Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Holiday Rounds


If you're called on to work through Christmas and New Year’s, there's a bright side. This is typically a quieter period and may allow more time to learn from clinically excellent role models.

I work as a teaching attending for several two-week blocks each year. For years, I’ve taken the weeks that cover Christmas and New Year’s. Colleagues appreciate this, but truthfully, not as much as I like doing it. For one thing, there’s comradeship and holiday spirit, even if it isn’t my holiday that fills the air. Moreover, the inpatient teams are laser focused on patient care and the schedule is trimmed of conferences. There’s no morning report. No noon conference. No chief’s rounds. No special sessions. We do our morning report in the workroom or at the bedside. We work through diagnostic problems with short “chalk” talks. I have more time to watch the house staff in action with time for feedback. We practice skills. We read and edit patient care notes together. We go to the lab or the radiology reading room. We go back to re-examine patients together. We talk with the patient, their nurse, and the patient’s family, as suits them. It’s a pretty good holiday, if you ask me.


One holiday my resident asked if he could come in on his day off. Typically, one weekend day, the team is off and the attending rounds alone. The resident said, “I want to come in Sunday to see what you really do.” He was going into practice in six months. His purpose was to see what a seasoned (no offense) physician really did when seeing patients. I thought about this. Residents—at least in the contemporary inpatient routine—don’t often get to see patient care stripped of the myriad curricular distractions. Furthermore, there are few opportunities to see how senior faculty put it all together, so to say. They hear us tell them what we do or should do. We may demonstrate specific skills during team rounds, then watch team members interact with patients followed by feedback. However, they rarely see us in action with patients from start to finish—how we prioritize whom to see first, what we preview before rounds, whom we talk to about our patients, and what information we seek. How do we enter the room? How do we start the bedside visit? What questions do we ask. How do we ask? Which parts of the physical examine do we perform for every patient and which for a patient with a particular condition? Do we take time with the nurse, therapist, or family? How do we use that information to guide patient care? The importance of these individual elements seems obvious, but when I thought about it, our residents rarely see how we put it all together. (Picture a surgery resident seeing snippets of surgery out of order, but never the whole operation from opening to closing.) I checked—there was no duty-hour problem. We agreed—I would do what I do, he would be a fly on the wall.


Sunday we met in the team room. I like to start early. However, it’s too early for most patients, so I use that time to read and jot notes, look at images or lab, then prioritize what to do. He noticed that I was wearing a jacket and tie. I told him that my practice was to dress on weekends like weekdays so patients wouldn’t think I was eager to get out the door. When I refreshed my supply of tongue depressors, cotton swabs on a stick (for sensory exam and wound probing), lubricant jelly, and checked the illumination of my ophthalmoscope and otoscope. I regularly start rounds with the team by stocking my white coat before we see patients. Some get the hint, but maybe I should be more explicit.


The first patient we went to see was new on our service. She arrived to the floor late in the evening. Her vital signs were fine. We knocked lightly, opened the door gently, and peeked in. She was snoring loudly. We quietly closed the door to return later. The next patient had been admitted to the intensive care unit for treatment of septic shock, but was now stable and transferred to our team. We again knocked gently. The light in the room was on. His nurse was setting up his breakfast tray. We greeted him and his nurse. We asked how he was, saying that we would come back after he had had a chance to eat. He looked pleased. This happened a few more times while we rounded—either the patient was on the toilet or getting ready to eat or a nurse or therapist was going about their work. In each instance we stepped aside, while taking advantage to watch how well the patient was able to pay attention, sit up, or feed themselves, or to hear about the patient’s progress from the nurse or therapist. The resident learned that much of this information showed up in my progress notes. We do this on teaching rounds, too, but I’m not sure how well it stands out against residents getting paged, side conversations among trailing team members, anxiety in anticipation of bedside presentations, or pressure to get to conference.


My resident appreciated that we weren’t waking patients or flipping on the light while simultaneously asking if they minded if we came in. We sat down like there was no rush. We began most visits with some social talk, recalling something of personal interest to the patient. Some liked fun banter—for others, a different tone seemed more appropriate. Most always, we asked about the patient’s comfort, meals, bowel and bladder function, or how the patient thought care was going. We were careful to position patients properly for physical exam, even if took a bit of extra time to get staff assistance. We performed our exam the same way we were taught without short cuts because, as my resident saw, we really used the information to make important decisions. Sitters, when asked, had something to say more often than not, added information only they would know, and made helpful suggestions. The resident told me that he had not appreciated how much we could pack into rounds, yet remain efficient. He remarked, as Yogi Berra said, “You can observe a lot by just watching.”


Overall, it was a good morning’s rounds. I wrote notes. We stopped by the nurse’s station before leaving to go over a few orders. The resident and I debriefed along the way. Not much that he saw had not been part of teaching rounds. Rather, the sum was greater than the parts.


He still reminds me of our distraction free holiday and shadowing, when on occasion I see him in the hospital hallway, as an attending physician with his own entourage of students, interns, and resident. He’s a good teacher and role model. I wish more students, interns, and residents could see him action, then practice what they saw. I wish he had more time to see them in action. That would make a good holiday all around, if you ask me.