Things We Do for No Reason™: Card Flipping Rounds

Next, faculty should ensure that BSR remains efficient.⁹ We believe that efficiency starts by setting expectations with patients. Patient expectations can be set by an attending or a supervising resident and should include a preview about how each encounter will progress, who will be in the room, how large the team will be, and what their role is during the encounter. Patients should be invited to be part of the discussion, offered an opportunity to opt out, and informed that questions arising from or clarifications needed following encounters can be addressed later within the day or after BSR. Nurses should be invited to actively participate during patient presentations. Each bedside encounter should be kept brief and standardized.^20,21 To maximize efficiency, we also believe that roles should be delegated ahead of time and positioning in the room should be deliberate.²² Team members should know who is speaking when and in what order, who is accessing the electronic health record, and who will be examining the patient. Ideally, goals should be set ahead of time and tailored to each individual encounter. Finally, ensure everyone is on the same page by huddling briefly before each encounter to establish goals and roles and huddle afterward to debrief for learning and teamwork calibration.

In order to mitigate the learner’s anxiety about presenting in front of patients, build a partnership with the trainee, and time should be allotted to establish a safe learning environment.⁹ Sustain a supportive learning environment by providing positive feedback to learners in front of patients and teams. Faculty members should demonstrate how to bedside round effectively by leading initial encounters and generate momentum by selecting initial patient encounters that are most likely to succeed.²³ Checklists can also be useful cognitive aids to facilitate an encounter and manage the cognitive load of learners.²⁴ Ultimately, hesitancies can be overcome with experience.

Faculty members should ensure that bedside encounters are educationally valuable for an entire team.⁹ This initiative starts by preparing ahead of time, which allows the mental energy during encounters to be directly observed by learners in action.¹⁶ Preparation also allows the presentation to focus more on clinical reasoning rather than data gathering.²⁰ Faculty members should also consider ways to foster resident autonomy and establish the role of a supervising resident as the team leader. Positioning in the room is critical²²; we suggest that faculty members should position themselves near the head of the bed, out of a patient’s direct eyesight. In this way, they can observe how individual team members and the team as a whole interact with patients. The supervising resident should be at the foot of the bed, central to the team and the focal point of a patient’s view. The presenting intern or student should be seated near the head of the bed and opposite the supervising attending. Clinical teaching should also be kept short and pertinent to the patient, and questions should be phrased as “how” or “why” rather than “what” to reduce the risk of “wrong” answers in front of patients and the team.