agree on the plans for the day and the patient and family should have their questions answered. We try to include nursing staff during these rounds both to get their input and to facilitate communication of the care plan. We strive to cover one patient every 10 minutes with this approach, on average. This requires adhering to the five-minute presentation rule and limiting teaching to the most important points.

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What is gained from this bedside rounding? By using a structured format for gathering and presenting information, students and residents are taught the utility of obtaining all of the required clinical data. Trainees’ clinical reasoning skills are stimulated by creating an assessment and treatment plan for each patient every day. While these rounds are not a substitute for didactic sessions and more detailed literature discussions, they do allow attending hospitalists to expand teaching from the conference room to the bedside, where medicine is actually practiced.

As a part of the goals and objectives of the rotation, we emphasize at the first day “all-team meeting” that rounds involve questioning to improve patient care and to determine the extent of the learner’s knowledge and add to it. Attendings are encouraged to model professionalism by acknowledging what we don’t know. Our responsibility is to demonstrate respect during the questioning and to make points that are accurate and relevant to patient care. Bedside rounds also provide a rich and immediate source for teaching physical diagnosis skills.

Another pivotal advantage of this approach is that the attending hospitalist is clearly seen as the physician leader and teacher. Having all team members present at the bedside on rounds emphasizes to patients and families that a highly detailed team approach is being utilized and that an expert attending hospitalist is guiding care. Decisions that residents might otherwise defer until an attending is present later in the day can be addressed immediately and directly. Complaints or concerns that patients may raise are acknowledged and provide teaching opportunities through the attending’s modeling of professionalism and communication skills. In general, this approach fosters patient trust and communication, as patients and families are present for the discussion and can observe why and how their physicians make specific recommendations.

A few caveats are appropriate, however. Thought should be given to whether patients might react negatively to having their medical information discussed openly in front of them. A prospective study of the effects of bedside presentation found no such deleterious effects (N Engl J Med 1989:321:1273-1275). It is also important to have group and departmental buy-in of the bedside rounding approach before initiating it. The first months of implementation require a strong champion; leadership support is necessary to effect the culture change associated with bedside rounds.

Some attending hospitalists may be initially anxious about this model, concerned that they may not know the answers to all the questions raised at the bedside. They may also feel that their physical diagnosis skills need honing. We’ve found that even our most experienced bedside clinicians are willing to say, “I don’t know, but I’ll find out.” Doing so models professionalism and lifelong learning and gains additional respect from patients and their families.

Drs. Zwillich and Anderson are faculty members in the Department of Medicine at the University of Colorado and the Veterans Affairs Medical Center in Denver.

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On Rounds

New patient bedside presentation (5-minute time limit)
Chief complaint: What led the patient to seek medical attention?
History of present illness: Includes all details pertinent to patient’s presenting complaint. Should include pertinent ROS. Try to avoid past medical hx except as related to HPI. Please include any ancillary information obtained from family/eyewitnesses/nursing home staff.
Past medical history: List most relevant history first, including both past medical/surgical history. Include chart review and details of significant past studies. Include PCP here.
Medicines: Complete list of patient’s current outpatient medications. Make sure you know and report generic names of drugs.
Social: Special attention to tobacco/alcohol/drug use. Would also include home situation, previous/current employment, contact numbers for next-of-kin of other decision makers in this section.
Family: Pertinent or unusual family history.
ROS: Any complaints that were not included in HPI. Although you should do a complete ROS, only report pertinent positives/negatives.
Exam: Make sure to include vitals and weight (may include ER + floor findings if significant differences noted). Would include a complete general description of patient’s appearance. Mental status can be deferred to neuro exam if needed. Initial exam should be comprehensive, but would include only pertinent positives/negatives at bedside.
Labs/studies: Significant positives/negatives from both blood work and diagnostic imaging. Would include past labs if helpful to follow trends.
Assessment/plan: At this point, briefly summarize case, touching on pertinent points from chief complaint/HPI/past history, significant physical and diagnosis findings. Then, outline what you think is going on to explain the above, and what treatments or further diagnostic work-up you have done/planned. After the chief complaint/problem has been dealt with, then address other issues that have been discovered (e.g., unrelated leg rash, hypokalemia, etc.).
Questions: Plan to answer questions from other team members.
Multi-disciplinary input: PCP, RN, case manager, pharmacist, etc.
Patient involvement prior to team leaving room: If appropriate, begin discussion regarding level of care to pursue.

5-minute follow-up bedside presentation
New symptoms: Report any new symptoms or clinical events over past 24 hours.
Status of previous symptoms: Update on previous symptoms.
Vital signs: Report trends as well as current values for T, P, WT, BP, RR, SaO2.
I&O: Report totals as well as relevant breakdown for both intake and output. Report weight and trends in net fluid balance over preceding days.
Physical exam: State important new physical findings, and status of previous findings. Give level of invasion (Foley, IV, ETT, etc.) and number of days for each. Be prepared to defend the appliances and to make the case that no iatrogenic complication has occurred (infection, thrombosis, pneumothorax, etc.).
Medication list: Run the generic drug list daily to avoid inappropriate dosing and reduce polypharmacy as soon as possible. Are doses and intervals appropriate for renal/hepatic function? If it takes too long to run the drug list, the drug list is probably too long.
New lab/imaging/procedure results: Report new lab data including status of crucial lab tests (i.e. collected but not run yet). If a lab is not important enough to report, it probably was not important enough to get.
Chart review: Report new information from nursing, consultants, social services, etc.
Assessment and plan: A prioritized problem-focused discussion of the major issues should be stated. The diagnostic aspect of the problem should be stated first followed by the treatment plan. Disposition must be included.
Multi-disciplinary input: RN, pharmacist, etc.
Questions: An effective presentation covers 90%+ of data. Plan to answer questions other team members have.
Patient involvement/education prior to leaving room: Does the patient and/or family members understand and agree (informed consent)?

Source: Clifford W. Zwillich, MACP, Veterans Affairs Medical Center, Denver.

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© 2008 ACP Hospitalist and American College of Physicians

ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated