Things We Do for No Reason™: Card Flipping Rounds

The cited reasons for provider hesitancy to BSR, including possible patient harm and inefficiency, may be mostly related to individual perceptions and have recently been questioned.^10,11

Several studies have suggested that bedside rounds may be better for patients’ experience over traditional walk-­rounding or card-flipping models. In these studies, patients signal a preference for bedside rounds and suggest that discussing sensitive issues or concerning differential diagnoses during BSR may not be as concerning as physicians worry.¹¹ For example, one randomized trial found that 87% of patients are untroubled by bedside discussions,¹² and another trial revealed no difference between rounding models in emotional distress to patients or families.¹¹ Patients and families also report higher levels of clarity from physicians, and they cited significantly improved levels of understanding their illness¹⁰ and test results.⁹ Furthermore, patients describe that physicians spend about twice as much time on their care when BSR is used.¹² In many related studies, patients report a preference for BSR as a rounding strategy.^2,11-13 For example, one study found that 99% of patients prefer BSR.¹³ Another study showed that 85% of families request to be part of bedside family-centered rounds over traditional walk rounding.²

Rounding away from a patient via card flipping or walk rounding seems more efficient, but this idea may be illusory. Although these strategies may seem faster, the lack of communication and coordination between team members and the patient may cause inefficiencies and delays in care throughout the day.¹⁴ For example, one study has demonstrated that family-­centered bedside rounds are about 20% longer than walk rounding, but everyone involved, including housestaff, felt it was more efficient and saved time later in the day.² Additionally, a study comparing BSR with walk rounding¹³ found no difference in time spent per patient, and another study has shown similar results in terms of family-centered rounds.¹⁵ Both studies have reported a similar amount of time spent per patient.

Physicians should return to BSR not only to improve patient experience but also to develop the clinical skills of trainees. The direct observation of trainees with patients allows high-­level impactful clinical feedback and provides a basis for calibrating how much autonomy to allow.¹⁶ Trainees also indicate that teaching is more impactful during BSR than during walk rounding or card flipping, and clinical skill training during BSR is superior to a discussion in a conference room or a hallway context.^2,3,15,17,18 One study has even suggested that the education of bedside rounds may help improve clinical skills in comparison with traditional models.¹⁸

The lack of BSR during medical school and residency training results in a deleterious cycle. Trainees become less proficient and less comfortable with BSR skills and therefore graduate as faculty members who are unskilled or uncomfortable insisting on BSR. As such, the cycle continues. As a result and as the traditional cornerstone of clinical training and inpatient care, BSR is recommended as standard practice by some professional organizations.¹⁹

Developing buy-in is an important first step for engaging in BSR. We recommend starting by demonstrating the value of BSR to overcome initial team or trainee hesitancy. Regardless of systems established to improve the efficiency of BSR, it is our experience that learners hesitantly engage if they do not understand the value of a given activity. We also urge attendings to demonstrate value by articulating how BSR fits in a patient-centered approach to emphasize the evidence-based positive impacts of BSR on patients.⁹ Beyond reviewing the benefits, faculty should set an expectation that the team will carry out BSR.⁹ Doing so sets an informal curriculum showing that BSR is important and sets the standard of care, which allows an inpatient team to adapt early in a rotation.