A major debate taking place in the hospital medicine community over the last several years concerns the way in which we cohort patients on the medical floors. The traditional way is to have patients belonging to each doctor scattered across the hospital on several different floors. This is in contrast to designing a geographical system where all the patients for any one doctor are located on a single floor.
On the surface, it seems like a good idea to have this latter model, which is why it’s being advocated by some people. Theoretically, rounding in this manner will be more efficient and the amount of pages and calls from nurses should be reduced. As someone who has worked in both extremes as an attending physician, I’ve got to experience the pros and cons of both types of rounding — which I’m going to call geographical versus traditional. I believe that both have their own advantages, and I’ve witnessed some interesting quirks to each one. Here is my informal and honest summary of the geographic model of rounding, with 5 pros and 5 cons:
Pros
1. Having all patients located on one floor saves both time and energy, and reduces the amount of walking we do in-between floors.
2. Doctors are always closer to their patients and will be quick to get to them if and when the need arises.
3. It’s easy for nurses to locate doctors if they have a question. The same applies to any other staff who may need to speak with the doctor.
4. It fosters more of a “team-based” environment, where doctors get to know the floor staff including the nurses and case managers.
5. May be easier to assign patients to each doctor within the group when making the list.
Cons
1. Reduces the amount that doctors walk at work (I deliberately listed this as a con as well as a pro, because walking a lot at work may not necessarily be a bad thing for our cardiovascular health according to some studies.)
2. It can cause a feeling of monotony and “being stuck on one floor for the whole day.”
3. Doctors are more inclined to leave things waiting that don’t seem urgent, and then get to them later in the day. When rounding on different floors, the inclination is to try to finish everything before moving on to the next floor.
4. Loss of continuity. If a patient who a doctor knows very well is readmitted to another floor, they will not see them in a strict geographic system.
5. Will likely need to incorporate “floor rotations” into the program, which could complicate scheduling. On each particular floor e.g. cardiac, neurological — the hospital doctor may see less variety of patients and interact with fewer specialists.
Neutral
Supposedly, geographical rounding is supposed to reduce the number of pages and workflow interruptions, but in my experience this may not always be the case. Doctors are very easy to find as soon as a question arises! Questions that may have been thought about more carefully by the nurse or case manager if the doctor wasn’t geographically present.
That’s my 10 cents having worked in both types of systems. I’ve heard colleagues vouch for each model, with its fans and detractors. I’ve also heard some members of the hospital medicine community advocating for standardization of a floor-based system as an “ideal state” for hospital physicians and groups to aspire to. This needs to be thought through very carefully. Unlike nurses, typically hospital doctors (including specialists) do not work on one particular floor only — unless of course they are emergency room or ICU physicians. Should the gold standard future hospital medicine physician be located on one floor for the whole day? I’m not so sure. For me personally, the ideal is somewhere in between the two. Maybe two or three floors a day — not just one — but not more than a half dozen either.
Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being. He blogs at his self-titled site, Suneel Dhand.
