Attending Rounds: A Survey of Physician Attitudes KURT KROENKE, MD, LTC, MC, USA, JOHN O. SIMMONS, MD, MPH, JOHN B. COPLEY, MD, CRAIG SMITH, MD, MAJ, MC, USA To d e t e r m i n e attitudes r e g a r d i n g a t t e n d i n g rounds, the a u t h o r s surveyed all i n t e r n a l medicine residents a n d att e n d i n g p h y s i c i a n s a t the eight A r m y teaching hospitals. The r e s p o n s e rate w a s 86%, including 166 (76%) o f 217 residents a n d 246 (93%) o f 264 attendings. O f 12 educat i o n a l activities, a t t e n d i n g r o u n d s were r a n k e d s e v e n t h by residents in t h e i r p e r c e i v e d value. Both residents a n d attendings f a v o r e d s e s s i o n s t h a t l a s t e d 9 0 m i n u t e s o r less a n d were h e l d t h r e e to f o u r times p e r week_ M o s t respondents f e l t case p r e s e n t a t i o n s s h o u l d take 5 m i n u t e s o r less a n d be delivered a w a y f r o m the p a t i e n t ' s bedside. On average, residents p r e f e r r e d less time a t the bedside t h a n d i d attendings ( 2 5 % vs. 34% o f a t t e n d i n g r o u n d t i m e ) . Resid e n t s desired substantial c o n t r o l o f the a g e n d a f o r r o u n d s a n d also w a n t e d to be responsible f o r one-third o f t h e teaching. The attending-physician attributes that residents valued m o s t highly were f u n d o f knowledge, availability, a n d relating well to housestaff. Since residents" a n d att e n d i n g physicians" anitudes m a y differ, expectations reg a r d i n g a t t e n d i n g r o u n d s s h o u l d be clarified a t the beginn i n g o f a w a r d r o t a t i o n so that mutually acceptable goals c a n be e s t a b l i s h e d . Key words.- a t t e n d i n g rounds; residents; e d u c a t i o n . J GENINTERNMED1990; 5:229-233.
HOSPITAL INPATIENTS managed b y w a r d teams of residents and students u n d e r the supervision of a staff attending physician continue to serve as a major c o m p o nent of clinical training. Typically, a ward t e a m meets w i t h an attending physician for regular teaching sessions called "attending r o u n d s . " In contrast to lectures, teaching on the wards involves small-group discussions w i t h learners at various levels o f training on topics that often arise u n a n n o u n c e d . Furthermore, the ward attending must c o n t e n d w i t h noise, r e p e a t e d interruptions, and, frequently, a corridor for a classroom. The literature on clinical teaching includes reviews,L 2 observational studies, 3"9 analysis of teacher ratings, 9"H and physician surveys. ~2"1a However, most studies have b e e n restricted to single institutions or have polled just a f e w individuals f r o m several institutions. Furthermore, the focus has often b e e n limited to one or two issues, such as the optimal format for rounds or attributes of the ideal attending. Given the considerable time e x p e n d e d on clinical teaching as w e l l as the Received from the Departments of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and Walter Reed Army Medical Center, Washington, D.C. (KK), and Brooke Army Medical Center, Fort Sam Houston, Texas (JOS, JBC, CS). Presented in part at the 12th Annual Meeting of the Society of General Internal Medicine, Washington, D.C., April 28, 1989. Address correspondence and reprint requests to LTCKroenke: Department of Medicine, USUHS,4301 Jones Bridge Road, Bethesda, MD 80214.
growing interest in faculty d e v e l o p m e n t , w e d e c i d e d to investigate the attitudes of larger n u m b e r s of residents and attending physicians w i t h regard to a b r o a d e r range of attending r o u n d issues.
METHODS Study Population
The survey sites for this study w e r e the eight Army medical centers (AMC) that have internal m e d i c i n e residency programs: Brooke AMC, in San Antonio, Texas; Dwight David Eisenhower AMC, in Augusta, Georgia; Fitzsimons AMC, in Denver, Colorado; Letterman AMC, in San Francisco, California; Madigan AMC, in Tacoma, Washington; Tripler AMC, in Honolulu, Hawaii; William Beaumont AMC, in El Paso, Texas; and Walter Reed AMC, in Washington, D.C. At the time of the survey, there w e r e 217 residents and 264 attending physicians in these eight programs. Individual m e d i c i n e programs ranged in size from 18 to 39 residents and f r o m 18 to 60 attending physicians. The t e r m " r e s i d e n t s " in o u r study e n c o m p a s s e d house officers in all three years of training, including interns, junior residents, and senior residents. Of the 481 individuals surveyed, 414 (86%) comp l e t e d the questionnaire, including 166 (76%) of the residents and 248 (94%) of the attending physicians. At each medical center, surveys w e r e distributed through the d e p a r t m e n t chairmen, w h o e n c o u r a g e d c o m p l e tion and return of the forms. All responses, however, r e m a i n e d confidential. Among the house officers, response rates differed by class, w i t h 41 (60%) o f 68 interns, 52 (73%) of 71 junior residents, and 73 (94%) of 78 senior residents c o m p l e t i n g the questionnaire. Among respondents, the m e a n age of house ofricers was 29.5 years (range, 26 to 42) and that of attendings, 37.4 years (range, 28 to 56). Seventy-six p e r c e n t of the attending physicians t h e m s e l v e s had trained in military residency programs. Eighty-two percent of the attendings w e r e subspecialists, representing 11 medical specialties, w h i l e 18% w e r e general internists. On average, each staff physician attended 3.3 months p e r year on the inpatient wards.
Questionnaire The survey instrument was a four-page self-administered questionnaire requiring a b o u t 10 minutes to c o m p l e t e . Items addressed on the questionnaire inc l u d e d attitudes regarding: ZZ9
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1. Optimal number of rounding sessions per week, length of rounding sessions, length and site of case presentations, and use of chart review, lectures, journal articles, and feedback. 2. How attending round time should be allocated among bedside teaching, conference room teaching, chart review, and other activities. 3. The importance of 11 attending physician attributes (see Table 2), each rated on a 1 (unimportant)-to-7 (very important) scale. 4. The value of 12 educational activities, each rated on a 1 (not valuable)-to-7 (very valuable) scale. 5. The optimal balance in five teaching areas where conflict is frequently felt, namely: bedside vs. conference room teaching; spontaneous vs. planned discussions; interactive vs. didactic teaching; attending physician vs. housestaff responsibility for teaching on rounds; and attending physician vs. housestaff control of the agenda on rounds. Respondents could indicate on a 0-to-100 Likert scale the optimal balance point within each pair; although intervals of 10 (0, 10, 20, etc.) were designated on the scale, respondents could place their marks anywhere. For example, an individual could indicate that the optimal teaching site was 100% bedside, or 70% bedside/ 30% conference room, or 35% bedside/65% conference room. Statistical analysis for response frequencies used chi-square methods. Two-sample t-tests w e r e used to test differences b e t w e e n means. Relative rankings for attending physician attributes and educational activities w e r e done b y rank sum methods. All significance levels are two-tailed. Responses for each variable w e r e e x a m i n e d b y individual medical center and for the eight centers combined. Individual center and p o o l e d data w e r e generally similar; therefore only p o o l e d responses are reported.
RESULTS The majority of respondents desired attending round sessions that lasted 90 minutes or less and w e r e held three to four times p e r week. On average, residents preferred shorter sessions (75.6 vs. 86.4 minutes) and less frequent rounds (3.1 vs. 3.6 times p e r w e e k ) than did attendings. Concise case presentations w e r e generally preferred. Although attendings a c c e p t e d a slightly longer presentation (5.3 vs. 4.6 minutes), 75% of attendings and 89% of residents desired n e w cases to be presented in 5 minutes or less. Most r e s p o n d e n t s (96% of residents and 88% of attending physicians) p r e f e r r e d that cases not be p r e s e n t e d at the patient's bedside. Overall, physicians b e l i e v e d that 30% o f attending r o u n d t i m e should be spent at the bedside, w i t h residents desiring less time than attendings (25% vs. 34%). Respondents considered it a p p r o p r i a t e to s p e n d over half (52%) of the time in a c o n f e r e n c e r o o m or other
setting away f r o m the bedside for discussions o f specific patients (32%) or general topics (20%). It was felt that the remaining 18% of attending r o u n d time c o u l d be devoted to examining special studies, such as radiographs and b l o o d smears, reviewing charts, talking to consultants, and carrying out other activities. Respondents believed that the attending physician should devote about an h o u r p e r day outside rounds to his or her w a r d responsibilities. Residents estimated less time for these duties than did attendings ( 5 1 . 7 vs. 6 5 . 0 minutes). Over three-fourths o f all r e s p o n d e n t s felt the attending should r e v i e w charts alone rather than with the team. On average, respondents felt the optimal balance for discussions on rounds w o u l d be 57% spontaneous (i.e., topics discussed at the time they arise) and 43% p l a n n e d (i.e., discussion deferred to a s u b s e q u e n t session to a l l o w p r e p a r a t i o n a n d / o r assignments). The optimal balance in discussion format was considered 58% interactive and 42% didactic. With respect to these issues o f type and format, the mean g r o u p responses of residents and attending physicians w e r e similar. Likewise, the m a x i m u m lengths for attending r o u n d lectures advocated b y the two groups w e r e similar ( 1 6 . 8 vs. 16.1 minutes), w i t h 70% of residents and 73% of attending physicians feeling lectures on rounds should not e x c e e d 20 minutes. Control of the agenda and teaching on rounds w e r e considered joint responsibilities. However, residents and attending physicians disagreed on the o p t i m a l resident's " s h a r e " of control (64% vs. 53%, p < 0 . 0 0 1 ) and of teaching responsibilities (37% vs. 42%, p = 0 . 0 2 ) . We also d e t e r m i n e d h o w m a n y respondents favored p r e d o m i n a n c e of one g r o u p or the other in terms of responsibility for control of the agenda and for teaching. Defining p r e d o m i n a n c e as 70% or m o r e of the responsibility, resident-predominant control of the agenda was favored b y 41% of residents (vs. 20% of attendings), whereas attending-predominant control was desired b y only 4% of residents (vs. 20% of attendings). The r e m a i n d e r of the respondents (55% of residents and 60% o f attending physicians) did not favor p r e d o m i n a n c e b y either group. Attending-predominant teaching was favored b y 48% of residents and 34% o f attendings, w h i l e resident-predominant teaching was seldom advocated (4% and 6%, respectively). Respondents varied considerably regarding the f r e q u e n c y w i t h w h i c h attending physicians should observe various resident activities, such as patient interview, physical examination, and p e r f o r m a n c e of technical procedures. In general, attending physicians favored m o r e frequent observation than did residents (Table 1). W o r k rounds in particular w e r e considered a good o p p o r t u n i t y for observation, w i t h 79% of residents and 84% of attending physicians expressing a desire that the attending a c c o m p a n y the residents on w o r k rounds at least twice a month.
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Nearly half of the housestafffelt feedback provided by attending physicians was inadequate: 12% felt it was not helpful, 6% felt it was helpful but not frequent enough, and 30% felt it was neither frequent enough nor helpful. In contrast, two-thirds of attendings felt feedback provided to housestaff was sufficiently frequent and helpful. This difference between housestaff and attending opinions was significant (p < 0.001). Fund of knowledge, availability, relating well to housestaff and the willingness to share teaching responsibilities were the attending physician attributes valued most highly by housestaff (Table 2). On the other hand, specific teaching skills, such as lgcturing and asking questions, and bedside skills, such as physical examination and relating well to patients, were considered highly important by less than half of all housestaff. Attending rounds were considered to be of medium educational value, comparable with other structured activities, such as morning report and department conferences. They were ranked somewhat lower than patient care and reading but were considered more valuable than resident work rounds, rounds with the department chief, or formal consultations provided by subspecialists.
DISCUSSION In the first study of attending rounds to survey all residents and attending physicians in multiple training programs, we have determined attitudes regarding a number of important issues, including time allocation, format, teacher characteristics, and distribution of responsibilities. On certain matters, residents and attending physicians agreed. As in a national survey, ~a most respondents preferred efficient rounds with sessions not exceeding 90 minutes three to four times weekly. Brevity of case presentations and of lectures on rounds and relegation of certain activities, such as chart review, to
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TABLE 1 PhysicianAttitudes RegardingFrequencieswith Which Certain HousestaffActivities Should Be Observedby the Attending Physician Optimal Frequency*
Housestaff (%)
Attendings (%)
Significance of Difference
Interviewing a patient 0 1- 2 >3
22 65 13
9 56 35
p < 0.001
Examininga patient 0 1-2 >3
18 63 19
7 56 37
p < 0.001
33 44 23
14 41 45
p < 0.001
13 36 51
8 25 67
p < 0.002
Performing a procedure 0
1-2 ->3 Conductingwork rounds 0 1-2 ->3
*Average number of times per month the activity should be observed.
time outside rounds were also advocated. It was felt that discussions could reasonably constitute 50% of attending round time and should involve all levels of learners, rather than aim consistently at the highest, the lowest, or an intermediate level of understanding. Although Maxwell and colleagues 9 concluded that "rounds should be pitched at the intern's level," they surveyed fewer than 20 residents. Our respondents favored a " 6 0 - 4 0 " balance regarding discussion content (specific patients vs. general topics), timing (spontaneous vs. deferred), and methodology (interactive vs. didactic). The value of balanced rounds has been previously recognized. 8, 9, 16, ~7 Deferral of discussions may be particularly useful when time is running short, when tired residents are recovering from call, or when additional reading is required.
TABLE Z Ranking of Various Attending PhysicianAttributes Ranked Highly Important* Attending Attribute Fund of knowledge Availability Relatingwell to housestaff Sharing teaching Providing feedback Flexibility Physical examination skills Lecuring skills on rounds Questioningskills on rounds Relating well to patients
Ranking (Mean Value) By Housestaff By Attendings 1 (6.3) 2 (6.2) 3 (5.9) 4 (5.8) 5 (5.6) 6 (5.6) 7 (5.5) 8 (5.3) 9 (4.9) 10 (4.9)
3 (6.0) 1 (6.5) 2 (6.2) 7 (5.6) 5 (5.9) 9 (5.5) 6 (5.7) 10 (5.1) 8 (5.5) 4 (6.0)
*Percentageof resondentswho ranked this attribute 6 or 7 on a seven-pointscale.
By Housestaff
By Attendings
(%)
(%)
81 77 69 61 53 52 49 45 29 32
70 89 78 53 68 50 61 41 52 72
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Attitudinal differences b e t w e e n residents and attending physicians were identified in the areas of bedside rounds, observation, feedback, and resident control of rounds. Respondents felt that only about 30% of attending round time should be spent at the patient's bedside, and residents preferred even less time than did attending physicians. Previous estimates o f time actually spent at the bedside have b e e n similarly Iow, ranging from 15% to 25%. 3, 7, 13. 16 Few respondents felt that cases should be presented at the patient's bedside. This reluctance may relate to learner fatigue during lengthy ward rounds and to c o n c e r n about patient privacy.~, 19, 20 Previous surveys have demonstrated that patients actually appreciate bedside presentations. 19-21 Learning climate issues related to bedside and corridor teaching, including distractions, group size, and the r e q u i r e m e n t for standing, probably explain the common desire for selective and efficient bedside visits a, 2o, 21 From an educational standpoint, the optimal apportionment b e t w e e n bedside and c o n f e r e n c e room time remains to be determined. What is probably important is that visits to specific patients focus most on what is best accomplished in their presence, namely interviewing, physical examination, explanation, and humanistic skills. Compared with what attending physicians considered optimal, residents felt less of a need to be observed in specific patient interactions but more o f a need for improvements in feedback. This apparent paradox may be partly due to faculty difficulties in assessing clinical competence.22, 23 Even w h e n observations are correct, the quality and quantity of feedback provided by attending physicians to learners are often inadequate. 13, 24 The dual e n h a n c e m e n t of observational and feedback skills might lead to greater agreement between residents and faculty regarding the need for these two activities, particularly since housestaff deficiencies in history taking and physical examination have been documented. 2s-27 Residents desired a substantial share in control of the agenda and in teaching on rounds. While faculty t e n d e d to support substantial resident participation, residents expressed a desire for more control of rounds than attending physicians advocated. Recent developments in quality assurance and in r e i m b u r s e m e n t may dictate an increasing involvement of attending physicians in direct patient management. Nonetheless, on attending rounds themselves, residents can play an important role in selection of patients to visit and discuss, in identification of teaching points, and in demonstration of skills. A principle of adult education confirmed in studies of clinical teaching s. 14, 2s is that learner participation enhances both satisfaction and understanding. Attributes of the attending physician that have a direct impact on residents, such as availability, flexibility, and the ability to relate well to house officers, share responsibility, and provide feedback, were all valued
more highly by housestaff than were bedside skills such as physical examination and relating well to patients. This high value placed on " t e a m skills" has also been reported by others. 8, 14, 15 While Shankel and Mazzaferri 18 and Coppernoll and Davies 12 found rounds to be rated somewhat higher than we did, their surveys were limited to c h i e f residents, department chairmen, and students, individuals whose attitudes may differ from those of attending physicians and residents. The latter have many competing responsibilities, including substantial time commitments for direct patient care. Furthermore, the last decade has witnessed dramatic changes in hospital-based training. Concerns about resident stress and work schedules, shorter hospital stays, and progressive shifting of patient care to the ambulatory setting c o m p e l a continual reassessment of the structure of attending rounds and their proportional share in the educational " p a c k a g e " provided residents. Although our survey is the largest sample of physician attitudes on attending rounds to date, it was restricted to military medical centers. These centers provide comprehensive care for all active duty and retired military personnel and their dependents, and the patient demographics and case mix are similar to those seen in civilian practice. 29 Due to competitive federal scholarship programs, current residents in military programs c o m e from a diversity of medical schools and academically rank in the u p p e r tertile of their graduating medical school classes. Like their civilian counterparts, attending physicians in military programs act as both teachers and the legal physicians of record for patients cared for by the ward team. Therefore, decisions made on attending rounds directly affect patient management. Our study sample did not include medical students. Although their opinions on selected issues have been previously reported, 9"1~,2o, 24, 28 the inclusion of students in future studies may be important in light of a declining interest in internal medicine careers. Finally, we measured attitudes rather than actual learning. It remains to be proven that what physicians perceive as optimal is in fact educationally effective. Meanwhile, our findings provide a useful framework to help clarify the expectations of attending physicians and residents beginning a ward rotation together. Areas of concordance as well as disagreement can be identified so that potential conflicts may b e resolved in advance. Since individual preferences for attending rounds may differ substantially, this negotiation of goals at the team level may p r o d u c e a climate more conducive to learning.
REFERENCES 1. DaggettCJ, CassieJM, Collins GF. Researchon clinical teaching. Rev Educ Res. 1979;49:151-69. 2. Snell L. Bibliography of clinical teaching. J Gen Intern Med. 1988;3:611-5.
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3. Jason H. A study of medical teaching practices. J ivied Educ. 1962;37:1258-84. 4. Reichsman F, Browning FE, HinshawJR. Observations of undergraduate clinical teaching in action. J Med Educ. 1964; 39:147-63. 5. Payson HE, Barghas JD. A time study of medical teaching rounds. N EnglJ Med. 1965;273:1468-71. 6. Foley R, SmilanskyJ, Yonke A. Teacher-student interaction in a medical clerkship. J Med Educ. 1979;54:622-6. 7. Tremonti LP, Biddle WB. Teaching behaviors of residents and faculty members. J Med Educ. 1982;57:854-9. 8. Mattern WD, Weinholtz D, Friedman CP. The attending physician as teacher. N EnglJ Med. 1983;308:1129-32. 9. MaxwellJA, Cohen RaM,ReinhardJD.Aqualitativestudyofteaching rounds in a department of medicine. Proc Res Med Educ. 1983;192-7. 10. Cotsonas NJ, Kaiser HF. Student evaluation of clinical teaching. J Med Educ. 1963;38:742-5. 11. Metz R, Haring O. An apparent relationship between the seniority of faculty members and their ratings as bedside teachers. J Med Educ. 1966;41:1057-62. 12. Coppernoll PS, Davies DF. Goal-oriented evaluation of teaching methods by medical students and faculty. J Med Educ. 1974;49:424-30. 13. Collins GF, Cassie JM, Daggett CJ. The role of the attending physician in clinical training. J Med Educ. 1978;53:429-31. 14. Stritter FT, Hain JD, Grimes DA. Clinical teaching examined. J Med Educ. 1975;50:876-82. 15. Irby DM, Rakestraw P. Evaluating clinical teaching in medicine. J Med Educ. 1981;56:181-6. 16. Schor EL, Grayson M. Outstanding clinical teachers: methods, characteristics and behaviors. Proc Res Med Educ. 1984 ;271-6. 17. McLeod PJ. A successful formula for ward rounds. Can MedAssoc J. 1986;134:902-4.
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18. Shankel SW, Mazzaferri EL. Teaching the resident in internal medicine: present practices and suggestions for the future. JAMA. 1986;256:725-9. 19. Linfors EW, Neelon FA. The case for bedside rounds. N Engl J Med. 1980;303:230-3. 20. Wang-Cheng RM, Barnas GP, Riendl PA, Young MJ. Bedside case presentations: why patients like them but learners don't. J Gen Intern Med. 1989;4:284-7. 21. Simons RJ, Baily RG, Zelis R, Zwillich CW. The physiologic and psychological effects of the bedside presentation. N Engl J Med. 1989;321:1273-5. 22. Elliot DL, Hickam DH. Evaluationofphysicalexaminationskills. Reliability of faculty observers and patient instructors. JAMA. 1987;258:3405-8. 23. Herbers JE, Noel GL, Cooper GS, Harvey J, Pangaro LN, Weaver MJ. How accurate are faculty evaluations of clinical competence? J Gen Intern Med. 1989;4:202-8. 24. Gil DH, Heins M, Jones PB. Perceptions of medical school faculty members and students on clinical clerkship feedback. J Med Educ. 1984;59:856-64. 25. Mandel JH, Rich EC, Luxenberg MG, Spilane MT, Kern DC, Parrino TA. Preparation for practice in internal medicine: a study of ten years of residency graduates. Arch Intern Med. 1988; 148:853-6. 26. Wray NP, Friedland JA. Detection and correction of house staff error in physical diagnosis. JAMA. 1983;249:1035-7. 27. Johnson JE, Carpenter JL. Medical house staff performance in physical examination. Arch Intern Med. 1986;146:937-41. 28. Jewett LS, Greenberg LW, Goldberg RM. Teaching residents how to teach: a one-year study. J Med Educ. 1982;57:361-6. 29. Johnson JE, Pinholt EM, Jenkins TR, Carpenter JL. Content of ambulatory internal medicine practice in an academic Army medical center and an Army community hospital. Milit Med. 1988;153:21-5.
HOSPITAL INPATIENTS managed b y w a r d teams of residents and students u n d e r the supervision of a staff attending physician continue to serve as a major c o m p o nent of clinical training. Typically, a ward t e a m meets w i t h an attending physician for regular teaching sessions called "attending r o u n d s . " In contrast to lectures, teaching on the wards involves small-group discussions w i t h learners at various levels o f training on topics that often arise u n a n n o u n c e d . Furthermore, the ward attending must c o n t e n d w i t h noise, r e p e a t e d interruptions, and, frequently, a corridor for a classroom. The literature on clinical teaching includes reviews,L 2 observational studies, 3"9 analysis of teacher ratings, 9"H and physician surveys. ~2"1a However, most studies have b e e n restricted to single institutions or have polled just a f e w individuals f r o m several institutions. Furthermore, the focus has often b e e n limited to one or two issues, such as the optimal format for rounds or attributes of the ideal attending. Given the considerable time e x p e n d e d on clinical teaching as w e l l as the Received from the Departments of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and Walter Reed Army Medical Center, Washington, D.C. (KK), and Brooke Army Medical Center, Fort Sam Houston, Texas (JOS, JBC, CS). Presented in part at the 12th Annual Meeting of the Society of General Internal Medicine, Washington, D.C., April 28, 1989. Address correspondence and reprint requests to LTCKroenke: Department of Medicine, USUHS,4301 Jones Bridge Road, Bethesda, MD 80214.
growing interest in faculty d e v e l o p m e n t , w e d e c i d e d to investigate the attitudes of larger n u m b e r s of residents and attending physicians w i t h regard to a b r o a d e r range of attending r o u n d issues.
METHODS Study Population
The survey sites for this study w e r e the eight Army medical centers (AMC) that have internal m e d i c i n e residency programs: Brooke AMC, in San Antonio, Texas; Dwight David Eisenhower AMC, in Augusta, Georgia; Fitzsimons AMC, in Denver, Colorado; Letterman AMC, in San Francisco, California; Madigan AMC, in Tacoma, Washington; Tripler AMC, in Honolulu, Hawaii; William Beaumont AMC, in El Paso, Texas; and Walter Reed AMC, in Washington, D.C. At the time of the survey, there w e r e 217 residents and 264 attending physicians in these eight programs. Individual m e d i c i n e programs ranged in size from 18 to 39 residents and f r o m 18 to 60 attending physicians. The t e r m " r e s i d e n t s " in o u r study e n c o m p a s s e d house officers in all three years of training, including interns, junior residents, and senior residents. Of the 481 individuals surveyed, 414 (86%) comp l e t e d the questionnaire, including 166 (76%) of the residents and 248 (94%) of the attending physicians. At each medical center, surveys w e r e distributed through the d e p a r t m e n t chairmen, w h o e n c o u r a g e d c o m p l e tion and return of the forms. All responses, however, r e m a i n e d confidential. Among the house officers, response rates differed by class, w i t h 41 (60%) o f 68 interns, 52 (73%) of 71 junior residents, and 73 (94%) of 78 senior residents c o m p l e t i n g the questionnaire. Among respondents, the m e a n age of house ofricers was 29.5 years (range, 26 to 42) and that of attendings, 37.4 years (range, 28 to 56). Seventy-six p e r c e n t of the attending physicians t h e m s e l v e s had trained in military residency programs. Eighty-two percent of the attendings w e r e subspecialists, representing 11 medical specialties, w h i l e 18% w e r e general internists. On average, each staff physician attended 3.3 months p e r year on the inpatient wards.
Questionnaire The survey instrument was a four-page self-administered questionnaire requiring a b o u t 10 minutes to c o m p l e t e . Items addressed on the questionnaire inc l u d e d attitudes regarding: ZZ9
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1. Optimal number of rounding sessions per week, length of rounding sessions, length and site of case presentations, and use of chart review, lectures, journal articles, and feedback. 2. How attending round time should be allocated among bedside teaching, conference room teaching, chart review, and other activities. 3. The importance of 11 attending physician attributes (see Table 2), each rated on a 1 (unimportant)-to-7 (very important) scale. 4. The value of 12 educational activities, each rated on a 1 (not valuable)-to-7 (very valuable) scale. 5. The optimal balance in five teaching areas where conflict is frequently felt, namely: bedside vs. conference room teaching; spontaneous vs. planned discussions; interactive vs. didactic teaching; attending physician vs. housestaff responsibility for teaching on rounds; and attending physician vs. housestaff control of the agenda on rounds. Respondents could indicate on a 0-to-100 Likert scale the optimal balance point within each pair; although intervals of 10 (0, 10, 20, etc.) were designated on the scale, respondents could place their marks anywhere. For example, an individual could indicate that the optimal teaching site was 100% bedside, or 70% bedside/ 30% conference room, or 35% bedside/65% conference room. Statistical analysis for response frequencies used chi-square methods. Two-sample t-tests w e r e used to test differences b e t w e e n means. Relative rankings for attending physician attributes and educational activities w e r e done b y rank sum methods. All significance levels are two-tailed. Responses for each variable w e r e e x a m i n e d b y individual medical center and for the eight centers combined. Individual center and p o o l e d data w e r e generally similar; therefore only p o o l e d responses are reported.
RESULTS The majority of respondents desired attending round sessions that lasted 90 minutes or less and w e r e held three to four times p e r week. On average, residents preferred shorter sessions (75.6 vs. 86.4 minutes) and less frequent rounds (3.1 vs. 3.6 times p e r w e e k ) than did attendings. Concise case presentations w e r e generally preferred. Although attendings a c c e p t e d a slightly longer presentation (5.3 vs. 4.6 minutes), 75% of attendings and 89% of residents desired n e w cases to be presented in 5 minutes or less. Most r e s p o n d e n t s (96% of residents and 88% of attending physicians) p r e f e r r e d that cases not be p r e s e n t e d at the patient's bedside. Overall, physicians b e l i e v e d that 30% o f attending r o u n d t i m e should be spent at the bedside, w i t h residents desiring less time than attendings (25% vs. 34%). Respondents considered it a p p r o p r i a t e to s p e n d over half (52%) of the time in a c o n f e r e n c e r o o m or other
setting away f r o m the bedside for discussions o f specific patients (32%) or general topics (20%). It was felt that the remaining 18% of attending r o u n d time c o u l d be devoted to examining special studies, such as radiographs and b l o o d smears, reviewing charts, talking to consultants, and carrying out other activities. Respondents believed that the attending physician should devote about an h o u r p e r day outside rounds to his or her w a r d responsibilities. Residents estimated less time for these duties than did attendings ( 5 1 . 7 vs. 6 5 . 0 minutes). Over three-fourths o f all r e s p o n d e n t s felt the attending should r e v i e w charts alone rather than with the team. On average, respondents felt the optimal balance for discussions on rounds w o u l d be 57% spontaneous (i.e., topics discussed at the time they arise) and 43% p l a n n e d (i.e., discussion deferred to a s u b s e q u e n t session to a l l o w p r e p a r a t i o n a n d / o r assignments). The optimal balance in discussion format was considered 58% interactive and 42% didactic. With respect to these issues o f type and format, the mean g r o u p responses of residents and attending physicians w e r e similar. Likewise, the m a x i m u m lengths for attending r o u n d lectures advocated b y the two groups w e r e similar ( 1 6 . 8 vs. 16.1 minutes), w i t h 70% of residents and 73% of attending physicians feeling lectures on rounds should not e x c e e d 20 minutes. Control of the agenda and teaching on rounds w e r e considered joint responsibilities. However, residents and attending physicians disagreed on the o p t i m a l resident's " s h a r e " of control (64% vs. 53%, p < 0 . 0 0 1 ) and of teaching responsibilities (37% vs. 42%, p = 0 . 0 2 ) . We also d e t e r m i n e d h o w m a n y respondents favored p r e d o m i n a n c e of one g r o u p or the other in terms of responsibility for control of the agenda and for teaching. Defining p r e d o m i n a n c e as 70% or m o r e of the responsibility, resident-predominant control of the agenda was favored b y 41% of residents (vs. 20% of attendings), whereas attending-predominant control was desired b y only 4% of residents (vs. 20% of attendings). The r e m a i n d e r of the respondents (55% of residents and 60% o f attending physicians) did not favor p r e d o m i n a n c e b y either group. Attending-predominant teaching was favored b y 48% of residents and 34% o f attendings, w h i l e resident-predominant teaching was seldom advocated (4% and 6%, respectively). Respondents varied considerably regarding the f r e q u e n c y w i t h w h i c h attending physicians should observe various resident activities, such as patient interview, physical examination, and p e r f o r m a n c e of technical procedures. In general, attending physicians favored m o r e frequent observation than did residents (Table 1). W o r k rounds in particular w e r e considered a good o p p o r t u n i t y for observation, w i t h 79% of residents and 84% of attending physicians expressing a desire that the attending a c c o m p a n y the residents on w o r k rounds at least twice a month.
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Nearly half of the housestafffelt feedback provided by attending physicians was inadequate: 12% felt it was not helpful, 6% felt it was helpful but not frequent enough, and 30% felt it was neither frequent enough nor helpful. In contrast, two-thirds of attendings felt feedback provided to housestaff was sufficiently frequent and helpful. This difference between housestaff and attending opinions was significant (p < 0.001). Fund of knowledge, availability, relating well to housestaff and the willingness to share teaching responsibilities were the attending physician attributes valued most highly by housestaff (Table 2). On the other hand, specific teaching skills, such as lgcturing and asking questions, and bedside skills, such as physical examination and relating well to patients, were considered highly important by less than half of all housestaff. Attending rounds were considered to be of medium educational value, comparable with other structured activities, such as morning report and department conferences. They were ranked somewhat lower than patient care and reading but were considered more valuable than resident work rounds, rounds with the department chief, or formal consultations provided by subspecialists.
DISCUSSION In the first study of attending rounds to survey all residents and attending physicians in multiple training programs, we have determined attitudes regarding a number of important issues, including time allocation, format, teacher characteristics, and distribution of responsibilities. On certain matters, residents and attending physicians agreed. As in a national survey, ~a most respondents preferred efficient rounds with sessions not exceeding 90 minutes three to four times weekly. Brevity of case presentations and of lectures on rounds and relegation of certain activities, such as chart review, to
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TABLE 1 PhysicianAttitudes RegardingFrequencieswith Which Certain HousestaffActivities Should Be Observedby the Attending Physician Optimal Frequency*
Housestaff (%)
Attendings (%)
Significance of Difference
Interviewing a patient 0 1- 2 >3
22 65 13
9 56 35
p < 0.001
Examininga patient 0 1-2 >3
18 63 19
7 56 37
p < 0.001
33 44 23
14 41 45
p < 0.001
13 36 51
8 25 67
p < 0.002
Performing a procedure 0
1-2 ->3 Conductingwork rounds 0 1-2 ->3
*Average number of times per month the activity should be observed.
time outside rounds were also advocated. It was felt that discussions could reasonably constitute 50% of attending round time and should involve all levels of learners, rather than aim consistently at the highest, the lowest, or an intermediate level of understanding. Although Maxwell and colleagues 9 concluded that "rounds should be pitched at the intern's level," they surveyed fewer than 20 residents. Our respondents favored a " 6 0 - 4 0 " balance regarding discussion content (specific patients vs. general topics), timing (spontaneous vs. deferred), and methodology (interactive vs. didactic). The value of balanced rounds has been previously recognized. 8, 9, 16, ~7 Deferral of discussions may be particularly useful when time is running short, when tired residents are recovering from call, or when additional reading is required.
TABLE Z Ranking of Various Attending PhysicianAttributes Ranked Highly Important* Attending Attribute Fund of knowledge Availability Relatingwell to housestaff Sharing teaching Providing feedback Flexibility Physical examination skills Lecuring skills on rounds Questioningskills on rounds Relating well to patients
Ranking (Mean Value) By Housestaff By Attendings 1 (6.3) 2 (6.2) 3 (5.9) 4 (5.8) 5 (5.6) 6 (5.6) 7 (5.5) 8 (5.3) 9 (4.9) 10 (4.9)
3 (6.0) 1 (6.5) 2 (6.2) 7 (5.6) 5 (5.9) 9 (5.5) 6 (5.7) 10 (5.1) 8 (5.5) 4 (6.0)
*Percentageof resondentswho ranked this attribute 6 or 7 on a seven-pointscale.
By Housestaff
By Attendings
(%)
(%)
81 77 69 61 53 52 49 45 29 32
70 89 78 53 68 50 61 41 52 72
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Attitudinal differences b e t w e e n residents and attending physicians were identified in the areas of bedside rounds, observation, feedback, and resident control of rounds. Respondents felt that only about 30% of attending round time should be spent at the patient's bedside, and residents preferred even less time than did attending physicians. Previous estimates o f time actually spent at the bedside have b e e n similarly Iow, ranging from 15% to 25%. 3, 7, 13. 16 Few respondents felt that cases should be presented at the patient's bedside. This reluctance may relate to learner fatigue during lengthy ward rounds and to c o n c e r n about patient privacy.~, 19, 20 Previous surveys have demonstrated that patients actually appreciate bedside presentations. 19-21 Learning climate issues related to bedside and corridor teaching, including distractions, group size, and the r e q u i r e m e n t for standing, probably explain the common desire for selective and efficient bedside visits a, 2o, 21 From an educational standpoint, the optimal apportionment b e t w e e n bedside and c o n f e r e n c e room time remains to be determined. What is probably important is that visits to specific patients focus most on what is best accomplished in their presence, namely interviewing, physical examination, explanation, and humanistic skills. Compared with what attending physicians considered optimal, residents felt less of a need to be observed in specific patient interactions but more o f a need for improvements in feedback. This apparent paradox may be partly due to faculty difficulties in assessing clinical competence.22, 23 Even w h e n observations are correct, the quality and quantity of feedback provided by attending physicians to learners are often inadequate. 13, 24 The dual e n h a n c e m e n t of observational and feedback skills might lead to greater agreement between residents and faculty regarding the need for these two activities, particularly since housestaff deficiencies in history taking and physical examination have been documented. 2s-27 Residents desired a substantial share in control of the agenda and in teaching on rounds. While faculty t e n d e d to support substantial resident participation, residents expressed a desire for more control of rounds than attending physicians advocated. Recent developments in quality assurance and in r e i m b u r s e m e n t may dictate an increasing involvement of attending physicians in direct patient management. Nonetheless, on attending rounds themselves, residents can play an important role in selection of patients to visit and discuss, in identification of teaching points, and in demonstration of skills. A principle of adult education confirmed in studies of clinical teaching s. 14, 2s is that learner participation enhances both satisfaction and understanding. Attributes of the attending physician that have a direct impact on residents, such as availability, flexibility, and the ability to relate well to house officers, share responsibility, and provide feedback, were all valued
more highly by housestaff than were bedside skills such as physical examination and relating well to patients. This high value placed on " t e a m skills" has also been reported by others. 8, 14, 15 While Shankel and Mazzaferri 18 and Coppernoll and Davies 12 found rounds to be rated somewhat higher than we did, their surveys were limited to c h i e f residents, department chairmen, and students, individuals whose attitudes may differ from those of attending physicians and residents. The latter have many competing responsibilities, including substantial time commitments for direct patient care. Furthermore, the last decade has witnessed dramatic changes in hospital-based training. Concerns about resident stress and work schedules, shorter hospital stays, and progressive shifting of patient care to the ambulatory setting c o m p e l a continual reassessment of the structure of attending rounds and their proportional share in the educational " p a c k a g e " provided residents. Although our survey is the largest sample of physician attitudes on attending rounds to date, it was restricted to military medical centers. These centers provide comprehensive care for all active duty and retired military personnel and their dependents, and the patient demographics and case mix are similar to those seen in civilian practice. 29 Due to competitive federal scholarship programs, current residents in military programs c o m e from a diversity of medical schools and academically rank in the u p p e r tertile of their graduating medical school classes. Like their civilian counterparts, attending physicians in military programs act as both teachers and the legal physicians of record for patients cared for by the ward team. Therefore, decisions made on attending rounds directly affect patient management. Our study sample did not include medical students. Although their opinions on selected issues have been previously reported, 9"1~,2o, 24, 28 the inclusion of students in future studies may be important in light of a declining interest in internal medicine careers. Finally, we measured attitudes rather than actual learning. It remains to be proven that what physicians perceive as optimal is in fact educationally effective. Meanwhile, our findings provide a useful framework to help clarify the expectations of attending physicians and residents beginning a ward rotation together. Areas of concordance as well as disagreement can be identified so that potential conflicts may b e resolved in advance. Since individual preferences for attending rounds may differ substantially, this negotiation of goals at the team level may p r o d u c e a climate more conducive to learning.
REFERENCES 1. DaggettCJ, CassieJM, Collins GF. Researchon clinical teaching. Rev Educ Res. 1979;49:151-69. 2. Snell L. Bibliography of clinical teaching. J Gen Intern Med. 1988;3:611-5.
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3. Jason H. A study of medical teaching practices. J ivied Educ. 1962;37:1258-84. 4. Reichsman F, Browning FE, HinshawJR. Observations of undergraduate clinical teaching in action. J Med Educ. 1964; 39:147-63. 5. Payson HE, Barghas JD. A time study of medical teaching rounds. N EnglJ Med. 1965;273:1468-71. 6. Foley R, SmilanskyJ, Yonke A. Teacher-student interaction in a medical clerkship. J Med Educ. 1979;54:622-6. 7. Tremonti LP, Biddle WB. Teaching behaviors of residents and faculty members. J Med Educ. 1982;57:854-9. 8. Mattern WD, Weinholtz D, Friedman CP. The attending physician as teacher. N EnglJ Med. 1983;308:1129-32. 9. MaxwellJA, Cohen RaM,ReinhardJD.Aqualitativestudyofteaching rounds in a department of medicine. Proc Res Med Educ. 1983;192-7. 10. Cotsonas NJ, Kaiser HF. Student evaluation of clinical teaching. J Med Educ. 1963;38:742-5. 11. Metz R, Haring O. An apparent relationship between the seniority of faculty members and their ratings as bedside teachers. J Med Educ. 1966;41:1057-62. 12. Coppernoll PS, Davies DF. Goal-oriented evaluation of teaching methods by medical students and faculty. J Med Educ. 1974;49:424-30. 13. Collins GF, Cassie JM, Daggett CJ. The role of the attending physician in clinical training. J Med Educ. 1978;53:429-31. 14. Stritter FT, Hain JD, Grimes DA. Clinical teaching examined. J Med Educ. 1975;50:876-82. 15. Irby DM, Rakestraw P. Evaluating clinical teaching in medicine. J Med Educ. 1981;56:181-6. 16. Schor EL, Grayson M. Outstanding clinical teachers: methods, characteristics and behaviors. Proc Res Med Educ. 1984 ;271-6. 17. McLeod PJ. A successful formula for ward rounds. Can MedAssoc J. 1986;134:902-4.
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18. Shankel SW, Mazzaferri EL. Teaching the resident in internal medicine: present practices and suggestions for the future. JAMA. 1986;256:725-9. 19. Linfors EW, Neelon FA. The case for bedside rounds. N Engl J Med. 1980;303:230-3. 20. Wang-Cheng RM, Barnas GP, Riendl PA, Young MJ. Bedside case presentations: why patients like them but learners don't. J Gen Intern Med. 1989;4:284-7. 21. Simons RJ, Baily RG, Zelis R, Zwillich CW. The physiologic and psychological effects of the bedside presentation. N Engl J Med. 1989;321:1273-5. 22. Elliot DL, Hickam DH. Evaluationofphysicalexaminationskills. Reliability of faculty observers and patient instructors. JAMA. 1987;258:3405-8. 23. Herbers JE, Noel GL, Cooper GS, Harvey J, Pangaro LN, Weaver MJ. How accurate are faculty evaluations of clinical competence? J Gen Intern Med. 1989;4:202-8. 24. Gil DH, Heins M, Jones PB. Perceptions of medical school faculty members and students on clinical clerkship feedback. J Med Educ. 1984;59:856-64. 25. Mandel JH, Rich EC, Luxenberg MG, Spilane MT, Kern DC, Parrino TA. Preparation for practice in internal medicine: a study of ten years of residency graduates. Arch Intern Med. 1988; 148:853-6. 26. Wray NP, Friedland JA. Detection and correction of house staff error in physical diagnosis. JAMA. 1983;249:1035-7. 27. Johnson JE, Carpenter JL. Medical house staff performance in physical examination. Arch Intern Med. 1986;146:937-41. 28. Jewett LS, Greenberg LW, Goldberg RM. Teaching residents how to teach: a one-year study. J Med Educ. 1982;57:361-6. 29. Johnson JE, Pinholt EM, Jenkins TR, Carpenter JL. Content of ambulatory internal medicine practice in an academic Army medical center and an Army community hospital. Milit Med. 1988;153:21-5.
