Things We Do for No Reason™: Card Flipping Rounds

Inspired by the ABIM Foundation’s Choosing Wisely^® campaign, the “Things We Do for No Reason^™” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent clear-cut conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

A 32-year-old man with a history of polysubstance use disorder is hospitalized with endocarditis. The senior resident on the inpatient medical team suggests that the team “card flip” on this patient, citing a large number of patients on the team census, time constraints, and concerns that his substance use history will make bedside rounds uncomfortable.

“Rounds” is an inpatient care model in which teams of practitioners assess patients, determine care plans, and communicate with patients, families, and other healthcare professionals.¹ One form of rounds is bedside rounding (BSR) through which an entire patient presentation occurs at the bedside, analogous to family-centered rounds common in pediatric inpatient care.² This style of rounding is distinct from “walk rounding” that involves presentations occurring separately from a patient followed by a brief team bedside encounter. BSR is also different from “card flipping” or “table rounding” that involves presentations of a case separately without a team-patient encounter. The frequency of BSR at academic institutions has markedly decreased across the United States, and the time spent at the bedside is only a small fraction of rounding time.³

There are several reasons to employ strategies such as card-flipping or walk-rounding for discussing patient care away from the bedside. These BSR risks can be organized into patient harm, inefficiency, and risks to healthcare professional training.

First, BSR may result in patient harm. For example, discussing private health information in a semiprivate room may not only be uncomfortable for patients but may also violate patient privacy.⁴ Care teams are often large in number and rounding at the bedside can simultaneously trigger anxiety among patients, cause confusion about plans, or result in lack of clarity on the role of each provider.⁴ Furthermore, delivering bad news during BSR, or discussing sensitive topics such as substance use, psychiatric illness, or concerns of malingering behavior, may be difficult and uncomfortable.^4,5 Additionally, some potential diagnoses, such as cancer or human immunodeficiency virus, even if unlikely, could induce panic among patients when they hear them being discussed.⁵ Trainees may also lose situational awareness because they focus on the agenda of bedside rounds and fail to respond to patients’ emotional needs.⁶

Efficiency is another reason to avoid BSR. The systemic factors of changing hospital demographics, such as short length of stay and increasing patient volumes, generate a substantial administrative burden on trainees.⁷ Modern trainees are also constrained by work hour restrictions, engagement with mandatory curricula, and other professional development opportunities. Furthermore, changes in a medical work environment cause trainees to rely heavily on electronic health records, which forces them to be at a computer instead of in a patient’s room.⁸ This confluence of factors results in substantial time pressure, and BSR is perceived as an inefficient use of time.⁹

The impact on education and trainee development is another concern of BSR. Rounding away from a patient ensures a safe environment for learners to interpret data and articulate clinical reasoning without the risk of embarrassment in front of a patient. This time outside a patient room also allows the team to have a shared mental model so that communication is aligned when a patient encounter does occur. Card flipping may result in improved trainee autonomy because the constant presence of attending supervision, particularly in front of patients, can risk undermining resident leadership and patient trust.⁹