The New England Journal of MedicineTo Preround or Not to Preround

Case Vignette: A Hospitalist Preparing to Join a Team of Residents

A newly assigned attending internal medicine hospitalist is contemplating the approach to rounding with a team of residents. She reflects on her experience as an intern with prerounding, considering its potential benefits and drawbacks. The hospitalist is deciding whether to instruct interns to visit their patients independently before team rounds or to wait and see clinically stable patients together during rounds.

Option 1: Recommend Visiting Each Patient Daily Before Rounds
Daniel Ricotta, MD – Department of Medicine, Beth Israel Deaconess Medical Center, Boston

Advantages:

• Autonomy and Ownership: Interns develop autonomy and a sense of ownership by independently assessing patients and formulating preliminary care plans.
• Enhanced Observation: Bedside prerounding allows interns to identify subtle clinical changes that may not be evident from electronic health records.
• Learning and Retention: Independent patient evaluations enhance learning, critical thinking, and diagnostic accuracy through hands-on experience and repeated observations.
• Professional Development: Direct patient contact fosters doctor–patient relationships, communication skills, and professional identity formation, preparing interns for attending roles.

Criticisms and Mitigation:

• Intrusiveness: Early morning visits can disrupt patient sleep. This can be mitigated through proactive communication and individualized prerounding processes.
• Efficiency: Concerns about inefficiency can be addressed by goal-oriented prerounding encounters and streamlined team rounds to avoid redundancy.

Conclusion: Bedside prerounding benefits patient care and intern development, outweighing the inconvenience. It should be encouraged for fostering autonomy, critical thinking, and professional growth.

“Direct patient contact during bedside prerounding cultivates the doctor–patient relationship and establishes an intern as the patient’s doctor.”
— Daniel Ricotta, MD

Option 2: Recommend Waiting to See Clinically Stable Patients During Rounds
Michelle M. Kittleson, MD, PhD – Department of Cardiology, Smidt Heart Institute, Cedars–Sinai Medical Center, Los Angeles

Advantages:

• Tailored Approach: Prerounding should be tailored to the patient’s condition and whether the assessment will change management.
• Minimize Disruption: Avoiding unnecessary early morning visits preserves patient sleep and reduces stress, promoting healing.
• Efficient Rounds: Proper preparation, including chart reviews and contingency plans, ensures efficient and focused morning rounds.
• Patient Care: Observing patients later in the morning may provide more accurate and useful information for decision-making.

Conclusion: Prerounding does not require disturbing patients early in the morning. Efficient preparation and a tailored approach improve patient care and minimize the negative impacts of hospitalization.

“As treating clinicians, our actions must heal, not harm — and unnecessarily awakening patients will not promote healing.”
– Michelle M. Kittleson, MD, PhD

Key Points:

• Prerounding enhances autonomy, critical thinking, and professional development in interns.
• Tailored prerounding can minimize patient disruption and promote efficient rounds.
• Balancing independence and efficiency is crucial in residency training.

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