VCU Internal Medicine Training Program
How to run work rounds:
A perspective of various Internal Medicine programs
Mayo Clinic Jacksonville
Residents, along with interns and students, see each patient during work rounds. They then meet with the attending and discuss the less interesting or less involved cases over the table, and walk to see the more involved or more interesting cases at bedside (usually 2-3 patients). The attendings will have to round themselves on patients not seen with the group and go over any recommendations or changes later in the day (over the phone)
University of Maryland
6:30 am - 7:15 am - Intern pre-rounds
7:15 am - 8:00 am - Work rounds: The resident, interns, and students walk and "see" each patient together. The interns present tests from the previous day and significant events that have occurred overnight, and formulate a plan for the day. The resident modifies the plan and they move on. The acute patients are seen first. If an interesting physical finding is noted, it is reviewed with the students and interns. Patients with less acuity are seen very briefly.
8:15 - 9:00 am - Morning Report
9: 05 am - 11: 00 (11: 30) am - Attending Rounds: After the new patients are presented and seen, the attending and senior resident ONLY discuss the old patients and modify the day's plan. The whole team only sees the new patients, and acute patients together.
In our program, we do walking work rounds before morning report (7-8 approx.) Then MR is 8-9 and attending rounds from 9-11. Unless there is something remarkable, attendings are not to discuss old cases at attending rounds. That communication happens between the attending and the team resident. The resident then communicates info from the attending to the interns. Not talking about old patients during attending rounds (and I'm not sure if you even do this) cuts down on the length of attending rounds and empowers the resident during work rounds and the rest of the day.
VAGLAHCS, West Los Angeles
7:30a-9:00am - Work Rounds Resident does bedside/work rounds with the team which includes the two interns, social worker, case manager, dietician, and pharmacist.
10:00a-12:00pm - Attending rounds with the team.
Most of our attendings round on the patient by themselves with regards to exam, etc. If there seems to be something the team didn't pick up, or the patient presents something new in his/her history, the attending will later review this with the entire team at the bedside.
University of Mississippi
At UMC (Jackson, MS), we have morning report at 9AM. The ward teams meet usually around 7:30 or 8 AM, depending on patient census, and the houseofficers round with the medical students. The students will have already seen the patients and we try to take care of as many orders as possible while on work rounds. It's helpful to carry the charts around with the team to facilitate this process. Attending rounds start at 10 AM, and usually last until noon conference. This process works pretty well for us.
We have resident-led work rounds with the resident, interns, and students seeing each patient between 7:30am to 9:00am. The interns and students pre-round prior to this. From 9:00am-10:00am we have morning report. Immediately after morning report, we start teaching rounds with the staff that lasts until 12:00pm. This has worked out well from both standpoints of the residents teaching and getting their work done. It leaves ample time for teaching by staff.
UCLA
Here at UCLA we have work rounds with the interns and residents from 7:30 to 8:30 where we see all the patients quickly and talk about management issues/problems. Then the residents (and interns if they have time) go to morning report from 8:30-9:30. Attending rounds are from 10am to 11am or 12 noon and we aim to just touch on key teaching points, didactic patient based teaching, presentations on relevant topics by the residents and/or medical students. We shy away from "nit picky" management during attending rounds unless the residents have specific questions and focus on teaching. It works well here.
UT San Antonio
From 7:00-8:00 am the residents conduct work rounds with the students and interns. All patients have been pre-rounded on and seen by either the student or the intern. The focus of work rounds is to catch up on what has happened over the last 24 hrs. The resident/interns/students see and selectively talk with/examine the patients, and the resident is able to do some teaching on each patient. Over an hour, the team can comfortably see up to 12-15 patients. Work rounds significantly cut down the time needed during attending rounds, and allows for a more focused, problem-oriented discussion. If the attending has different ideas on management, the team will spend time discussing this. This system gives the resident the autonomy and authority to be a true team leader. Attending rounds are happening between 10:30- 12:00. The time between 8- 10:30 is used for lecture and morning report for residents while the interns are taking care of daily business.
Maimonides Medical Center
We instituted work rounds about two years ago. I believe they are one of the most valuable parts of the day because they incorporate patient management with a great educational opportunity. We do team work rounds. The resident goes with the interns and medical students from bed to bed to see each patient. If the patient has been there for some time and does not have many active issues, the team may only spend a minute discussing the case. If the patient is new or more complicated, we would spend more time reviewing details of the history and going over the physical exam (making sure each member of the team auscultates, palpates, etc.). We then discuss differential diagnoses and management.
Doing the work rounds gives us the chance to formulate a plan of management before the service attending has a chance to, and gives us autonomy over the patient care. The service attending is used for guidance in the case rather than to manage the case on his own.
Tulane
At Tulane we have had work rounds at our hospitals for many years. Our current format includes resident work rounds from 7:30 (or 8:00 depending on pt load) to 9:00. The resident rounds with the whole team at the bedside, hears about any problems, reviews labs, and points out important clinical findings. For every decision or problem that arises, the resident then teaches the students and the interns an approach to the issue in a brief 2-3 min format. They also make sure all the labs are written for and all x-rays, etc. are viewed. After that we go to morning report from 9-10am and staff rounds are from 10-11:45. For us, staff rounds are traditional rounds only on the post call days when we will go see all the patients and have the students present them in a traditional way. But on the other days we try to only see a patient as a team if there is a real problem. Otherwise we will discuss the patients in a problem-focused way and the remainder of the time is spent with the staff teaching something. This could mean going around and doing physical exam maneuvers on patients or discussing the pathophysiology of a particular disease. Later the staff can see the patients briefly on their own to write their notes and make any suggestions for things they think the team has missed. This format is beloved by the residents.
