You Are Worthless and Weak

What is rounding?

At it’s most basic, rounding is the process of visiting hospitalized patients as part of a team. The team usually consists of an Attending Physician, a collection of upper level and junior residents and medical students.

The Attending Physician, or the “Attending” is the boss. He is usually a senior physician with academic and clinical credentials who is responsible for all of the patients on his service. At medical schools he is most likely a professor and you may also have seen him lecturing to you during first and second year.

The day-to-day running of the service is the responsibility of the upper level resident. On a medicine service this is usually a third year resident who is in his last year of training. He will discuss the patients with the attending who will will rely on his judgment and skill in all but the most unusual cases.

The lower level residents, such as interns who are in their first year of post-graduate medical training, are responsible for the nuts and bolts of patient care. They are assigned patients and follow them, managing the many details of their treatment. This includes both working up new patients (clarifying their history and developing a plan) as well as managing existing patients.
Basically the lower level residents manage a patient from admission to discharge.

Your job as a medical student is to learn, in your turn, the nuts and bolts of patient care as well as to increase your clinical knowledge. You do this by following patients of your own, usually under the direct supervision of the lower level residents.

Nobody is going to expect you, on the first day of third year, to pick up a new patient, formulate a well considered plan, and implement it resulting in a miraculous cure. Nor are you going to be, as you may see on various popular television dramas, at constant odds with your team as you try to fight the corrupt system to get your patient the care he deserves. This is not “Patch Adams.” No matter how smart you think you are on the first day of third year you are going to feel like the biggest idiot on earth and you will be thankful if the worst thing that ever happens to you is that you are ignored.

Additionally you will probably see more straight-up medical knowledge and clinical skill in one place, represented by your Attending and upper-level resident, than you ever knew existed.
Consequently the keys to third year are to keep your mouth shut and your eyes and ears open. You also need to be enthusiastic and willing to work hard without, it must be added, being a kiss-ass about it.

Don’t be a tool. That is, don’t be that guy who asks idiotic questions the answer to which he could look up himself except he likes to hear the sound of his own voice and really thinks the Attending doesn’t know he is a tool.

Silence is golden because invariably after being assigned a patient or patients you will be required to present them.

Typically you will walk down the hall and stop at a patient’s room. After a brief pause, the person following the patient is expected to begin a short, succinct narrative describing the patient’s history, what happened since the previous day, and the plan for the patient. This narrative includes many things but if you think about it the SOAP note described in the previous section is a good place to start. If you write a good note before rounds and understand what is going on with the patient presenting to the team should be a snap.

Naturally you should know any pertinent lab values and the meaning of either their normalcy or derangement. You should also know what consultants have advised, either by talking to them informally (a “curbside” consult) or the contents of their formal written recommendations.
Any studies or images ordered on the previous day also need to be reviewed. You should look at the films if possible ( this is getting easier because many hospitals have them on line) but at least read or listen to the dictated reports.

Rounds can be a lot of things. They can be grueling tests of your endurance as is typical on an internal medicine or medicine subspecialty service. You might, for example, spend an hour in front of a patients room listening to the Attending opine on the meaning and significance of a low serum potassium followed by a half-hour discussion of his differential diagnosis. A learning experience to be sure but quite tiring after the first five hours.

Get comfortable shoes.

There is such a thing as “speed rounds” which are typical of most busy surgery services. In this case the attending wants you to be succinct . Typically the discussion will focus on the presenting complaint only with an eye to cormorbidities only as they impact the progression of the surgical patient towards his usual state of health.

In other words, your goal is to diagnose his ischemic bowel, surgically repair the damage, and manage his recovery to whatever good or bad state of heath he was in before the operation. Surgeons have full time jobs in the operating room so while rounds are important, they are a necessary evil.

Occasionally you will have “sit down” rounds where the patients will be discussed around a table after which you will go as a team for “speed rounds.”

A note on rounding etiquette.

Do I need to state the obvious that you should be attentive to the attending and the chief resident? Pay attention and keep your mouth shut unless asked a question or unless you have something relevant to add to the discussion. Maybe even if it is a joke but you should carefully assess your Attendings disposition before you make a foray into humor.

Generally, as a medical student you will have very little of relevance to add to the discussion. Your attempts to demonstrate your limited knowledge will make you look like a tool so look interested, stand where you can be seen, and keep yer’ cake hole shut.

Since one purpose of rounds is for the Attending to confirm physical exam findings, you should accompany him into the patient’s room and stand ready to assist him in his physical exam. Not only is this expected but you will also pick up invaluable physical exam pointers which will serve you well in later years.

Keep notes. Often your resident or Attending will make what you think is an off-hand remark about a lab value she’d like to see. Meaning that she’d like it ordered so she can see it. Don’t hesitate to clarify the plan before you move to the next patient by confirming your impression of what is needed.

Of course you need to be punctual for rounds, even if they start at some ungodly early hour like they will for most surgery rotations. You also need to dress up, not down, on your first day unless explicitly told to do otherwise. Many Attendings are “old school” and expect a shirt and tie for rounds. If your Attending and residents are in scrubs then you can emulate them.

A word about “pimping.” During the course of rounds (and during surgery, clinic, and just about every other activity for that matter) your Attending or residents will ask you questions to test the limits of your medical knowledge. This practice, known as “pimping,” is traditional and a valuable part of the learning process. Invariably however you will be asked a question which you know you should know but don’t and will stand gaping like a fish making apologetic noises or inarticulate grunts.

Don’t sweat it. Nobody expects you know everything. More on pimping in the next section.

What are the keys to rounding as a third year?

Enthusiasm, punctuality, attention to detail, and a little bit of humility. You are not going to save the world and you are not, despite what anybody tells you, a vital part of the health care team.