Organizers and Facilitators: Jack Badawy, Jack Cunningham, Sonia Dalal, Adriana Dhawan, Gregory Leslie, Amit Pahwa, Lucy Shi, Vasundhara Singh

Background

Morning rounds often serve as the clinical and educational foundation for hospitalists working on inpatient wards teams with learners. Bedside rounds may enhance patient experience, but the choice of rounding styles is often influenced by many other factors. This summary explores the benefits and challenges of different styles and identifies implementation barriers.

Impact of Different Rounding Styles on Learner Education

Direct Observation

Bedside rounds allow the strongest ability to directly observe learner skills in communication, physical exam, and shared decision making. Hallway rounds also allow for some observation, however card flipping limits direct feedback opportunities.

Communication

Bedside rounds can help learners show how they communicate with patients of all health literacy levels and medical complexity. Others felt that using technical jargon away from the bedside can increase precision in the discussion and prefer hallway rounds as a hybrid. Many noted that rounding as a team allows the attending to model clinical skills and communication such as translating medical jargon or conveying uncertainty.

Depth of Discussion

For patients where a selected subset of the team go into the room together, hallway or card flipping rounds can allow all of the team to learn from the patients' case. Bedside rounds can force the team to focus only on the main problems at the bedside, minimizing perseveration on minor problems. On the other hand, card flipping or hallway rounds can allow more in-depth discussion about the evidence behind decisions, but some felt that card flipping can lead to less discussion with the unspoken focus on getting through rounds quickly.

Psychological Safety

Hallway rounds and card flipping rounds can improve the psychological safety of rounds to allow the learner to test out decision making with the team and feel more confident with the patient. Bedside rounds may induce fear of giving incorrect information and losing trust with the patient for early learners or struggling learners.

Autonomy and Learner-Patient Relationship

Card flipping rounds can increase resident autonomy to make independent decisions, but can inadvertently reinforce separation between team members with the attending perceived as the final authority, weakening trainee rapport and ownership. Rounding together allows team members to clearly identify their roles and promote the learner as the patient's primary physician.

"When our learners have a chance to show off what they know in front of the patient, it can enhance that patient learner relationship so they're really seeing either that student or resident as their doctor."

Impact of Different Rounding Styles on Clinical Care

Consistency of Communication

Card flipping rounds can lead to fragmentation in care and disconnected messaging. If the attending comes separately with an updated plan, this can lead to confusion, frustration, or mistrust. Miscommunication occurs less in bedside rounds because everyone is seeing the patient at the same time and hearing the same information. For some patients, hallway rounds may increase satisfaction compared with bedside with the team coming in with a unified message. Hallway and bedside rounds can also allow the incorporation of bedside nurses.

Efficiency

Card flipping rounds are perceived as more efficient but may lead to more back-and-forth communication later in the day after the attending obtains new information, which subsequently delays clinical decision making. Relying solely on card flipping may also delay the recognition of clinical changes. However, rounding together, particularly if one patient takes longer than expected, can lead to more compressed time for other patients.

Asynchronous Rounding

Sometimes rounding separately can be another opportunity for patients to bring up complaints later in the day with the same team checking in multiple times a day. Some participants prefer to spend more time separately with the patient to obtain a more thorough history and physical to ensure the accuracy of the information.

"It feels more efficient to card flip but I think we need to study and figure out if it actually is. I can't tell you the number of times where the resident tells me something, I go talk to the patient, they tell me something different and then there's back and forth."

Factors That Influence Success Different Rounding Styles

Learner

One of the biggest contributors to success of bedside rounds was learner buy-in. Attendings who push for bedside rounds have lower resident evaluations, leading to attendings to choose card flipping rounds to appease residents. Those who found success in bedside rounds emphasized the need to prepare the team in effective patient-centered communication and what to expect. Medical students often need additional guidance for successful bedside rounds. No matter the location of rounds, struggling learners can slow the team down, which feels more prominent at the bedside.

Patient

Participants strongly emphasized the importance of patient selection and preference when deciding on rounding style. Bedside rounds can be detrimental for some patients such as those who are confused or those with prior trauma. Many use the perceived learning value to maximize the benefit of seeing some patients as a team while taking advantage of increased speed of card-flipping rounds for other patients.

"It can be really almost frightening for the patient to have a whole team come and stand around them and talk about them and they're not really understanding what's happening."

Attending

More experienced educators have more comfort with navigating unexpected bumps during bedside rounds and how to increase team efficiency overall whereas less experienced attendings may care more about appeasing residents and sticking to resident preference for card flipping.

Institutional

Geographic distribution was highlighted as a major barrier to seeing patients together. Time constraints can also push participants to choose card flipping rounds. Some institutional metrics such as early discharges can make it harder to round together but can be mitigated by splitting team roles with one person placing orders while another presents. Other institutions emphasize hallway or bedside rounds to improve collaboration with nursing staff.

Service Expectations

Some residency programs and hospitalist programs set expectations for rounding style, which can influence local practice. A policy for a certain percentage of rounds being at the bedside increases institutional normalization and resident acceptance. High institutional structure for bedside rounds lends itself to more efficient and integrated bedside rounds. In all cases, taking the time to set clear expectations and clearly defined roles can set the team up for success.

"We need to maintain flexibility like we do in patient care all the time. There's not one right way to do it, and as much as I love bedside rounds and push them hard on residents, I recognize that there are appropriate times for card flipping and hallway rounds on really complicated patients."

Conclusion

Participants highlighted time and resident buy-in as major barriers to rounding as a team although the educational value and patient focus of these rounds was felt to be higher. Addressing structural components such as geographic cohorting and having clear service expectations can help address these challenges. More than anything else, there is not one right way to round with a team and rounds should adapt to the learner and patients' needs.

Our next HOMERuN meeting will be on October 10, 2025.

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