Earlier in my career, I rounded with interns, residents, a chart rack, and a charge nurse. We disagreed and had competing demands, but working alongside one another gave us some sense of what was happening down the hallway. I knew when a nurse was doing something that could not wait. The nurses knew when I was examining a patient, teaching, or helping a family understand that someone was dying. We could see the work we were asking one another to interrupt.
I miss that mutual awareness when it is difficult to finish a sentence on rounds. A page arrives, someone approaches with a request, and another message appears before we recover the discussion. A diet question can interrupt a conversation about care near the end of life. If waiting carries a clinical consequence, I need to know. If the question can wait, the resident and I need time to finish our discussion. In one observational study, researchers recorded 378 interruptions across 30 attending rounds sessions.
During resuscitation, everyone understands why concentration matters. Its value is less visible when a resident and I are discussing a patient with heart failure and twelve other conditions. We have to reconcile treatments that may work against one another and decide what the patient can manage at home. How much supervision a resident needs depends on their experience, the task, and the circumstances of care. If we lose the thread, I may give the resident an answer before I hear how they reached theirs. I lose the chance to see what they noticed or missed, and we may leave an assumption about the patient’s care unexamined.
In clinic, a resident may ask how to explain a difficult decision to a patient. A request comes in, and I pause to find out whether it needs an answer now. It could have waited. By the time we return to the conversation, the next patient may already be waiting. We may still agree on a plan, but the chance to talk through how to explain it can slip away. Meanwhile, unfinished notes follow residents and faculty home, sometimes to bed. The charts eventually close, and the hours it took to close them disappear from view.
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Physicians owe colleagues reliable responses and a willingness to be interrupted when something changes. Our colleagues need a way to say what makes a request urgent and to know when a routine question will be answered. Institutions owe us similar consideration. I once asked a leader how many of his meetings had changed something for patients. He understood the question. He also faced demands he had little authority to change. Agreement can be sincere and still leave the work exactly where it was.
In the 1990s, I was a senior physician helping put an early rapid-response team concept into practice for hospitalized patients whose condition changed acutely. I saw what it meant to have people with the right skills ready to respond. In a teaching clinic, designated staff could handle symptom calls, urgent assessments, and questions that exceed a medical assistant’s training. Registered nurses and advanced practice clinicians could respond within their competencies, with clear escalation and physician backup. The role needs time of its own. Giving it to someone with a full assignment simply moves the interruption down the hall.
I would start with one recurring interruption. In an existing weekly meeting, physicians, residents, nurses, assistants, and clerks could choose a change they can try that week. Someone in the room should be able to approve it or take responsibility for getting a decision. On the wards, the team could agree when routine requests will be reviewed and keep an immediate route open for urgent concerns. In clinic, patient-specific messages could go to the responsible team, with designated help for matters that need triage. The following week, the people doing the work could ask whether requests were answered in time, whether teams could finish their discussions, and whether the change overloaded someone else. A residency sponsor has a responsibility to make supervised care possible, including giving local teams the authority and time to make those adjustments.
What I regard as sacred is the attention we give a person when we are trying to understand their suffering and decide what might help. I remember how much easier it was to protect that attention when we could see what our colleagues were doing. We can begin to recover some of that awareness by listening to one another and making one change people can feel in the work of caring for patients.
Gus W. Krucke is board-certified in internal medicine and emergency medicine and certified as a hospice medical director. After decades in academic medicine and physician education in Texas, he now serves as core faculty in internal medicine at Northeast Georgia Health System in Gainesville, Georgia. He is also medical director of Omega House HIV/AIDS Hospice in Houston, Texas.
Dr. Krucke writes on physician identity, moral courage, medical education, the corporatization of health care, and the preservation of professional judgment in modern medicine. His essays explore the tension between metrics and meaning, the human consequences of diffuse accountability, and the enduring importance of bedside presence, integrity, and fortitude in patient care.
His scholarly work includes publications in MedEdPublish, Proceedings of Baylor University Medical Center, Texas Heart Institute Journal, World Journal of AIDS, Consultant, The Breast Journal, The American Journal of Emergency Medicine, and Critical Care Medicine. His writing and research have addressed scholarly productivity in residency education, complex infectious disease cases, HIV-related dermatologic disease, diagnostic challenges, migraine treatment, critical care monitoring, and the central role of the individual patient in medical education. More information is available through Krucke’s Medicine, Doximity, LinkedIn, and X.
