*How to round with Paul Williams*

Tips for medical students, interns, and the curious - a thread

Just in case this might be helpful. Your mileage may vary with other attendings, who may violently disagree with these. (1/16)

Before we start together, it's really helpful for me to know what things you're trying to improve on. This will help me know how to best tailor my feedback for you as we go through the rotation together. (2/16)

You're in charge of coming up with the assessment and plan. I will do my best to agree with your plan, but please tell me why you’re thinking what you’re thinking.

If I ever dictate the plan, it’s because I’m worried we are drifting into oncoming traffic. (3/16)

For me, the history is the thing. There is nothing more important to me than the story.

A brief history can be a marker for premature closure. (4/16)

Nothing makes me happier than intellectual curiosity. If a patient is anemic, we should be asking why. If a creatinine bumps, we should wonder why. Same goes for VTEs, MIs in young patients, and so on and so on.
(5/16)

This is basic stuff, but please report vitals, and please address trends.

Please tell our night floats that PRN antihypertensives will result in great anger and furious vengeance. (6/16)

If there is a leukocytosis, please be prepared with a differential. If there is an anemia, please be prepared to tell me the morphology (microcytic, normocytic, macrocytic) and what the hemoglobin trend has been; please follow the bouncing creatinine. (7/16)

If we ordered an EKG, I will want to see it, and will ask someone to interpret it. If there is a student with us, it will probably be them. Same goes for imaging. (8/16)

Shorter, more up-to-date notes are preferred over the metastatic monsters I see with every imaging study ordered since conception and a plan for chronic gout that has been quiescent since 1973. (9/16)

Please revise and re-order your assessments and plans on a daily basis, with the most important problem listed first. I know that you know this, but it’s sometimes good to repeat it.

For your daily progress notes-if there was an acute event overnight, please document it. (10/16)

We should know where the patient is coming from, and where they are going. Who do they live with? Are there stairs? Are they going back there? Do they need a physical therapy consult? These are questions I will be asking often. (11/16)

I am not advocating for intellectual laziness, but patients are owed the standard of care, and the best care we can give them. As long as we have a concrete, reasonable question that we have been unable to safely or promptly answer, we should be thinking about a consult. (12/16)

If you are thinking about calling an ICU consult, call the ICU consult. (13/16)

Please let our night floats/nighttime coverage know that I need to be called about deaths, premature discharges, elopements, and ICU transfers. I do not mind being called. I do mind finding out on rounds the next day. (14/16)

Length of stay is important, but a good general rule of thumb is to not discharge patients who have been febrile in the past 24 hours, or who have a dropping hemoglobin or rising creatinine. (15/16)

Despite all of this proscriptive and prescriptive stuff, we should be having fun. I tend to give feedback on the fly, both positive and negative. Please give me feedback as well. I would like to be good at my job. (16/16)

I was not expecting this thread to get quite so much traction. Thanks for the nice comments. Since the HTN thing generated the most conversation, here's an excellent review: https://www.journalofhospitalmedicine.com/jhospmed/article/176615/hospital-medicine/acute-treatment-hypertensive-urgency