Way back after my first year of medical school, we were required to do a medical observership/attachment. Our school wasn’t too specific about where and in what specialty to do it, so I ended up shadowing/observing a general surgery attending in Toronto. I remember sitting in on his clinics in the beginning of the week, and scrubbing into surgery in the latter half. I was enthralled! I was excited! I’m trying to think back, and it may have very well been my first time scrubbed in the OR.
There was a peculiar thing that the surgeon would do each day as well – his secretary would print him off a patient list and we’d leave the office or OR and see patients in the hospital. Just me and him. He’d find the patient, have a brief look through the patient’s notes, pop in the patients room and say hi, find out how they’re doing. Then he’d leave and scribble a line or two in the notes. Then we were off to see the next patient.
He didn’t say much during this time, but I now realize that we were rounding on all his post-op patients. I think my perception of rounding was jaded by TV shows where an entire group of doctors goes from patient to patient presenting relevant details and the attending makes a plan while a scattered intern scribbles everything down in the patient’s notes. Where the attending asks relevant medical questions to pimp out the residents. There was none of that here.
And in reality, having a morning ward round for nearly two years now, I can still say that it’s nothing like what’s depicted on TV. Maybe it’s because I’m practicing in the UK where their system is a bit different. I’ve been on specialties that approach reviewing patients in different ways. In the ED, we gather in a seminar room every couple hours (during shift changes) to catch up on all the patients via a computer screen – who’s been seen, who’s been referred, who still needs a referral, who’s likely going home, and what the plan is for each patient. And in ED, your patient is basically your patient. A senior doctor will give their input or advice, but it’s your job to make sure all the investigations are done and checked, and a referral or discharge plan is acted on.
When I was on breast surgery, I was working under four different attendings. If one of them showed up in the morning, they only rounded on their patients; if they came at all. A lot of the times, I would round on the patients myself – check for any post op complications, check drains, make discharge decisions, write discharge letters.
When I was on acute medicine, there would normally be two ward rounds during the day, and every day it was with a different attending and a different set of patients because of the high turnover of the unit. On the opposite hand, when I was on acute geriatrics, the attending would only round on Tuesdays and Fridays, and it was up to us young residents to manage the patients every other day – mind you, there was nothing acute about the specialty because these patients were treated very quickly and then spent the next several weeks having physiotherapy and occupational therapy assessments.
When I was on Urology, a different attending led the ward round every day, and we would see all the patients under the urology team – this was probably the most problematic type of ward round because on Monday, we would have one plan in place for a patient, and the next day’s attending would make a different plan the following day.
The parts of the ward round that remain consistent between each different specialty I’ve been on include plenty of writing and creating a jobs list so that when the round was over, I’d be able to get to work with sorting out scans, X-rays, CTs, discharges. And perhaps it’s just the way the UK system works, but there hasn’t been much teaching during this time. Many times the attending tries to finish everything off before 9 to run to the OR or to clinic. A lot of the times, they’ll only see the sickest patients and then leave the senior resident to continue with all the other patients. There’s almost never any “pimping.” And when questions are asked, they’re asked usually to all residents. And a lot of the time, we’ve become so ingrained in creating a jobs list and working through those jobs for the rest of the day that we fail to make connections between our medical knowledge and its application to the patients. We forget the basics. And even worse, I feel we lack the motivation to later go on to educate ourselves on the facts we’ve missed out on.
This is why medicine involves lifelong learning. It’s simply not enough to show up to work to present a patient’s vitals and recent blood results when we can’t make the connection between why a patient in kidney failure has persistent hyperkalemia on routine bloods despite treatment. My knowledge has been somewhat refreshed after spending the last 6 months studying for the MCCEE. But since the exam, I’ve fallen back into being lazy. I come home, watch TV or waste time online, and go to sleep. It’s an easy trap to fall into, but it’ll eventually catch up and reflect in your work. I experienced that earlier in the week when dealing with a patient. So now, I’ve had that kick in the ass I needed to get back into gear.
Life is always going to be busy. You’re never going to have enough time. The important thing is to learn to manage your time wisely. Spend some of it enjoying yourself, and spend some of it educating yourself.