Resident Perspectives Regarding Education on Attending Rounds

Abstract

INTRODUCTION

An important component of internal medicine resident education is morning (attending) rounds. Effective aspects of medical education include involving all team members, minimizing distractions, asking questions, and having ready access to data, all of which may not be present during rounds. There is limited information on learner-centered rounds or resident perspectives about education during rounds. To inform a learner-centered approach to rounds, the investigators conducted a focus group study of Internal Medicine residents exploring their perceived strengths and weaknesses of rounds, and how rounds could be better used as a teaching tool.

METHODS

Three 60-min focus groups were conducted with N = 21 postgraduate year 2/3 Internal Medicine Residents at Montefiore Medical Center in Bronx, NY, USA in 2021-2022. Two resident investigators led the focus groups using a semistructured interview guide. Questions included defining types of rounds, benefits and pitfalls of various rounding styles, their impact on resident education, and recommendations to improve education on morning rounds. The sessions were audio recorded, transcribed verbatim, and de-identified. Transcripts were analyzed through inductive thematic analysis.

RESULTS

Rounding styles identified were bedside, table rounds, and a hybrid approach. Three themes emerged through analysis of the data: (1) A hybrid model offers an optimal balance of education; (2) full bedside rounds have unintended pitfalls; and (3) Attending preparation affects the quality of rounds.

CONCLUSIONS

Residents’ perceptions of the education on attending rounds are impacted by both attending rounding style and advanced preparation. Our participants’ insights could inform a rounding approach that optimizes both patient- and learner-centeredness.

Introduction

In many academic medical centers in the United States, morning rounds encompass presenting and reviewing overnight admissions and discussing the team's prior patient census with the supervising attending physician. Morning attending rounds (rounds) are an important educational aspect of the day for Internal Medicine residents during inpatient rotations, however the educational value of attending rounds is variable and remains relatively underexplored.^1,2 There is a growing tension in US Graduate Medical Education between residents’ clinical obligations and education. ³ Increasingly, evidence suggests that education separate from the workplace—classroom-based education—may help ease this tension. Classroom-based education separates the needs of patients and health systems from direct educational activities that can serve the educational needs of trainees. ³ With the advent of classroom-based education, the expectation is that classroom and clinical activities will become complementary in resident education. ⁴ Despite the increase in classroom-based educational activities, residents spend the majority of their time on the wards, and attending rounds serve as a focal point for education on the wards. While graduate medical education has been evolving, inclusive of duty hour restrictions and the increasing complexity of hospitalized patients, the gold standard of bedside rounds as the “preferred” modality of attending rounds has persisted. ²

Although it seems to be common knowledge that bedside rounds are the preferred modality for hospital-based rounding, the impetus for bedside rounds is primarily drawn from hospitalized patients’ satisfaction ratings.^5,6 In a study of 182 hospitalized patients published more than 25 years ago, the authors concluded that bedside case presentations are “at least as good as conference room presentations, and perhaps preferable.” ⁵ The only favorable outcome was increased perception of time spent with their physicians in bedside versus conference room-based rounds, while patient perceptions of care did not differ significantly between the two groups. This single-site study may not reflect the educational, linguistic, and socioeconomic diversity of our current patient population. Given that the complexity of hospitalized patients has increased over time, ⁷ these patients likely had fewer comorbidities to discuss at the bedside than our currently hospitalized patients. Furthermore, a study of bedside rounds conducted by nonteaching hospitalist services showed no positive impact on patient perceptions of their care. ⁶

In addition to patients, residents are important stakeholders to consider during rounds, yet their perspectives remain understudied. Expert opinion remains divided regarding how best to structure rounds, specifically regarding rounding at the bedside or away from patients. ⁸ Attendings’ bedside teaching practices have been qualitatively explored, ⁹ and bedside teaching activities quantified.^1,2 Observational research quantifying the activities of attending rounds demonstrated frequent discussion of patient care plans, review of diagnostic studies, and communication with patients. ¹ While these are all important aspects of patient care, the investigators uncovered a lack of learner-centered education, including education on learner-initiated topics, despite the study being conducted within a university teaching system. ¹ Learner satisfaction with attending rounds has been quantitatively assessed, ¹⁰ as well as through one question as part of a larger study, ² but to our knowledge, there have been limited explorations of resident perspectives of attending rounds, and their perception of the influence that the structure of rounds has on their education is even less well understood. Without further understanding of the perspectives of these important stakeholders, initiatives to enhance learner-centered education during attending rounds will be stymied. To address this gap, we conducted a focus group (FG) study of Internal Medicine residents to explore what they view as strengths and weaknesses of rounds, and how rounds could be better used as a teaching tool.

Methods

We recruited a convenience sample of resident volunteers (participants) from within the postgraduate year (PGY) two and three classes of an internal medicine program at an urban, academic medical center in Bronx, NY between October 2021 and January 2022 for this qualitative study. This residency program has approximately 114 categorial Internal Medicine residents who work at two main inpatient clinical sites. PGY-1 residents were excluded given limited time of exposure to the inpatient wards in comparison to PGY-2 and PGY-3 residents. We conducted 60-min FGs virtually throughout regularly scheduled resident didactic time during clinic rotations and all PGY-2 and PGY-3 residents who were available were included. Email announcements were sent beforehand, and participation was optional; written informed consent was obtained from all participants. Two resident investigators (AS, IL) led the FGs using a semistructured interview guide. This guide was created iteratively by the investigative team based on perceptions of impactful medical education related to topics covered in the Stanford Faculty Development Center for Medical Teachers seminar series. ¹¹ It was reviewed with the senior author (CMG-an expert medical educator and a trained facilitator of the seminar series) after the first FG to identify areas for revision. Broadly, questions elicited participant perspectives on various topics including identifying benefits and pitfalls of various rounding styles, obtaining participants’ perspectives on the impact of various styles on their education, and recommendations to improve education on rounds. The sessions were audio recorded, transcribed verbatim, and de-identified.

In terms of reflexivity, two of the investigators were current residents and specifically immersed in the Medical Education Pathway, while the third was faculty who teaches in the Pathway. All are invested in resident education and strive to maintain engaged curiosity and make space for divergent opinions throughout the analytic process.

Data Analysis

Transcripts were analyzed using inductive thematic analysis methods. ¹² Two investigators independently reviewed each FG transcript in order to identify topics covered, generating preliminary codes. The two investigators met to discuss the codes, arrive at consensus of their meanings, and create a codebook. The codebook was then applied to all transcripts. The investigators identified associations between codes, discussed their meanings, and generated themes in an iterative process. All procedures were approved by the Institutional Review Board of the Albert Einstein College of Medicine (Reference # 077821).

Results

We conducted three FGs for a total N = 21 participants (range 6-8 participants per group). In total, 62% (13/21) of the participants were female, 38% were male and 62% were PGY-3 residents. Participants discussed three different rounding styles identified were bedside, table rounds, and a hybrid approach. Bedside rounds were defined as rounds that took place entirely at the bedside including the entirety of the presentation, assessment, and management plan. Table rounds, in contrast, were defined as rounds that were conducted completely independent from the bedside of the patient. Lastly, a hybrid approach was a combination of review of the presentation, objective data, and assessment and plan-making away from the bedside followed by a bedside component where the team visited the patient together to complete rounds (ie gather additional subjective information, examine the patient, explain the plan, etc) Three themes emerged through analysis of the data relevant to the identified rounding styles: (1) A hybrid model offers an optimal balance of education; (2) full bedside rounds have unintended pitfalls; and (3) Attending preparation affects the quality of rounds.

Theme 1: Resident Trainees Prefer Hybrid Attending Rounds

A hybrid approach of discussing the patients in a conference room followed by seeing the patients as a team thereby combining elements of table rounds and bedside rounds, resonated with our participants. In each FG participants came to the same conclusion while defining rounding styles and highlighting the advantages and drawbacks of each defined approach to rounds: They perceived a hybrid approach to most evenly balance the opportunities and obstacles introduced by both completely bedside and completely table rounds rounding styles. One participant noted I think there is an educational value in laying eyes on the patient and examining the patient. But I think you lose some of the educational component if it's all by the bedside. I really like having a quiet space around a table with a whiteboard or a monitor to talk about the patient and look things up (FG2). Participants appreciated the combination of less interruptions and the ability to discuss complex problems and develop broad differential diagnoses with the ability to clarify clinical questions in real-time and review of physical exam maneuvers.

By separating presentations from the patients themselves, participants were more confident and comfortable in offering their own clinical reasoning without fear of confusing and frightening patients with medical jargon. One participant stated, If you're trying to come up with broad differentials and think through things sometimes, the words and the jargon that you're throwing out can scare patients and [go] into holes that you don't necessarily want to go down. But it is important to think about, you know, about malignancies and other things that may not always be best to be shared at the bedside (FG2). Although participants noted diverse experiences across attendings’ practice variability, overall they perceived conducting part of rounds away from the patients to be both educationally beneficial and time efficient.

Theme 2: Full Bedside Rounds Have Unintended Pitfalls

Many participants appeared frustrated when describing full bedside encounters, which they regarded as an ineffective use of their time. (FG3) Participants noted that attendings frequently re-elicit the entire history and that the goal of making rounds educational is sometimes at odds with…[patients’] priorities (FG1). Re-eliciting the history takes away from education, because it's just a time crunch so you're hearing the history two or three different times and then that means that there's less time to actually focus on learning points (FG2). Additional teaching points may be lost at the bedside for other reasons. For example, The overwhelming, I think, feeling from residents is that they feel less comfortable asking questions or showing that they don't know an answer so it if it's done entirely bedside it can decrease the learning from that perspective (FG2). Avoiding demonstrating uncertainty in front of patients may be an unintended consequence of bedside rounds.

Theme 3: Attending Preparation Affects the Quality of Rounds

Participants agreed that although attendings had varied approaches for rounding, perceived preparation by attendings improved their educational experience. The best attendings have clearly looked into the admission already, and they have prepared their teaching points [before rounds] (FG3). Participants noted [Attendings could] look at the list of patients that are from overnight and just kind of look at what main problem they came in with and then just sort of quickly prepare something before coming into rounds (FG2). Participants observed that attendings who prepared for rounds had enough familiarity with the history so that they may not feel compelled to have to gather the entire history on their own. Any gaps in the history that need to be filled can be done so later at the bedside. Some participants advocated for standardization or short faculty trainings. What I'm getting a sense of is that a lot of the discrepancies how attendings use [rounding] formats and maybe having some sort of standardization or some sort of short training for attendings [would be beneficial] (FG3). Faculty development may better prepare attendings to approach rounds with more of an emphasis on resident education.

Discussion

Our study highlights the educational benefits and pitfalls of various rounding styles, while offering suggestions to improve the educational outcomes of morning rounds from one group of important stakeholders, learners. Our participants preferred rounding style included a hybrid of bedside and table rounds that optimized opportunities for both education and patient-centered care. Full bedside rounds had the unintended consequence of perceived loss of teaching opportunities. Participants noted frustration in re-eliciting patient history and poor use of time when rounds were conducted completely at the bedside. To enhance the learner-centeredness of rounds, participants suggested attendings read the charts prior to better focus on education and participate in brief faculty development programs on providing effective education on morning rounds.

In hybrid model rounds, the table-side portion away from the patient offers opportunities for teaching more akin to classroom-based education where the focus can be on developing clinical knowledge. McGee (2014) notes that complex discussions surrounding pathophysiology and clinical management lend themselves towards teaching in a classroom setting, while communication, professionalism, and clinical skills may be better evaluated at the bedside. ¹³ The bedside portion allows for practical workplace-based learning where residents learn by doing—by examining the patient or clarifying key portions of the history. Our participants noted the education benefit of “laying eyes” on the patient as a team, and examining the patient facilitates attending supervision of physical exam skills and bedside clinical skills that cannot be perfected away from patients. Examining the patients as a team also signifies to the patient who their care team is and shows that many people are involved in discussing their care which may make patients feel cared for.

However, when the entirety of rounds occurs at the bedside, there is a substantial risk for inefficiency and inadequate management of time which conflicts with learning opportunities. Our participants note this predominantly when the time at the bedside is spent solely on obtaining history that was already presented previously leading to redundancy with no educational benefit. Strategies to navigate this conflict include discussing as a team what are the goals of the bedside portion of rounds on each case—what exam findings need to be evaluated? What history needs to be clarified? Having a structured plan when transitioning from the table to the bedside as a team would avoid aimless patient interactions and improper use of time.

A qualitative study from 2016 evaluating internal medicine and pediatric resident's perspectives regarding rounds noted three major themes encompassing the purpose of rounds: patient care, clinical education, and patient/family involvement, while noting that the multiple competing purposes lead to conflict and perceptions of less teaching on rounds as a result. ¹⁴ Additionally, Roy et al (2012) presented five domains for successful attending rounds that were gleaned from both learners and attending physicians: Learning Atmosphere, Clinical Teaching, Teaching Style, Communicating Expectations, and Team Management. ¹⁵ The themes we have elicited from our participants can augment this perceived decrease in teaching on rounds and build upon the domains previously described in the literature. A hybrid style of rounding aids in optimizing the learning environment and affording opportunities for clinical teaching in the appropriate context. A hybrid model of rounding also allows for a diversity of teaching styles and learning styles. Mitigating the unintended pitfalls of full bedside rounds enhances the clinical teaching on rounds by providing learners a safe space to ask questions and reducing redundancy.

Engaging stakeholders is a key component of curriculum development in medical education. The dearth of research engaging residents as stakeholders and investigating their perspectives on the educational value of rounds is therefore striking. Given the literature on patient perspectives that have seemed to influence faculty attitudes towards rounding styles, it is valuable to hear from residents themselves regarding education on rounds. Many aspects of effective medical education including having a space where all team members can participate without distractions, ask questions, and have ready access to all the available data, ¹⁶ are often not present in bedside rounding. As we seek to improve the educational value of attending rounds while balancing that with optimal patient outcomes, maintaining a focus on the perspectives of learners remains imperative.

Our participants’ insights could inform residency program efforts to enhance the educational value of rounds. There has been an increasing proportion of inpatient teaching responsibilities shifted to hospitalists. Similarly to other attendings, most hospitalists have not received formal education in teaching. A 2014 study has shown success in increasing the confidence of academic hospitalists in regard to teaching by implementing a simple peer observation tool. ¹⁷ Interventions like this to improve attendings training in clinical education could greatly benefit the educational value for learners on rounds and the self-efficacy of their teachers.

The next steps include collaborating with experts in faculty development programs to integrate resident perspectives as we strive to improve the educational value of attending rounds, balance service duties, and optimize patient outcomes. We expect to repeatedly engage with residents to explore their perspectives of implemented changes in a continuous quality improvement process.

Limitations

Limitations exist regarding our study. First, while we were able to determine a preferred modality for the conduct of rounds, our findings do not sufficiently specify how to conduct them. Further research is therefore required. While a hybrid approach to rounding is favored by the participants of our study, how rounds proceed will likely be affected by practice variability among different attendings. Different strategies have been described previously to help negotiate the perceived inefficiencies of rounds. A 2022 study investigating a novel rounding approach described multiple ways to enhance rounds including methods to improve time management and to focus the bedside portion by triaging patients more effectively. ¹⁸ Different attendings will likely incorporate a variable amount of these strategies, such that there is no “one size fits all” method of hybrid rounding. Additionally, rounds are increasingly becoming less “provider-centric” and there are more interdisciplinary members on rounds which may further change the variation seen by learners in the future. ¹⁹

Second, while our participants had a clear preference, this preference was developed at a particular center with a particular set of faculty; key differences in how rounds are conducted in other centers may influence these preferences. In addition, we included only PGY-2 and PGY-3 residents; while they all had experienced participating in rounds at a more junior phase of their training, it is possible that the recency of their current roles may have superseded perspectives they might have held when they were more junior.

Conclusion

Different rounding styles have unintended benefits and pitfalls that impact the educational value of attending rounds for residents; our participants suggested a hybrid rounding model would reconcile these tensions. Advanced preparation by attending may enhance the effectiveness of teaching on rounds. Future initiatives to improve the educational value of inpatient rotations and support attending's success conducting rounds should integrate the perspectives of learners as key stakeholders.