Dark Rounds

It's 5 a.m. and I have just finished rounds on my busy general inpatient service. I have done a history and physical exam on 18 patients—of whom 10 were new admissions—on eight different, geographically separate nursing units on five floors. I am tired, but the day has not really begun. I must dictate my notes; go over yesterday's correspondence; answer phone calls from the East Coast (the Midwest and West Coast will have to wait until “working hours”); then go to morning report, teaching rounds, noon committees or conference; and see outpatients, students, and faculty. By 3 p.m., I will be a mental fungus.

Being a teaching attending in an academic medical center has changed since I was a house officer 30 years ago. My attendings would come in 3 days a week, sit with us in a small room for an hour and a half, listen to the presentation, and then—perhaps having shaken hands with the patient, though just as often never having seen them—discuss pathophysiology, biochemistry, differential diagnosis, and therapeusis of a disorder (which the patient might or might not have) of greatest interest to the attending. Care of the patients was almost entirely in the hands of the housestaff, and it frightens me, in retrospect, to think of the decisions we made alone.

Now, on a university internal medicine service, my team of resident, two interns, a senior student on clerkship, and two to three 3rd-year students admits patients 3 days out of 5. Each one of these patients must have a history and a physical exam done personally by the attending, and the work must be extensively documented in a formulaic but periodically inexplicably mutated style acceptable to the third-party payers and the federal government. A daily follow-up exam and note on each “old” patient are …