Bedside Rounds as Cultural Jig: Keeping Trainee Attention Directed

Consider the following case: a man is admitted to the intensive care unit (ICU) with septic shock and respiratory failure due to pneumonia. He is treated with intravenous antibiotics, vasopressors, and BiPAP. The next day, his blood pressure is stable off vasopressors, and he is weaned off BiPAP to oxygen via nasal cannula. On rounds, the resident presents the case to the attending physician. The resident—his back to the patient—confidently recommends, “He is off pressors, only needing a few liters of O2, and I think we can transfer him out of the ICU today.” The attending asks a simple question: “Have you seen him?” The team turns around to see a somnolent man, slumped over in the bed, a poster child for a patient who would get sent back to the ICU moments after arriving on the inpatient medicine ward.

This resident was me, postgraduate year 3, finding yet another occasion to practice the virtue of humility. I of course had seen the patient prior to rounds, and everyone knows that a patient's condition can change quickly. But this story illustrates one of the primary—and increasingly underrecognized—purposes of rounds: the directing of a trainee's attention toward the patient. Viewed in this way, bedside rounds can be thought of as a structure or “jig” that constrains the demands on our attention so that it is concentrated on the flesh-and-blood human patient.

Rounding is when the hospital medical team presents each patient case to the attending physician to review new cases, provide updates on old ones, and finalize the plans for that day for each of them. In bedside rounding, the team goes to each patient's bedside to discuss and examine the patient together. When rounds are performed in the absence of the patient—what I refer to as table rounds—the team often remains in a workroom and reviews the data on the computer, developing a plan based on that data and standard diagnostic and therapeutic pathways. Afterwards the attending physician typically examines patients on their own and updates the team later with any changes to the plan.

Table rounds, or card flipping rounds, are popular among trainees for their perceived efficiency, while bedside rounds are dreaded for their perceived lack of efficiency. Spending all that time away from a computer—not being able to covertly work on notes, place orders, or not so covertly make phone calls—causes many interns and residents to become anxious. When the decision was left to me as a senior resident, I routinely opted for bedside rounding. This was not born from an anachronistic desire to keep things the way that they used to be. Instead, beyond the obvious advantages for the patient (improved communication, improved understanding of their results, a sense of feeling seen and heard), I saw bedside rounds as critical for building both the skills and virtues required to become a good physician. Learning to communicate with patients, to elicit important information in an interview, and to read the body via the physical examination, all require a resource that is scarce in the hospital: attention.

In The World Beyond Your Head: On Becoming an Individual in an Age of Distraction,¹  Matthew B. Crawford examines the importance of attention for learning complex skills and practices. Anyone who has matched into a residency program is likely already familiar with the importance of attention for learning difficult material. However, in medical school, we had more control over the use of our attention. In the preclinical years, we could hole up in the library, silence our phones, and rewrite biochemical pathways or draw out the nerves of the brachial plexus. Even in the clinical years of medical school, students are less preoccupied with documentation, pages, and ancillary tasks than residents and attendings, and relatively freer to focus on the patient.

I see bedside rounding as a means by which the attending physician (or senior resident) can direct the attention of the medical team. As Crawford observes, “to keep action on track, according to some guiding purpose, one has to keep attention properly directed.”¹  The guiding purposes of rounds in a teaching hospital are the health of the patient and the education of residents and medical students. To realize these purposes, we need structures that orient our attention properly. These structures are what Crawford refers to as cultural jigs. Crawford defines a jig as “a device or procedure that guides a repeated action by constraining the environment in such a way as to make the action go smoothly, the same each time, without having to think about it…a jig reduces the degrees of freedom afforded by the environment.”¹  Many craftspeople are familiar with jigs, such as those used in woodworking to repeat the same cut multiple times. A cultural jig, then, is a “nestled set of mutually reinforcing moral norms”¹  that tend to produce certain attitudes or behaviors.

Thought of in this way, bedside rounds are a fitting antidote to training in a health care system that encourages physicians to spend much more time with the electronic health record than with the patient.²  Bedside rounds serve as a cultural jig by constraining the environment in a way that brings the patient—with all their “inefficient” questions, concerns, vulnerabilities, and clinical findings—to the forefront of our attention. Further, the set of mutually reinforcing moral norms that can be cultivated on rounds could include important virtues, such as humility, avoiding bias, diagnostic curiosity, and empathy, to name a few.

One model of attention in cognitive psychology views attention as a limited resource that is depleted as it is used. We know that divided attention leads to “increased processing time spent on complex tasks, impaired working memory, and bias.”³  Further, diagnostic errors can result from inadequate physical examination,⁴  which in part is due to a lack of quality attention. Table rounds not only diminish the importance of physical diagnosis—they deprive the team of the environment in which attention to the patient can be sustained.

I am not suggesting that there is no role for discussing cases behind closed doors, especially when long teaching sessions may be included, difficult patient personalities are at play, or when following up on stable patients. My concern is that if table rounds become the norm, our clinical skills will atrophy, and the electronic health record will claim more of the attention that the patient deserves. Employing a jig that dedicates time and cognitive load to patient interview and physical examination frees residents and medical students from the distractions and abstractions of the workroom and allows them to attend to the particular flesh and blood patient. For Osler, part of the duty of the clinician educator is to train “the eye to see, the ear to hear and the finger to feel.”⁵  Bedside rounds place us in the physical and cognitive environments in which these skills of attention and observation can be mastered.