Let’s Pre-Round!

Doc Gurley is the guest at Medscape’s Pre-Rounds! Check out her interview by Nick Genes, the creator of Pre-Rounds at Medscape and Grand Rounds of blogs. So what the heck is pre-rounds? Other than something less impressive-sounding than Grand Rounds? Medscape Pre-Rounds, in inimitable Nick Genes style, means an early, in-depth interview with a writer who’s hosting Grand Rounds of healthcare blogs. Real pre-rounds, in actual practice, are a time-honored hospital process that you pretty much never see in the TV versions of medicine. Here’s an insider peek at the whole complicated process:

When you’re the lowest on the team’s totem pole (intern, med student), your job is to wake up in the dark, and get to the hospital before any of the rest of the team. Bleary-eyed, you check vitals and examine every single one of your patients before the resident arrives (usually at 7:30- 8 a.m. on medicine services, or as early as 6 a.m. on surgery services). At the appointed hour, all the residents sail in, looking fluffed and rested with a steaming latte and a sarcastic comment ready to fire at you. That’s when actual rounds (including additional team members like pharmacists) truly begin. One of the greatest “gifts” a resident can give her exhausted team is permission to not pre-round the next morning – it’s a gift of at least an extra hour of sleep. Oh, the looks of sheer gratitude. Never again will you be so adored. So what’s the point of pre-rounds, other than sheer torture for the intern? Well, a typical hospital team is usually one resident and two (or more) interns/medical students. If you (the resident) have a huge service (“service” is the slang for the number of patients your collective team has), there is no efficient way to make it through seeing all the patients if you’re sorting through vital signs, asking the nurse how the night went, doing a thorough exam on each one. Pre-rounds allows the resident to hear about the patient, dash in and check the pertinent issues, then dash on to the next person. Pre-rounds and rounds (including specialty ICU/CCU type rounds) both have to occur before attending rounds (talk about waltzing in later!). Many residency programs now try to “cap” (or limit) the number of patients on any one service. Without caps, it’s not that rare for a service to get as large as 30-35 acutely ill patients, including several in the ICU/CCU. Imagine how carefully an intern on that team will try to calculate the exact hour he must get up in the morning if he knows he’s going to need to examine 21 people before 8 am (that’s really what all those math prerequisites for med school are for). What happens if no one pre-rounds? If there are no pre-rounds, and a service is large, some patients won’t get checked on until the afternoon – and that’s a problem, both because people can get sicker really fast, and because once things get delayed, everything dominoes into later and later in the day. No one wants to be calling radiology to come do an X-ray at 7p.m. that should have been ordered before dawn.

Med students and interns begin their training hating pre-rounds. Then there’s something odd that happens. Sometime about three months into the year, you ask the nurse how the night went, you flip through the vitals outside the door, and then you tip-toe into a darkened room. You whisper to your patient that you’re sorry to wake them as you warm your stethoscope between your hands. You slide the thin woven covers back and put your stethoscope on your patient’s back and you listen to someone breathe, half-awake. You whisper a question – is that pain gone? and you get a sleep-crusted smile. You tuck your patient’s covers as you whisper a good-bye, that you’ll be back later with the team. Then, as you power-walk through the heavy sighing door onto another wing, you suddenly realize what an honor it is to have this morning time, to be the one who checks first, the one who makes sure nothing bad happened over night – before the day cranks out of control and the long discussions begin of diagnosis and disposition and discharge. You smile and pick up the pace, half-jogging to the next room, wanting to see what’s next.

So why doesn’t Hollywood use pre-rounds in its medical shows? Honestly, I think it’s because they just don’t know about pre-rounds – because, boy, is it a great process for depicting drama, in-fighting, posturing, power, and insider details. The whole orchestrated process can involve (as you can imagine) a lot of egos. Interns are dashing back and forth, grabbing charts, waking patients, badgering nurses, and the whole time the clock is ticking – the residents (arrogant, kind, furious, or distracted) are arriving, hurry, hurry!

But I admit, I could be wrong about that. It could be that television doesn’t typically use pre-rounds as a concept because NO ONE (not even Dr. Dreamy) can look great stumbling into the hospital before dawn with flattened bed-head and drool crusted on a cheek.
Or maybe that’s just me.

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