Friday, September 14, 2012

I dread/ hate "Family-Centered Rounds"

* I apologize in advance for the number of times I use the word “hate” in this post, but it’s gone beyond dreading into the realm of hating. Let me explain:

I have a background in Health Promotion and I always try to find ways to incorporate patient understanding and literacy in to my interactions. I realized early in medical school that I dread and now hate rounding. Absolutely hate it. As I have often seen it, it is Team-Centered with the patient/ family on the periphery. It is not health promoting. The literacy level is directed to professionals. All big no nos.

After a week on the Wards, I realized yet again that I hate “Family Centered Rounding” for pediatric patients due to the following reasons:
- way too much information is being spewed at parents who have probably just woken up
- way too much detailed information is being reported; if medical students and Interns have trouble keeping up how do we expect families to?
- there are way too many people in the room who have only minimal involvement with the care of a particular patient
- it is unprofessional and unappealing when folks with minimal involvement are only half-present (ex. the other Interns working feverishly to complete notes and orders on other patients)

And my biggest concern is are we hurting patient care when we list detailed and often scary differential diagnoses and mention lab tests that we probably will not perform?

I could go on and on but I won’t. I think Family-Centered Rounds has the potential to be a wonderful educational tool for families, a way to increase engagement in the medical decision making process. At least as I have seen it (at a large urban tertiary care center and at a medium size community hospital), it falls short. Rather than complaining without taking action, I am very interested in helping make these rounds better at my hospital, for our patients. I am motivated, selfishly, to at least work toward making the process less dread and hate-inducing for myself so that I don’t completely omit becoming a Hospitalist from my list of possible future careers.

Questions:
1. How do Family-Centered or Patient-Centered Rounds work (or fail to) at your institution?
2. If you could change this process and make it better given time constraints, what would you do?

I think I see a Quality Improvement project simmering . . . .

12 comments:

  1. As a patient parent, I have a couple of suggestions (just tiny things that would make it much easier on us when my son is in hospital).
    1) give the parents a 5 minute headsup that you're coming in. Give them a second to wake up, grab their notes, go to the bathroom.
    2) knock on the door and introduce yourself and everyone with you. I find rounds with residents and med students and interns to be the worst because there are 12 people in the room, you have no clue who they are or why they're there,and they're all ignoring you as a parent. Just having everyone go around in a circle and say their names and what they do makes life easier.
    3) pull up a chair for you and the parents, so at least the parent knows who they're supposed to be talking to. Or do it in a conference room.
    4) teach the parent. Pimp the parent. Involve the parent in the discussion - they have a really vested interest in what you're trying to teach, and the parents will feel mastery when they can answer questions and also will be treated as an equal part of the team, instead of outside of it.
    5) if someone doesn't need to be there, or seems disinterested, tell them to have their say, then wait in the hall. Otherwise it sends the message that your team doesn't care about our kid as a person, which isn't true.
    Scary differentials and overwhelming information doesn't scare me anywhere near as much as ambivalent professionals and lack of information.
    I hope that's what you meant, and that this was helpful.
    Thank you.

    ReplyDelete
  2. Passing along a comment that came in via email:

    http://medicine.emory.edu/vitals/sibr-placing-patients-and-training-at-the-center-of-care.cfm

    I read about it in the Emory magazine and it sounded like the good version of family centered rounds she's looking for, perhaps.

    ReplyDelete
  3. I second the suggestion to make everyone introduce themselves. When I was in the hospital post-partum, I found I actually didn't mind the crowd, but I reeeeaaaalllly didn't want a med student examining me (i.e. my classmate). Since nobody was wearing white coats it was impossible to tell who was a resident and who was a student.

    ReplyDelete
  4. I'm in peds training in a program two different sites. One of our two hospitals is pretty successful at family centered rounds. The gen peds team rounds with the attending, resident, intern(s), med students (usually 3), the charge nurse, the pharmacist (+/- a pharmacy student), and the social worker. Our rooms are small, so in generally whoever is presenting and the attending squeeze in first, followed by everyone else.
    In general, its a good way for everyone to plan for the rest of the day, especially with discharges. I tend to bring up sensitive issues outside the room before we walk in and let the attending decide whether its worth mentioning in the room. I've also told parents to be prepared for information to be presented during rounds in the morning if its something that may make them upset. On our end, I feel like we have a lot of patient who don't care one way or another but many who really like hearing what we have to say about their child in front of them instead of only among themselves.

    ReplyDelete
  5. Hello, I am a recent public health graduate, turned medical student so naturally found this post very interesting. Already within the first 3 weeks of medical school I am realizing that medicine really does have its own language and that regardless of your level of education as a patient it is unlikely that you would be able to follow along. Furthermore as medical students we are working so hard to learn and keep up in this new language that we don't practice translating back in ways patients (even if hypothetical for me at the moment) would understand.

    So to get back to your questions - I would say that even outside of ward rounds more focus needs to be placed on patient education in medical school and other training programs and find ways to involve patients from all types of backgrounds and clinical scenarios to give feedback and direction on how they would like to be communicated to and whether or not they can understand what is going on.

    ReplyDelete
  6. Have a whiteboard in the room in which patients can write their questions (this avoids possibly being overwhelmed or shy)

    -Have a way to give a printout or summary (as is done anyways after morning rounds from what ive been able to tell in getting copies of my in-pt records) to the patient/family of what was said or decided.

    I agreee about giving the patient/family a 5 minute or so heads up
    on when the residents/group will be around; even if it isnt completely accurate just having the chance TO WAKE UP A BIT before a gaggle of drs or even just 1 dr for that matter come by would be good and to me sound practice!

    Involve the patient.

    Erica
    www.rarelydefined.blogspot.com - MPS I H/S --> do you know what it is?!?

    ReplyDelete
  7. Thanks soo much for all of the comments! 1. Glad to know that parents generally are either excited to be included or ambivalent. 2. I will do better about waking folks up. 3. I just read the Emory article and will contact the folks there about getting a copy of the script that they use for SIBR.

    ReplyDelete
  8. I'm a chaplain, and really appreciate when I'm able to be involved in rounds, because it gives me a chance to see who I should make a particular point of trying to get to (besides the usual attempt to meet new patients, etc), especially on busy days. When they're actually patient-centered rounds, then it's a chance to make that initial connection and put a face on the name. Having me there is one more person in the room- but it's such a help for me.

    ReplyDelete
  9. It's disappointing to me to read your post, since it runs completely counter to the point of family centered rounds. Sounds like you and your teams are not conducting rounds in a particularly family and patient-centered way. It's not to "spew information" but rather to collaborate to come up with a shared plan, with active family participation.

    Family centered rounds are associated with higher family satisfaction: http://www.ncbi.nlm.nih.gov/pubmed/22778299 (from Pediatrics Aug 2012, among a growing body of research in this area)

    Would work to engage every team member in the patient's room to see it as a privilege and to be actively engaged, learning, or at the very least, quietly respectful. If not, they shouldn't be in the patient's room.

    Please post again to let us know how things evolve for you over time.

    ReplyDelete
  10. I did not think family-centered rounds worked very well at my institution, either. At least not in ICU. Most of the time, there was too much detailed information to cover, too many members on the team, and too many sensitive topics that weren't appropriate to bring up at that time and place. It would have been nice if we could have "pre-rounded" in a conference room with the attending (i.e. dietary, pharmacy, PT/OT, case managers all there) to discuss the nitty-gritties, and then the pared-down team could do real bedside FCRs where they could really focus on the patient and family's concerns, since orders/labs/meds would be already taken care of for the most part.

    FCRs did seem to work better on the general wards, FWIW.

    ReplyDelete
  11. I read about it in the Emory magazine and it sounded like the good version of family centered rounds she's looking for, perhaps.ED pills

    ReplyDelete
  12. Maybe they should revise medical training online to cover a more appropriate method to tell patients and their families about the former's condition.

    ReplyDelete

Comments on posts older than 14 days are moderated as a spam precaution. There may be a delay between submitting your comment and its publishing. Thanks for commenting!