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January 23/30, 2013

Attending Physicians on Ward Rounds

Author Affiliations

Letters Section Editor: Jody W. Zylke, MD, Senior Editor.

Author Affiliations: University of Alabama, Birmingham (Drs Centor and Roy) (rcentor@uab.edu); and University of Central Florida, Orlando (Dr Castiglioni).

JAMA. 2013;309(4):341. doi:10.1001/jama.2012.65887

To the Editor: Drs Wachter and Verghese1 considered the complexity of ward attending rounds in the current health care environment in a Viewpoint. We examined ward attending rounds2,3 using consumer preference techniques to learn how students, residents, and attending physicians view rounds. Our results complement and expand the observations in the Viewpoint.

We learned that successful attending rounds required a multidimensional skill set comprised of 5 distinct domains: learning atmosphere, clinical teaching, teaching style, communicating expectations, and team management. As Wachter and Verghese explained, current work hour restrictions and hospital expectations create a demand for team management skills, one of our domains. This domain includes timeliness, efficiency, and accommodating absences required for administrative demands.

While team management is an important domain, it did not outweigh clinical teaching, learning atmosphere, teaching style, or communicating expectations. Trainees valued teaching. They rated “sharing of attending's thought processes” as the top attribute for successful rounds. They also valued bedside teaching and role modeling. These less precise attributes of clinical wisdom trumped the teaching of evidence-based literature. Students and residents felt they could read books and medical literature, but they wanted and needed attending physicians to demonstrate clinical reasoning, patient communication, physical examination skills, and professional physician behavior.

Our studies also suggest the balance between teaching and efficiency is directly dependent on the daily workload. While trainees usually valued clinical teaching (including demonstrating clinical reasoning and physical examination skills on days with a high patient census), efficiency superseded teaching. Thus, attending physicians ought to be flexible and adjust their rounding style according to the team's needs.

Regardless of age, specialty, and institution, students and residents deserve attending physicians who demonstrate physician excellence and can explain what they are doing and why they are doing it. As Wachter and Verghese asserted, the attending role is complex and therefore requires deliberate training to improve. We have begun holding faculty development sessions in which we focus on the key issues our research identified.

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Article Information

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Wachter RM, Verghese A. The attending physician on the wards: finding a new homeostasis.  JAMA. 2012;308(10):977-978PubMedArticle
Castiglioni A, Shewchuk RM, Willett LL, Heudebert GR, Centor RM. A pilot study using nominal group technique to assess residents' perceptions of successful attending rounds.  J Gen Intern Med. 2008;23(7):1060-1065PubMedArticle
Roy B, Castiglioni A, Kraemer RR,  et al.  Using cognitive mapping to define key domains for successful attending rounds.  J Gen Intern Med. 2012;27(11):1492-1498PubMedArticle