Until a month ago, we'd really only experienced rounds in three areas -- the CICU (cardiac intensive care unit), the PICU (pediatric intensive care unit -- I'll have to tell my story from that unit sometime), and the medical/surgical floor that also serves as the cardiac step-down unit.
During our most recent hospital stay, Elli was admitted to a different area -- the general/community pediatrics floor. Apparently since her heart condition wasn't in question this time, they decided it would be better to send her to the regular-sick-kid unit. Except that the bed-planners (yes, there really is a job in that -- and it gets really complicated when the hospital is busy) didn't realize that Elli is never a "regular sick kid."
General/community pediatrics is a floor with its own personality. (Actually, I've discovered that every unit is unique, so no matter how experienced you are with hospitals, there's always a learning curve.) The most notable difference to us was the sheer number of doctors we ran into. I deduced that the swarm of doctors were coming to us from a) residency or b) medical school. Since it's a general pediatrics floor with no special focus, all residents (official doctors obtaining their required 3 years of hands-on medical experience) and medical students studying at the neighboring medical school rotate through to get their pediatrics experience, whether they intend to specialize in pediatrics or not.
During rounds each morning, every single one of them appears at one time, which is quite astonishing considering that normally, when you want a doctor, you can't even find an undergraduate biology major! They all (we counted at least 12) troop into each patient's rather average-sized room , three of them pushing laptops-on-wheels, and they stand around the patient's bed to discuss the past 24 hours and the plan for the day.Based on my observations and my best guess as to who was who (they introduce themselves, but that's a darn lot of names and roles to remember at once!), I believe that each medical student must interview a certain number of patients when they arrive, and then monitor them (with resident supervision, of course) whenever they are on duty until the family leaves or their rotation ends. That student then reports the patient's history and any developments in the past 24 hours during morning rounds. This gives them invaluable experience taking a medical history (which involves hearing what the family and/or patient is saying and not saying and asking the right questions to draw out the needed information), in reporting that medical history (it's like telephone -- you would be surprised at how much even a medical history can change when it's passed around!), and in reporting any new developments.
At our hospital, an increasing number of medical teams are encouraging families not only to listen to the discussion of their child during rounds, but also to participate as much as they are comfortable. This gives families a chance to correct anything in the medical history, fill in things we may have forgotten to give in the original admission interview, and add anything necessary related to recent developments. We also get to be part of the planning discussion, whether it's treatment plans for the day or discharge plans.
Our hospital has been on the forefront of this new model of rounds. Up until a few years ago, it was pretty much unheard of for patients or families to even get to listen in on rounds, let alone participate in them. Rounds are, in the eyes of teaching hospitals, primarily a time for teaching the students and residents.
But hospitals like ours have two main rebuttals to this. First, the primary purpose of any hospital is to get the patient well enough to go home. Training doctors is secondary to that purpose. Healing patients requires having the most accurate information and the best cooperation from the patient and family. Second, patients and families can make valuable contributions to the teaching discussions during rounds. (I think that us non-medical types can be less afraid to ask the "dumb" or obvious question than the students who are being graded and assessed.)
Studies show that you get better outcomes when you include families as equal members of the medical team. They know the patient's history the best, they know the patient's baseline the best, and they know how the patient responds to various things best. When the patient is chronically ill, the family and/or the patient also needs to know what is currently happening, because that information becomes their medical history in the future. I can't tell you how important it is to have accurate information to give!
One thing we don't know is what effect having these conversations may have on children. I've grown increasingly conscious of the kinds of conversations I have in front of, or in earshot, of my kids. I want to make sure that I can choose the time and the method for sharing difficult information with them.I would also guess that some children (and many parents) find rounds intimidating, daunting, even scary. It's rather like being naked, having that many people standing around discussing your most intimate physical issues in great detail. Children could easily misinterpret the meaning of that many people standing around their bed, thinking this must mean they are really badly sick or going to die.
Our hospital gives new arrivals a card, on which they can indicate their preference for rounds. We can request to be included in rounds or not to be, and whether we want to be woken up for rounds. We can also request that they round in the hallway, rather than in the patient's room. It's a catch-22 because if you round in the hall, anyone walking by can hear your child's personal medical information being discussed. However, lately I've decided that I'd rather keep those conversations out of her hearing.
In our recent stay, the medical team did come in a couple times (not sure if they didn't read the card or if I didn't check the correct box!). The group was stacked two deep all around Elli's bed. They stood around for a good half hour, relating her entire history and discussing her plan for the day. I appreciated the chance to hear how they saw her case and to ask my own questions. I also was more familiar with the faces who came in throughout the day and night to try to figure out what Elli's latest secret was. (Like I said, Elli wasn't your typical sick kid -- she kept everyone guessing for days and came up with good mysteries for those students to solve.) They also asked for my preference when we began to discuss going home -- was I comfortable going home at this particular time?
However, Elli was not a big fan of having rounds in her room. I think what bothered her most was not the content of the conversation, or being self-conscious because she was the center of attention (when she was younger, she ate this up, smiling and making eyes at everyone). I think what ticked her off was the resident who turned the volume completely down on her video! She will let you do just about anything to her or around her as long as she can see or hear her favorite movies or shows (we used to get IVs in her while she would watch Veggie Tales, and she wouldn't cry or even whine about it as long as no-one blocked her view of the TV).
So I'll be interested to read studies, hopefully coming out soon, on the effect of having rounds in front of pediatric patients at various stages of cognitive development. Meanwhile, it looks like I'll have to be pro-active in enforcing the preferences I give on those admissions cards!
