Nephrology Fellows' and Program Directors' Perceptions of Hospital Rounds in the United States

Abstract

Background and objectives: Hospital rounds are a traditional vehicle for patient-care delivery and experiential learning for trainees. We aimed to characterize practices and perceptions of rounds in United States nephrology training programs.

Design, setting, participants, & measurements: We conducted a national survey of United States nephrology fellows and program directors. Fellows received the survey after completing the 2019 National Board of Medical Examiners Nephrology In-Training Exam. Program directors received the survey at the American Society of Nephrology's 2019 Nephrology Training Program Directors' Retreat. Surveys assessed the structure and perceptions of rounds, focusing on workload, workflow, value for patient care, and fellows' clinical skill-building. Directors were queried about their expectations for fellow prerounds and efficiency of rounds. Responses were quantified by proportions.

Results: Fellow and program director response rates were 73% (n=621) and 70% (n=55). Most fellows (74%) report a patient census of >15, arrive at the hospital before 7:00 am (59%), and complete progress notes after 5:00 pm (46%). Among several rounding activities, fellows most valued bedside discussions for building their clinical skills (34%), but only 30% examine all patients with the attending at the bedside. Most directors (71%) expect fellows to both examine patients and collect data before attending-rounds. A majority (78%) of directors commonly complete their documentation after 5:00 pm, and for 36%, after 8:00 pm. Like fellows, directors most value bedside discussion for development of fellows' clinical skills (44%). Lack of preparedness for the rigors of nephrology fellowship was the most-cited barrier to efficient rounds (31%).

Conclusions: Hospital rounds in United States nephrology training programs are characterized by high patient volumes, early-morning starts, and late-evening clinical documentation. Fellows use a variety of prerounding styles and examine patients at the beside with their attendings at different frequencies.

Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_03_17_CJN.10190819.mp3.

Keywords: Censuses; Clinical Competence; Documentation; Motivation; Patient Care; Problem-Based Learning; Records; Surveys and Questionnaires; Teaching Rounds; Training Support; Workflow; Workload; clinical nephrology.

Graphical abstract

Figure 1.

Description of the survey audiences for the fellow and program director surveys. ASN, American Society of Nephrology, NBME, National Board of Medical Examiners.

Figure 2.

Program director perceptions of the relative importance of different activities for building fellows’ clinical skills. The values 1–4 represent the value of the activity from most (1) to least (4) valuable. The activities are analyzing laboratory results; formulating a differential diagnosis (dx) and management plan through writing consult and progress notes; bedside discussion of differential diagnosis and management plans with the attending; and remote discussion of differential diagnosis and management plans with the attending (for example, in an office).

Figure 3.

Program director perceptions of the relative significance of barriers to conducting efficient rounds. The values 1–5 represent barriers to conducting efficient rounds from most (1) to least (5) significant. The barriers are electronic medical records, trainee duty hours, fellows unprepared for the clinical demands of nephrology fellowship, competing clinical and administrative responsibilities for faculty, and competing clinical responsibilities for fellows (for example, outpatient clinic or procedures). One of the 54 respondents ranked only three of the five barriers.