Dark Rounds FREE

It's 5 a.m. and I have just finished rounds on my busy general inpatient service. I have done a history and physical exam on 18 patients—of whom 10 were new admissions—on eight different, geographically separate nursing units on five floors. I am tired, but the day has not really begun. I must dictate my notes; go over yesterday's correspondence; answer phone calls from the East Coast (the Midwest and West Coast will have to wait until “working hours”); then go to morning report, teaching rounds, noon committees or conference; and see outpatients, students, and faculty. By 3 p.m., I will be a mental fungus.

Being a teaching attending in an academic medical center has changed since I was a house officer 30 years ago. My attendings would come in 3 days a week, sit with us in a small room for an hour and a half, listen to the presentation, and then—perhaps having shaken hands with the patient, though just as often never having seen them—discuss pathophysiology, biochemistry, differential diagnosis, and therapeusis of a disorder (which the patient might or might not have) of greatest interest to the attending. Care of the patients was almost entirely in the hands of the housestaff, and it frightens me, in retrospect, to think of the decisions we made alone.

Now, on a university internal medicine service, my team of resident, two interns, a senior student on clerkship, and two to three 3rd-year students admits patients 3 days out of 5. Each one of these patients must have a history and a physical exam done personally by the attending, and the work must be extensively documented in a formulaic but periodically inexplicably mutated style acceptable to the third-party payers and the federal government. A daily follow-up exam and note on each “old” patient are also required. Inpatient length of stay is significantly shorter; the technologic diagnosis is considerably greater; and, depending on how one constructs it, teaching rounds often less resemble the archetypical faculty discussions than they do faculty functioning as a senior resident on work rounds.

My hospital has a schedule not unlike that of most academic teaching centers. The housestaff sees their patients before morning report. At 8:30 a.m. we join together for 1 hour at morning report, then, at least 3 days out of the week, we proceed to teaching rounds for 2 hours. The afternoons are left to work, new admissions, and discharges. The teaching attending, who is often assigned for a 3-week period, may also need to meet his or her other obligations throughout the period of the attending stint. There are no longer weekends to “catch up” on the paperwork, since patient care does not stop on weekends.

Perhaps most disturbing to me as an attending is the frequent inability to even find the patients, far less their charts. The hospital is a hive of activity during the day. Patients are taken away from their rooms for diagnostic studies, visited by consultants, or moved from room to room to accommodate other patients. Just tracking them down is a major effort, let alone spending time with them to listen to their history and do their physical exams in anything remotely resembling an environment suited for the interchange of intimate details between patient and physician.

“Teaching” rounds have become the presentation to the attendings of the facts of all the cases, which leaves little time for any discussion other than of the immediate pragmatic necessities for care and rapid discharge under the pressure of utilization review. Watching the other teams, as well as my own, it appears to me that the flow of information no longer moves from attending to student. Now it moves mostly from housestaff to attending, so he or she can write billable notes. I could not remember the names or the faces of my patients, much less the increasingly severe and complex multiple symptoms and findings they presented. It was particularly difficult when I would have 10 patients in follow-up and 10 new patients to evaluate in a single day.

One day, I do not know why, perhaps on another errand or by some whim, I got myself up out of bed and came into the hospital very early in the morning—about 3 a.m. I discovered a place not that unlike the predawn hospital of 30 years ago. The charts were all in their racks, the nurses were eager to tell you what was going on with your patients, and the patients were in their beds. Housestaff on cross-cover occasionally rushed by, but seldom had time to chat. I thought that the only differences between this place and hospitals that I remembered from my youth were the ubiquity of a blaring television over the foot of every comatose or confused patient's bed and the computer terminal from which laboratory results could be readily obtained—but only at night, when there is not a line of house officers and nurses waiting to use the modem.

I found out who my newly admitted patients were and visited them one by one. Having recently come in, they were dreadfully ill and did not seem to mind being visited by the attending at 3:30 or 4:00 in the morning. The room was relatively quiet once I turned off the television set, and I could sit at the bedside and listen to a history, do a physical exam (actually hearing murmurs and bruits because the decibel level was low enough to allow for such sensory data to penetrate), and compare my findings with those of the housestaff admission notes. I was delighted to find that I could still discover things that they did not know and so augment their work. I could easily write notes in the charts because the charts were there. I genuinely enjoyed that since during teaching rounds later that same morning after morning report I knew exactly which patients I wanted to take my housestaff to see to demonstrate physical findings, to illuminate a piece of history, to model interactions, or to make inquiry at the bedside of their impressions. Some patients told me, in a variety of ways, that they needed us to come by as a team, both for their therapeutic comfort and for their desire to participate in teaching. I was prepared to discuss the issues surrounding the patients, since I had already met all of them. Most of all, I did not feel rushed. I saw the patients, I wrote the notes, and now the 2 hours of teaching rounds could be pure teaching.

And so I began to come in during every attending stint in the darkness before—way before—the dawn and more wonders appeared. The nurses appreciated the time and the colleagueship and could tell me things that I otherwise would never had known both about the patients and themselves. Their generosity of spirit, their true concern for patients, and their professional expertise became much more evident than it had been to me in the more frenzied environment of the daytime. We had coffee together as we discussed the patients, and I was able to teach them, as they were able to teach me. I had time to speak to families, particularly those of the severely ill, since the families would often be in the rooms with their dying parent or spouse, and they deeply appreciated the uninterrupted process of discussion—again a rarity during the daytime. Far from resenting my early visits, the sentient “old” patients asked me to be absolutely sure to wake them when I came, as they had much to tell me. I was able to dictate the findings of the complete history and physical exam very early in the morning, and I had the dictated record, both of new patients and follow-up, in the chart by that same afternoon. I felt again as if I were making a contribution to patient care, rather than serving in a secretarial function for billing purposes. I actually began to think what I said might make a difference, not just in the generation of clinical revenue, but that people might read my work-ups and get ideas from them. In short, write-ups became more enjoyable and less rote documentation for faceless bureaucrats to use to decide whether or not I was a cheat.

Yet other accruing advantages became clear over time: I began to be seen as virtuous by my colleagues and by those other services whose staff habitually worked nights—surgeons, emergency department physicians, on-call housestaff. I was one of them, and thus to be respected. Best of all, by late afternoon, people knew that I was functioning poorly, and often excused me from committee meetings and the other ancillary delights of academic medicine. After all, by 3 in the afternoon, I had often already been working for 15 hours (minus a 1- or 2-hour nap).

Not everyone can do this, obviously. Some are constitutionally unable—a matter of biorhythms, I think. Others have families who would protest, and justly. It is not with a recommendation that all follow suit that I write this piece, but rather to let those teaching physicians who are unhappy, frustrated, rushed, and harried in the modern academic environment know there is a quieter place, an older place, a more fulfilling place—the subdued hospital in the dark of night.

Faith T. Fitzgerald, MD

University of California, Davis, School of Medicine

Davis, CA 95616