Family Centered Rounds Are Bad

Normal Rounds:

Attending: So GI recommends a neuro consult, huh? Do you want to get one?

Me: Well, the patient actually has neuro outpatient follow-up scheduled in two weeks and no acute issues. The relevant genetic labs were drawn yesterday and will likely be pending for at least a week. And after speaking to the GI fellow, I believe he recommended we consult neuro as a way of tacitly implying that he thinks the GI consult was dumb.

Attending: Neuro wouldn’t want an MRI or anything? Nothing we could do inpatient?

Me: Well, a head ultrasound was normal, all he has are diffuse LMN signs without any focal abnormalities on exam – and dysmorphism alone isn’t an indication for a head MRI, especially with pending genetic labs… so…. honestly, definitely not.

Attending: Well, at least curbside neuro – if they agree, the family can go home today.

Family-Centered Rounds:

Me: So, sounds like we’ve gotten all the worrying symptoms under control! Do you feel comfortable going home, or would you prefer to stay another night?

Mother: No, I feel great! So relieved about the new medication. My ride should be here this afternoon!

Attending: Actually, GI floated the idea that we should get Neuro involved – they might want an MRI or something! We could get that done inpatient for you. What do you think?

Me: …!!

Mom: … well, I don’t know… would it help? Do you recommend it?

Me: erm.

Attending: Well, it couldn’t hurt! Here’s how the MRI would go: he likely wouldn’t have to be sedated, cause he’s so small, and I bet we could get you on the schedule for today!

Mom: Well… okay then!

Me: 😦

Status-post Family-Centered Rounds:

Neuro Fellow: Okay, so the kid has no acute issues and outpatient neuro follow-up already scheduled. What are you guys consulting us for?

Me: …. the question of whether a head MRI would be indicated.

Neuro Fellow: …

Me: Today. Stat.

Neuro Fellow: Without any focal abnormalities or UMN signs? Really? You’re consulting us for a head MRI for diffuse hypotonia?

… Hey, wait a minute – aren’t you supposed to be in our program in 2 years?

Me: …. that’s… that’s another intern. I’m someone else entirely. Please forget my name immediately, thanks.

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3 thoughts on “Family Centered Rounds Are Bad

  1. oh family-centered rounds…when I was in a pediatric hospital with cancer (as a 19 yr old…so I was in transition), some residents were completely clueless and asked my parents all the questions about what happened overnight, even though they don’t stay overnight and weren’t even in the room when the intern came to harass–I mean examine–me at the crack of dawn. and they asked my parents what THEY wanted to do even though *I* was the *adult* (albiet in a pediatric hospital, but I WAS OVER 18. SEESH). Luckily some peds residents (in any point of the program) knew to ask me what I wanted if they needed a decision from me. some drs even asked me questions, shared lab results in the room…and took time to pimp the residents, no make a teaching moment, out of something in my care. anything regarding my cared was discussed in front of me.

    • Ideally, that’s how Family-Centered Rounds are supposed to work: you just do the same discussion you would do outside the room, INSIDE the room. No secrets from the family.

      And that makes sense right up until the point where you remember that families don’t know medical terms, and it’s kind of rude to speak amongst yourselves in foreign terms in front of them –

      … so then rounds becomes “explaining things to the family in layman’s terms” time, which is FINE, except you haven’t actually officially discussed things in MEDICAL terms yet.

      And you’re not going to. Because you’ve already rounded.

      So relevant, important points of discussion don’t get brought up, the attending can’t be questioned in front of the family (and let it be remembered that the attending has 20+ patients and doesn’t know the fine details of each unless a discussion actually happens, so it’s a crucial omission), and both care and communication suffer.

      I still believe the ideal is table rounds / outside-the-door rounds combined with someone going inside the room to explain the team consensus to the family. I’d love to do a study on it but for the life of me, can’t think of who would fund it.

  2. Table rounds as a general practice would be a revolutionary improvement.

    Families are great, but you don’t want them in every discussion.

    Complicating that blanket statement, however, communication within the medical system across shifts and teams and between bedside providers and docs can be so shitty that the families & patients become the only people in the whole mess who know important parts of the story. It shouldn’t be that way, but it is.

    After my mother’s big SAH in 2007, she was having serious problems with delirium and she wasn’t sleeping well. Doctor after doctor, team after team would change things (more or less or different drugs/fluids/etc) on morning rounds, and by afternoon (her best time) the symptoms would be looking better and they’d declare victory and go home. The next day they’d come in and she’d have had a terrible night & be confused again.

    I had to spend the entire night at the bedside. I figured out that she was getting too delirious to use a call bell or ask for meds; then her pain would rage out of control and she wouldn’t sleep, which made her more delirious. What I had to do was watch her all night and make sure she got pain meds when she showed nonverbal pain cues. Delirium resolved.

    And all it took was a 24/7 bedside presence, for six days, in the neuro ICU of a major academic medical center. Messed up, no? Modern medicine shouldn’t be so disorganized that you need family watching over the patient. But here we all are.

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