Back to the Bedside: A Primer on Effective Walk Rounds Maggie Benson, MD Vikram Krishnasamy, MD Melissa McNeil, MD Shanta Zimmer, MD What do YOU want to learn today?
By a show of hands: Who leads walk rounds at your institution? o The resident mostly o Attending mostly o A combination of both Where do patient presentations take place most days? o In the team room o In the hallway o At the bedside Will you complete time as a ward attending during their chief year? o Yes o No
For the junior student.... It is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself. Sir William Osler, 1903 Walk Rounds: A Lost Art? Time spent at the bedside is decreasing o 2009 study of 102 med students and 51 residents o 27% of rounding time was spent at bedside o Case presentations given at bedside only 25% of the time Gonzalo, JD et al. Teaching and Learning in Medicine. 2009
Our objectives: To obtain a set of principles to apply to walk rounds o When leading rounds o When remediating rounds To identify strategies to overcome barriers to Walk Rounds To develop ideas on effective teaching during bedside rounds To encourage you to move rounds Back to the Bedside
Break Out Session 1 What are the goals of walk rounds? What are barriers to effective walk rounds? Reflect on your own experiences How do they work at your institution? Useful? Educational Benefit? 15 minutes for discussion 5 minutes for recap Back to the Bedside: Strategies for making bedside rounds work
Get your learners to believe! Orientation on Day 1 Ask your learners about their experiences Get buy-in from your team o 73% of residents believed bedside rounds are better for patient care 1 o Rounding at the bedside did NOT take more time 1 1. Gonzalo et al. JGIM. 2010 2. Lehman et al. NEJM 1997 What do patients think? 1997 study: Majority of patients prefer to have the discussion of their case in their hearing o Feel included o Reassured that they are in the know o Opportunity to correct information/assumptions o Opportunity to involve family Lehmann et al, NEJM, 1997 April 17; 336(16): 1150 5
More Data A 2003 study at the University of Washington showed: Increased patient satisfaction An increased preference for future presentations at the bedside A 1997 Australian study, patients surveyed noted: Increased understanding of the problem Minimal anxiety Would recommend it to other patients Rogers HD, Carline JD, Paauw DS. Examination room presentations in general internal medicine clinic: patients and students perceptions. Acad Med. 2003;78(9):945 94 NAIR, B.R., COUGHLAN, J.L. & HENSLEY,M.J. (1997) Student and patient perspectives on bedside teaching, Medical Education, 31, pp. 341 346. Set the Stage Set a start and end time o Rounds should NEVER last more than 2 hours o No more than 10 minutes per patient Expect all team members participate o Ask for minimized interruptions Define roles: o Medical students and interns present o Resident and attending roles will vary Institution Call and clinic schedules Make a plan prior to rounds
Help your learners succeed Presenting at the bedside can be anxiety-provoking Bedside presentations should be: o Organized SOSOAP o Focused Time limit: 3 minutes o Goal-directed Make a plan for the day Organization is Key! Summary statement o Engages all team members in the discussion o Should change as understanding improves Overnight Events Subjective o Can organize by problem list Objective: Exam and Data o Pertinent positives and negatives only Assessment and Plan
Saving the best for last: Assessment and Plan Organize the assessment and plan together by problem list Assessment o Includes a focused differential diagnosis and reasoning for newer patients and problems o May be brief and include the final diagnosis only once established Saving the best for last: Assessment and Plan Plan o To Do list for the day o Is specific and detailed Ex: Mr. Smith is currently on day 8 of 10 of pip/taz for HAP. o Does NOT include chronic problems No need to discuss hyperlipidemia and hypertension if controlled and no change to home medications o Identifies clinical questions and plan for researching answers
Less is more! Empower your learners only include information that impacts clinical reasoning o Mr. Smith is a 56 yo man who presented with sepsis secondary to an E. coli UTI. His dysuria and frequency have resolved. He remained afebrile overnight with an unchanged exam today. WBC has declined from 16,000 to 7,000. He is now on cefuroxime, day 4 of 7 and is ready for discharge to home. Bedside Presentations: Getting It Right Provide real-time and ongoing feedback
Implementing Your Rounds Who to See When? Think about who you need to see, and what you need to accomplish with each patient prior to rounds The resident manages the flow o Decides who is appropriate for bedside rounds o Decides who to see first Should change every day Flexibility is Key!
Who to See When? Who to see first: o Sick patients who need an immediate plan o Patients that require higher level clinical decisionmaking o High educational value for trainees Who to see later: o Clinically stable patients who have an established plan Who to defer bedside rounds: o Sensitive issues new cancer diagnosis, STD o Psychiatric illness or cognitive impairment o Use your judgment Time Management Total rounding time: 1.5 2 hours MAX o Set a start time o Set an end time and stick to it! Per patient: 10 minutes MAX o 3 minute presentation o 7 minutes for exam, discussion, wrap up o LESS for stable patients with unchanged plan
Time Management Round with the full team Involve interns in each other s patients If necessary, split the team o Family Discussions o Acute Deterioration o Early Discharges o Stat Consults Prepare your Patients Introduce the team Tell the patient what to expect Ask for permission to do an exam or discuss potentially sensitive topics Encourage participation o Give an opportunity to make additions or corrections o Summarize the plan for the day o Ask for questions
Overcoming patient discomfort Ensure privacy o Close the door o Draw curtains Make yourself comfortable o Gather team members around the bedside o Have leader sit down on the bed or in a chair Avoid medical jargon When done well, the bedside evaluation helps to preserve person-ality both the embodied identity of the patient and their humanity and it validates the patient s complaint by focusing attention on the soma. Verghese, A, et al. The Bedside Evaluation: Ritual and Reason. Ann Int Med. 2011. 155:550-553
What About Teaching During Bedside Rounds? When you are making bedside rounds with your team, have you had effective teaching moments? What kinds of things are best taught? How is it done most effectively? Benefits of Bedside Teaching Allows you to confirm data Opportunity for real time correction of mistakes More time with the patient and family Can be time efficient if done well Benefit of role modeling, which is extremely powerful as an educational tool!
Why Teaching at the Bedside is Helpful? Allows for direct observation of communication skills of the learner o Role modeling of excellence in communication, professionalism, and humanism o Role modeling of difficult conversations Allows for direct observation of physical diagnosis skills o Immediate correction of mistakes o Demonstration of appropriate technique Learner Perceived Value Learners believe bedside teaching is valuable Learners believe that bedside teaching is underutilized Williams KN, Ramani S, Fraser B, Orlander JD. Improving bedside teaching: findings from a focus group study of learners. Academic Medicine. 2008;83(3):257.
What Things Are Best Taught at the Bedside? Role modeling of professionalism Doctor-patient communication Physical diagnosis Humanism in the doctor-patient encounter Case based teaching Williams KN, Ramani S, Fraser B, Orlander JD. Improving bedside teaching: findings from a focus group study of learners. Academic Medicine. 2008;83(3):257.
Tips for Success Teaching points need to be CASE BASED Should be brief and focused to an issue at hand, not a dissertation Example: when I am trying to assess a patient s volume status, the orthostatic vital signs are one of the most sensitive indicators of volume depletion. Tips for Success Involve all learners Ask questions of team members not actively caring for the patient Keep all members of the team engaged o Example: OK, let s go around and everyone give me a treatment for hypercalcemia Brief, focused, pertinent Ramani S. Twelve tips to improve bedside teaching. Medical teacher. 2003;25(2):112 5.
Tips for Success Teach to your strengths o Remember, as a resident, you get to decide what teaching points you are going to make! Think out loud o model your decision making, even your uncertainties Clinical reasoning is a much desired skill o a GREAT time to voice your thinking (and to probe for the thinking of other team members) Teaching Techniques Broadening Targeting Novelty Up the Ladder Student as Teacher Change specifics of case to challenge team members Ask specific questions to specific leaners Offer newly published data, EBM Start with the most junior learner Have the intern teach the medical student Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: A pilot survey and systematic review of the literature. Medical Teacher. 2011;33(12):644 50.
Checklists Checklists remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance. Atul Gawande, The Checklist Manifesto Bedside Teaching Checklist Think out loud Teach to your strengths Model decision making Demonstrate physical exam Model communication techniques Evidence Based Medicine Delegate teaching topics to your team members
Checklist For Each Patient Prophylaxis: What is it and do they need it? Diet: Can it be advanced? Does the pt require a specific diet? Activity: Is PT necessary? Can Activity be advanced? Lines/Tubes: What lines or tubes are in place? Can they be removed? Derm: Has the skin been checked? Has the pt been turned? Are wounds healing? Family: Has the family been updated? Debrief Your Rounds Checklist Length Presentations Patients to spend more/less time at bedside Teaching Distractions
Break Out Session 2 Let s apply these principles! Take Home Points Bedside Rounds can promote patient care AND enhance learning WITHOUT increasing time Coach your learners to give focused presentations with a goal of making a plan for the day Hone your teaching points and teach to your strengths! Gonzalo JD, Chuang CH, Huang G, Smith C. The return of bedside rounds: an educational intervention. Journal of general internal medicine. 2010;25(8):792 8.
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