Surviving clinical rounds: tips and tales from a pediatric hematologist-oncologist [PODCAST]

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Today’s guest is Maha Al-Ghafry, a pediatric hematologist-oncologist who shares her experience with clinical rounds.

As health care professionals, we know the struggle of clinical rounds, where you receive patient handoffs, pre-round on EHR, physically pre-round on patients, and then move onto some form of “proper” rounds. You order medications, call consults, and try to avoid taking breaks even when you need to hydrate or use the bathroom.

Maha questions why they even call them rounds, as they often feel like you’re going round and round in circles, and even as an attending, it’s just as arduous. And then there’s always that one relative who finds your group and begins screaming about the care of their loved one.

Join us as Maha shares her experience as a pediatric hematologist-oncologist and how she navigates through clinical rounds.

Maha Al-Ghafry is a pediatric hematologist-oncologist.

She shares her story and discusses her KevinMD article, “The merry-go-round of rounding.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today we welcome back on the show Maha Al-Ghafry. She’s a pediatric hematologist-oncologist. Her KevinMD article is titled “The merry-go-round of rounding.” Welcome back to the show.

Maha Al-Ghafry: Thank you so much, Kevin. I really appreciate everything that you do, and for really giving physicians a voice.

Kevin Pho: Well, thank you so much for coming back on the show. Now, for those who didn’t get a chance to listen to our first episode together a few months ago, just briefly share your story and journey.

Maha Al-Ghafry: Yeah, so I’m a pediatric hematologist-oncologist, and I also did a year of transfusion medicine, and now I’m back to practice back home in Oman, in the Middle East.

Kevin Pho: All right, so you’re in Oman now. Tell me about your practice and what medicine is like in Oman.

Maha Al-Ghafry: Surprisingly, and we’ll get into our article, it’s very similar to how it was in the U.S. in a lot of ways. The nuances of availability of certain things are a little bit different, but one of the nice things is we do have universal health care, so you can even get your ibuprofen from the hospital on your way out for free, which is really kind of different from the practice in the U.S.

Kevin Pho: All right, so walk us through a typical day. Tell us some of the typical cases that you would see as a pediatric hematologist-oncologist.

Maha Al-Ghafry: Yeah, so my clinical practice is mostly both non-malignant and malignant, so mostly leukemias, and the non-malignant would be kind of your hemoglobinopathies, like sickle cell disease and beta thalassemias, thrombosis, bleeding issues like hemophilia, aplastic anemia, typical iron deficiency anemia, and so on. And like a lot of people, I have a hybrid of inpatient service, so you’re seeing the patients that are admitted to the hospital, kind of consults from anybody else in the other disciplines or the ER, as well as outpatient clinical practice.

Kevin Pho: Now, what is it about pediatric hematology-oncology that drew you to the field?

Maha Al-Ghafry: Yeah, so in residency I knew that I wanted to subspecialize, and I really loved how rooted pediatric hematology is in general pediatrics, especially looking at everything from basic neutropenia, basic anemia, basic, you know, iron deficiency. That’s all a lot of basic pediatric care that I felt that I got a lot of strong training in. And I really kind of loved that intersection, where it’s something that we can call non-malignant, like sickle cell disease, but with a myriad of implications and complications that entities like that can have for the rest of that person’s life. And then, you know, the intersection with oncology. So that’s what drew me in.

Kevin Pho: So by definition, you know, you’re seeing a lot of kids that have pretty severe disease. Some of them can be, of course, pretty sick just by the nature of the conditions that you see every day. How difficult is it as a physician to see that? Because a lot of people outside of medicine can’t even imagine their own child going through something like this, but as a physician, you see a lot of kids who have pretty severe conditions. Talk to us about that. How difficult is it for you to see that?

Maha Al-Ghafry: It’s really difficult, and I think one of the things I’d like to point out is that with patients that have an oncologic diagnosis, like leukemia or, you know, osteosarcoma, for example, with a very definitive treatment plan, where you know what they’re going to go through, a lot of those parents and families, even if they are hesitant about understanding this whole new world of oncology and trusting you with that, they kind of get it, and you can move along with the treatment plans.

Where it becomes a little bit difficult is those really gray spaces in hematology, things like thrombocytopenia or neutropenia, that are in general not, in and of themselves, a concern for a malignant problem. But the parents, you know, will Google, go online, and ask people, and they’re just worried: “This is leukemia, this is leukemia, this is leukemia,” no matter what you explain about immune thrombocytopenic purpura, and chronic, you know, ethnic, and I don’t like that word, but ethnic, for example. And then more of the spectrum of aplastic anemia and myelodysplastic syndrome, where it’s very difficult to diagnose those conditions, and sometimes it takes months to make sure that you hit all the criteria. The treatment plans kind of differ a little bit, and they are very, very rare cases compared to even some of the oncologic processes. So having families on board and really trusting what you’re saying is kind of the difficult part of the whole situation.

But, you know, as with a lot of things in medicine, you really get to know the families really well, and you get to know the patients really well. And as a pediatrician, I feel like our connection, or at least for me, a lot of my connection is with the parents, actually, rather than the child, because it’s difficult for the child to connect to you. They’re connecting with their parents, but the parents are the ones connecting to you.

Kevin Pho: Now, we have a lot of medical students who listen to this podcast. What kind of questions should they ask themselves if they perhaps may be interested in pediatric hematology-oncology?

Maha Al-Ghafry: Oh goodness, lots of things. I think that in pediatric hematology-oncology right now, it’s still a combined field. If you, as a medical student, are interested more in non-malignant hematology, for example, in adult medicine, internal medicine, you are able to, for example, go to a hematology-only fellowship rather than doing a combined program, and only take the boards for hematology. So I think that’s one of the things to stop and think about: Do you want to do the combination of both? If you like just one of them, then maybe go to the adult side. That’s just kind of thinking as a medical student.

And then from there on, just recognize that this is definitely going to be a field where you have a lot of multidisciplinary care. It’s not just you. You’re going to have to work with the pathologists, with the intensive care doctors, with all sorts of surgeons, you know, orthopedic surgeons for your osteosarcomas, and so on, and pathologists, etc. So you really need to be able to work with different teams and work within your own division really well to make sure that you’re providing appropriate care for these patients, and keeping up with a lot of the rapidly increasing data, thankfully, that we have on a lot of things that we didn’t have available before.

Kevin Pho: All right, so let’s talk about your KevinMD article, titled “The merry-go-round of rounding.” Now, how did this article come together?

Maha Al-Ghafry: The other titles were “I hate rounding” and “How to not make rounding suck.” And this is something that I’ve felt, and it’s not because of my current practice as an attending, but something that I’ve thought about all throughout my training, since I was a medical student. Rounding is a beast, especially as a resident and as a fellow. You’re in there in the mornings, and I kind of go through what a typical inpatient day looks like. I’m not going to hit on the surgical field, because I know they start rounding at 5 a.m., which is absolutely insane.

But the whole point of rounds is to collect patient information, disseminate patient information, and come up with management plans. And it just seems like the whole day you’re just rounding. You’re rounding with yourself, you’re rounding with other team members, you’re rounding with the nurses, rounding with your attending, you’re rounding with social work and case management, and at the end of the day you’re rounding with the unit receptionist, trying to get things done for a patient to be discharged, for example. There are just a lot of things that go into inpatient medicine, with rounding being the cornerstone of that.

And I’ve tried to search where this word comes from. Does it come from physically going around, you know, the Johns Hopkins, like, famed dome, of people going around, and that’s where it started? But to me, rounds do seem never-ending, honestly. You start your day and end your day just going round and round with the patient information that you have.

Kevin Pho: Well, go into more detail, though. I think that you mentioned earlier that rounding is a beast, and it’s been a while since I’ve done inpatient medicine, but I could imagine as a resident rounds would sometimes take three, four, five hours, depending on how the attending was, depending on how many patients you have. So from your experience when you were training, or even now, just take us into one of your rounds. What’s it like?

Maha Al-Ghafry: Yeah, so kind of thinking back to my experience as a fellow, this was definitely making sure that you come in at 6:30 a.m., when it’s so quiet. The handoff hasn’t happened yet, the nurses haven’t given their handoff yet, so nobody’s disturbing you quite yet, to kind of set the tone for your day. And by pre-rounding, I mean you’re sitting down, of course, at your computer, looking at all the patient information, seeing any active issues that happened overnight, checking that your patients received certain medications, any consults that might have come in, and so on.

And then you go into your formal rounds, and those are very person-specific, institution-specific, and attending-specific. Are you going to have the typical sit-down rounds at the computers? Are you going to have walk rounds with a computer, like a computer on wheels? Are you going to have patient-centered rounds? I feel like that’s maybe a little bit more of a pediatric thing, where you visit and you don’t say anything, but you physically just walk into the patient’s room and you start giving your rounding presentation with the parent. That’s its own thing. So there are these different types.

In typical, traditional rounds, you’re the team with the attending, whether it’s residents or fellows or advanced practice providers. Usually that’s the core team, but then are you including other people in that rounding? I personally love it when we are able to have nurses within our rounds. They give you such a breadth of information that you just can’t get by going through the computer by yourself or talking to each other, because they’ll tell you how thick the NGT output was, or if they’re having difficulty taking a specific medication, so do you need to come speak with a pharmacist about compounding it differently, and so on. So these are the kinds of aspects of rounds that you need to take into account.

Now, within our health care system, the problem is that rounds can’t last all day. Ideally, they would take as long as they need to take for you to speak to everybody that you need to speak to, to speak with the family, also to physically review every single medication that is ordered and whether it’s been administered or not, any PRN medications that were administered or not. Because if somebody’s getting morphine as needed every three hours, then maybe you need to be doing something else, right? And those are the little nuances that can get missed, even in detailed rounds. Do you have a clinical pharmacist that is helping you with any kind of drug-to-drug interaction?

So that’s kind of number one: Who are the members of the rounding team that you have with you? Other than the actual clinicians that are seeing the patients, are you including nurses, clinical pharmacists, and/or parents in this discussion? And then the next layer comes to: Great, now you’ve done all of this work. While you’re rounding, is somebody there putting in orders, putting in consults, doing any of the additional little work? If you’re not doing that, and you’ve finished five hours of rounding, and then you have the intern go put in medication changes or anything else like that, that’s delaying when you’re able to get to completing any of your tasks.

And then we’re not even going to include, for example, speaking to other services in the hospital. Do you need to consult the GI team? Who else do you need to include in this patient’s care, in addition to, as I had already mentioned, case management or social work? How are we going to get this person home? So as you can see, after your official rounds, you’re putting in your orders and writing your notes and so on, and then you get to a point where it’s almost time to hand off your patients, and now you’re doing another kind of mini round with your handoff in the afternoon. I remember that for me as a fellow, I used the handoff as a checklist of: Did we make sure that we did everything that we said that we’re going to do? So that’s your third rounds for the day, essentially.

But clinical medicine has evolved to be this behemoth that is, in a way, untamable, but it’s also very necessary for us to do all the things that we do. I like to say that 50 years ago we barely knew how to treat leukemia, right? We had a couple of drugs, and that was it. But now we have everything from your basic first lines to your second lines and third lines, and all the side effects that come from all of those different treatments that you really have to be on top of, and you have to have a whole medical team involved in taking care of that.

So that is the kind of gist of inpatient rounding. It’s not just about you and the patients. It’s about you, the rest of your team, and the extended team, and making sure things are done at the end of the day. And it’s very difficult within the time frame that you have. You only have 24 hours in a day to get anything done, but hopefully within your 12-hour-or-so shift you’re able to get that done. And if not, you’re going to be going home and finishing up notes, right, to get things done.

Kevin Pho: Well, I’m dating myself here, because when I did inpatient rounds, it was like 20 years ago. That was before the advent of electronic health records. So talk about that intersection between technology and rounding. I’m a primary care physician, and the computer sometimes can be a pretty big distraction in the exam room, in that it distracts the attention of the physician away from the patient, and physicians mostly focus on computers. Now, when you did inpatient rounds as a resident or fellow, or even now, tell us about that third entity in the rounds, the computer. How does that affect the communication and the interaction that you have with patients?

Maha Al-Ghafry: It really depends. If we’re talking about inpatient rounds, if you are going around rounding with a computer on wheels, sometimes you can have somebody else look up information, which is fantastic. I personally think having an electronic health record is very useful in terms of being able to see certain trends of things, really being able to see what medications were given and what was not given in a mobile form.

I haven’t really worked with paper charts or something like that, so it’s difficult for me to see the possible advantages of that. At least you have a little bit more consolidated information. Maybe things are laid out a little bit differently, maybe in one page. I know that, for example, some ICUs actually still use, you know, a paper chart, whereas in the electronic health record you have to go through so many different tabs to find what you need, right? And then your note will auto-populate with the range of vital signs, but if you’re not looking at the vital signs themselves, then you might miss key aspects of that. Like, sure, the range of temperature was 100 to 103, but if the patient is sitting in the 100 to 103 except for that one 100.0 temperature, then that’s something significant, right? So there are a lot of aspects of the health record that, although it’s trying to make life easier, if we don’t dig in to every single little aspect, you can miss important information.

And the other part, the good and the bad part, which I’d already mentioned, is you can take work home, right? With paper charts, you’re just writing things down, and whatever is done is done by the end of the day. But with electronic health records, you’re sitting there at home, you’re looking back on things, you’re editing things, you’re finishing things up, you’re adding an addendum, and so on. So the work never finishes with having an electronic health record, in that aspect.

But I think overall it is important. For example, I mostly work in places where you have everybody in one place, but if you’re a physician that covers multiple different hospitals, it’s really useful to be able to see that from your hospital, to monitor things from afar before, for example, having to come and see a patient, and so on. Also, if you’re on call at home as a fellow, this was definitely something that was really important, because we weren’t in-house, but we might as well have been, because of the hours that you were up all night, right? But it’s important for you to actually go into the patient’s chart and see what’s happening to them in the emergency department or the inpatient unit, and have a little bit more history. Because if you have a patient that shows up in the ER, if they’re not trained in heme, they’re not really going to be able to tell you the nuances of what chemotherapy they received and how many days ago, and you’re the one that’s going to have to know that. So for you to know where exactly they are in their cycle, what they have received recently, whether they are on certain medications at home right now, that’s going to change your differential diagnosis of what they’re coming in for and make you adjust your management plan.

So it’s a curse, for sure, I would say, because of the amount of information that’s available, but I don’t believe that modern medicine, at the rate that we’re going, can survive with paper charts.

Kevin Pho: Now, you said earlier that if we’re not careful, we could literally spend a whole day rounding. Now, if you were in charge, what kind of changes would you make to the rounding system to make rounds more effective and more efficient?

Maha Al-Ghafry: Yes, so I’m definitely a Type A person. I like order. I like things to have a systems-wise approach. So I think the kind of haphazard way of having different people wanting to do things in different ways, and by that I mean either attendings or residents or APPs, makes it difficult to have uniformity and to have a consensus on the patient.

So what I prefer is, for example, let’s say when people are pre-rounding, if you have a pre-rounding sheet, for example, that is already laid out in the way that you will present in rounds, then everybody knows that this is what’s going to happen in the presentation. For example, you know that they’re going to give you the patient’s one-liner, give you overnight events, give you vital signs, and then go system by system. Then you make sure that you don’t miss anything.

And I think that’s the biggest thing. When we’re going in a haphazard manner and everybody’s trying to do some sort of a SOAP-type round or a problem-based, problem-list-based kind of round, you miss a lot of things. Because if you’re not discussing, for example, line access, which for hematology-oncology is really important, because it’s not in your list, then you’re going to forget that this patient who is undergoing a transplant and has a double-lumen Broviac also actually has an access port line from their initial leukemia diagnosis, and they just spiked a fever, so you need to make sure that you’re culturing every single one of those lines. But if you’re not, in your rounds, making sure that everybody’s on the same page about what is going on with this patient to that level of detail, there are a lot of things that can be missed later on, when something happens to the patient, like spiking a fever, and you have this extra line that is hidden under their skin that you don’t know anything about. So that would be number one: making sure that everybody is on the same page about rounding in a very specific way, to allow everybody to be on the same page and to not miss anything.

And also, some people’s argument is that going through every single system takes longer. Just saying the patient is on room air and moving on does not really make anything longer. The number of times, during residency, fellowship, and now, that people have missed, “Oh, by the way, this patient is on one liter of oxygen.” That’s significant, because they went all off on the fever that happened, all the antimicrobial changes that happened, and they were a little bit hypotensive and you gave them a bolus, and so on. And then you walk into the room and the patient is on oxygen, and you’re like, “OK, well.” It looks bad on the team that you don’t know that level of information, right?

So it’s really about making sure you’re doing things in a safe, systematic way, and if everybody’s doing the same thing, it is better for everybody. I really love the book by Atul Gawande, The Checklist Manifesto, because even in the ORs and other places, having checklists or systems in place makes it safer for everybody to be on the same page and to make sure that the appropriate things are being done for patients.

Kevin Pho: And my final question: Just tell us some of your take-home messages that you want to leave with the KevinMD audience.

Maha Al-Ghafry: My take-home message is, if you can have within your group a systematic way of going about rounds, where the same things are brought up every single day in a systematic way with the entire health care team, including, hopefully, the nurses, social workers, and so on, and clinical pharmacists if you have them, that really makes your rounds more efficient and actually impactful at the end of the day.

Kevin Pho: Well, thank you so much for sharing your time and insight. Thanks again for coming back on the show.

Maha Al-Ghafry: Thank you so much, Kevin.

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