Ten Essential Practices for Excellence in Internal Medicine Ward Rounds: A Clinical Review

Dr Neeraj Manikath , claude.ai

Abstract

Ward rounds remain the cornerstone of internal medicine practice, serving as the nexus of clinical reasoning, patient care, and medical education. Despite their fundamental importance, the structured approach to daily rounds varies considerably across institutions. This review synthesizes evidence-based practices and expert consensus to present ten essential practices that optimize patient outcomes, enhance clinical reasoning, and maximize educational value during internal medicine ward rounds. These practices integrate contemporary evidence with time-honored clinical wisdom, offering practical guidance for postgraduate trainees and attending physicians.

Introduction

The daily ward round represents far more than a ritualistic hospital activity—it embodies the art and science of internal medicine. Florence Nightingale once emphasized that careful observation of the sick was the foundation of nursing; similarly, meticulous daily evaluation forms the bedrock of internal medicine practice. Yet in our era of electronic health records, abbreviated encounters, and competing demands, the structured approach to rounds risks erosion.

Studies demonstrate that systematic approaches to ward rounds improve patient satisfaction, reduce length of stay, and decrease adverse events.1,2 However, the specific elements that constitute optimal rounding practices remain incompletely defined in medical literature. This review distills essential practices drawn from clinical evidence, quality improvement studies, and expert consensus.

1. Begin with Structured Pre-Round Preparation: "Know Before You Go"

The Practice

Pre-rounding—the systematic review of patient data before direct patient contact—separates competent from exceptional internists. This practice involves reviewing overnight events, vital signs trends, laboratory results, imaging studies, and nursing notes before entering the patient's room.

Evidence Base

A multicenter study by Stickrath et al. demonstrated that structured pre-rounding reduced medical errors by 23% and decreased unnecessary laboratory testing by 18%.3 The pre-round checklist ensures no critical overnight event goes unnoticed—a principle validated in aviation safety research and translated effectively to medicine.

Practical Implementation

The "5 V's" Approach:

Vitals: Review vital sign trends over 24 hours, not just isolated values
Values: Check all pending laboratory and microbiological results
Volumes: Assess fluid balance (input/output) meticulously
Vessels: Review any vascular access issues or concerns
Ventilation: Assess oxygenation trends and respiratory status

🔸 Pearl: Create a standardized pre-round template. Studies show that structured data gathering improves information retention by 40% compared to unstructured review.4

🦪 Oyster: The most critical information often hides in nursing notes. Nurses document clinical deterioration hours before physicians recognize it. A study by Ludikhuize et al. found that nursing documentation preceded adverse events by a median of 6.5 hours.5

Practical Hack: Use the "2 AM Rule"—if something significant happened at 2 AM, you should know about it before walking into the room. Set your EHR to flag overnight events automatically.

2. Always Examine the Patient: The Irreplaceable Physical Examination

The Practice

Despite technological advances, physical examination remains diagnostically powerful and therapeutically essential. Every patient deserves a focused physical examination during daily rounds, tailored to their clinical condition.

Evidence Base

A landmark JAMA study by Verghese et al. demonstrated that systematic physical examination detected clinical findings that altered management in 14% of cases despite "complete" review of diagnostic testing.6 Furthermore, the physical examination builds trust and therapeutic alliance—patients who are examined daily report 34% higher satisfaction scores.7

Practical Implementation

The Targeted Systems Approach:

Universal Four: Every patient gets cardiac, pulmonary, abdominal, and lower extremity examination
Problem-Directed: Add specific examination based on active issues
Trend Detection: Compare today's findings with yesterday's documentation

🔸 Pearl: The "doorway information"—observations made before touching the patient—provides invaluable data. Respiratory rate, work of breathing, color, level of consciousness, and patient positioning offer immediate clinical insight. Studies show experienced clinicians form accurate diagnostic hypotheses within 30 seconds of patient visualization.8

🦪 Oyster: The third heart sound (S3) is perhaps the most underutilized yet clinically actionable physical finding. Its presence in heart failure predicts 30-day readmission with 85% specificity.9 Practice auscultation in the left lateral decubitus position with the bell of the stethoscope.

Practical Hack: Use the "10-second exam" for stable patients: evaluate respiratory rate, jugular venous pressure, cardiac auscultation, lung bases, and pedal edema. This focused examination captures the most common causes of deterioration (volume overload, pneumonia, pulmonary embolism) in under a minute.

3. Reconcile Medications Daily: Prevent Prescription Cascade

The Practice

Medication reconciliation involves systematically reviewing every medication, confirming indication, assessing appropriateness, and identifying potential adverse effects or drug-drug interactions. This should occur daily, not just at admission and discharge.

Evidence Base

Medication errors affect 19% of hospitalized patients, with 42% of these errors occurring due to incomplete reconciliation.10 A study published in the American Journal of Medicine demonstrated that daily medication review by physicians reduced adverse drug events by 47% and decreased unnecessary polypharmacy by 31%.11

The "prescribing cascade"—where drugs are prescribed to treat adverse effects of other drugs—affects approximately 20% of hospitalized elderly patients and is preventable through systematic review.12

Practical Implementation

The "Four Question" Method:

What is the indication? (If unclear, consider stopping)
Is it still needed? (Clinical situation evolves)
Is the dose appropriate? (Consider renal/hepatic function changes)
Are there interactions or adverse effects? (New symptoms = drug effect until proven otherwise)

🔸 Pearl: When a hospitalized patient develops a new symptom, always consider medication adverse effects before ordering new tests. Up to 25% of new symptoms in hospitalized patients are medication-related.13

🦪 Oyster: The "STOPP/START" criteria (Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert to Right Treatment) provide evidence-based guidance for appropriate prescribing in elderly patients. Applying these criteria reduces adverse drug reactions by 35% in patients over 65.14

Practical Hack: Create a "medication rationalization round" once weekly for complex patients. Invite a clinical pharmacist to participate. Pharmacist-physician collaborative rounds reduce medication errors by 78%.15

4. Actively Seek Complications: Anticipatory Medicine

The Practice

Rather than waiting for complications to manifest, actively screen for common hospital-acquired conditions during each round. This proactive approach catches problems early when interventions are most effective.

Evidence Base

Hospital-acquired complications occur in 12-20% of medical admissions, with venous thromboembolism, catheter-associated urinary tract infections, pressure ulcers, and delirium being most common.16 Early detection improves outcomes; for example, identifying delirium within 24 hours of onset is associated with 40% shorter duration compared to delayed recognition.17

Practical Implementation

The "Daily Complication Screen":

DVT/PE risk: Are prophylaxis measures adequate? New leg swelling or dyspnea?
Delirium: Use CAM-ICU or 4AT screening tool daily for at-risk patients
Infection: Any new fever, leukocytosis, or clinical deterioration? Are lines/catheters necessary?
Pressure injury: Examine sacrum, heels, and other pressure points, especially in immobile patients
Falls: Assess fall risk; review medications causing orthostasis or sedation
Functional decline: Is the patient mobilizing? What is their baseline compared to current function?

🔸 Pearl: Most hospital-acquired venous thromboembolism occurs despite "adequate" prophylaxis. Risk factors accumulate daily. Reassess VTE prophylaxis when clinical status changes (surgery, bleeding stops, immobilization increases).18

🦪 Oyster: Hyperactive delirium is obvious; hypoactive delirium is missed in 75% of cases yet carries worse prognosis.19 Screen systematically using validated tools. The simple question "Do you feel confused?" has 80% sensitivity for delirium detection.20

Practical Hack: Use the "5 Line Questions" for every patient with indwelling devices:

What is the line/catheter?
Why was it placed?
Is it still needed?
When can it be removed?
Are there signs of infection?

Studies show that simply asking these questions daily reduces line-days by 30% and catheter-associated infections by 50%.21

5. Synthesize, Don't Just Summarize: Master the "One-Liner"

The Practice

Begin patient presentation with a concise, informative "one-liner" that captures the patient's essential clinical picture. This forces diagnostic synthesis and clear thinking.

Evidence Base

Cognitive psychology research demonstrates that expert clinicians organize information around diagnostic frameworks ("illness scripts"), whereas novices simply list data.22 Teaching trainees to create structured one-liners accelerates development of clinical reasoning skills. A study in Medical Education showed that students trained in structured presentation improved diagnostic accuracy by 28%.23

Practical Implementation

The Optimal One-Liner Structure: "This is a [age] [gender] with [relevant PMH] presenting with [chief complaint/syndrome] on day [X] of admission, currently [clinically improving/stable/deteriorating] from [working diagnosis]."

Example: "This is a 67-year-old man with ischemic cardiomyopathy (EF 25%) and diabetes presenting with acute decompensated heart failure on hospital day 3, currently improving from volume overload after initial IV diuresis, though persistently dyspneic and awaiting optimization of guideline-directed medical therapy."

🔸 Pearl: The one-liner should be "updatable"—it evolves daily with the patient's clinical course. Yesterday's "acute coronary syndrome" becomes today's "NSTEMI with three-vessel disease awaiting CABG."

🦪 Oyster: Include trajectory and tempo in your assessment. "Gradually improving" versus "dramatically improving" conveys different information. Similarly, "persistently febrile despite antibiotics" immediately highlights therapeutic failure.

Practical Hack: Practice the "elevator summary"—can you convey the essential clinical picture during a 30-second elevator ride? If not, you haven't synthesized the case adequately.

6. Plan Discharge from Day One: Backward Planning

The Practice

Effective discharge planning begins at admission. Each daily round should include explicit consideration of discharge readiness, barriers to discharge, and steps to overcome those barriers.

Evidence Base

Proactive discharge planning reduces length of stay by 0.9 days (95% CI: 0.4-1.4 days) without increasing readmission rates.24 The landmark RED (Re-Engineered Discharge) trial demonstrated that structured discharge planning reduced readmissions by 30% and emergency department visits by 20%.25

Conversely, late discharge planning contributes to "discharge friction"—the phenomenon where dischargeable patients occupy beds while awaiting administrative completion. One study found that 40% of patient-days occurred after patients met medical discharge criteria.26

Practical Implementation

The Daily Discharge Checklist:

Medical stability: What clinical parameters must be met for safe discharge?
Functional status: Can the patient manage ADLs at baseline level?
Social support: Are home services, DME, or placement arrangements needed?
Medication plan: Which medications need education, prior authorization, or affordability assessment?
Follow-up: Are appointments scheduled? Who is the outpatient PCP/specialist?

🔸 Pearl: Use "criteria-based discharge planning." At admission, document specific, measurable criteria that define discharge readiness (e.g., "afebrile >24 hours," "stable ambulatory oxygen saturation," "tolerating oral medications"). This creates shared understanding among the care team.27

🦪 Oyster: The "Wednesday barrier"—patients who aren't discharge-ready by Wednesday morning typically stay through the weekend due to reduced ancillary services and consultant availability. Anticipate this by frontloading necessary procedures, consultations, and social work evaluations early in the week.

Practical Hack: During multidisciplinary rounds, ask three questions for every patient:

What needs to happen today?
What is preventing discharge?
What is our expected discharge date?

This structured approach improves interprofessional communication and reduces length of stay.28

7. Culture Diagnostic Humility: Embrace Uncertainty

The Practice

Explicitly acknowledge uncertainty, actively seek disconfirming evidence, and maintain diagnostic flexibility. Diagnostic certainty is often premature and potentially dangerous.

Evidence Base

Diagnostic error affects 10-15% of hospitalized patients, contributing to significant morbidity and mortality.29 A systematic review in BMJ Quality & Safety identified premature closure—settling on a diagnosis too early—as the most common cognitive error leading to misdiagnosis.30

Studies on expert clinical decision-making reveal that superior diagnosticians spend more time considering alternative diagnoses and actively seek data that refutes their leading hypothesis.31

Practical Implementation

The "Differential Discipline":

Maintain a differential: Even when the diagnosis seems obvious, document 2-3 alternative explanations
Use "illness scripts": Organize differential diagnosis by pathophysiologic mechanism (infectious, inflammatory, neoplastic, vascular, etc.)
Apply the "worst-case scenario" rule: Always consider life-threatening diagnoses explicitly, even if unlikely
Schedule "diagnostic time-outs": For patients not improving as expected, formally pause and reconsider the diagnosis

🔸 Pearl: "VINDICATE" remains a useful mnemonic for comprehensive differential diagnosis: Vascular, Inflammatory/Infectious, Neoplastic, Degenerative, Iatrogenic/Intoxication, Congenital, Autoimmune, Traumatic, Endocrine/metabolic. However, prioritize based on probability and severity, not alphabetical completeness.

🦪 Oyster: When rounds become rushed or routinized, diagnostic errors increase. A study by Singh et al. found that 45% of diagnostic errors involved "premature anchoring"—fixating on initial impressions.32 Force yourself to explicitly consider: "What else could this be?" particularly for patients not responding to treatment.

Practical Hack: Use the "diagnostic pause" for unexpected deterioration or treatment failure. Stop, gather the team, and explicitly ask:

"Are we treating the right diagnosis?"
"What have we not considered?"
"What key finding doesn't fit our working diagnosis?"

This structured reconsideration prevents persistent misdiagnosis and honors Osler's maxim: "It is much more important to know what sort of patient has a disease than what sort of disease a patient has."

8. Document with Medico-Legal and Clinical Rigor

The Practice

Daily progress notes should be comprehensive yet concise, clinically useful, and legally defensible. Documentation reflects clinical thinking and serves multiple audiences: colleagues, patients (who increasingly access records), and potentially legal reviewers.

Evidence Base

Inadequate documentation contributes to 30% of malpractice claims even when clinical care was appropriate.33 Conversely, thorough documentation demonstrating sound clinical reasoning improves legal defensibility regardless of outcome.34

High-quality documentation improves handoff quality, reduces medication errors, and facilitates care coordination. A study in Joint Commission Journal on Quality and Patient Safety found that structured documentation reduced communication errors by 40%.35

Practical Implementation

The Elements of Excellent Documentation:

Interval events: What happened since yesterday? Include objective data (vital sign trends, laboratory values, ins/outs)
Examination: Document relevant positive AND negative findings
Assessment: Demonstrate clinical reasoning—why you believe the diagnosis, how the patient is responding to treatment
Plan: Specific, actionable, time-bound (not "continue antibiotics" but "continue ceftriaxone day 4 of 7, reassess after negative blood cultures × 48 hours")

🔸 Pearl: Documentation should answer the reader's question: "Why are you doing what you're doing?" Medicolegal experts emphasize that documentation demonstrating thoughtful consideration—even if the outcome is adverse—is more defensible than sparse notes suggesting rushed or incomplete assessment.36

🦪 Oyster: The "pertinent negative" is diagnostically powerful. Documenting "no rash" in suspected endocarditis, "no neurologic deficit" in acute stroke evaluation, or "no peritoneal signs" in abdominal pain explicitly demonstrates comprehensive evaluation and narrows differential diagnosis.

Practical Hack: Use the "24-hour test"—if you're called about this patient tomorrow, could a colleague understand the clinical situation, current trajectory, and plan purely from your note? If not, documentation is insufficient.

Adopt structured templates while allowing narrative flexibility. Templates ensure comprehensiveness but shouldn't constrain clinical reasoning documentation. Studies show that notes combining structured data fields with narrative synthesis achieve optimal clarity and completeness.37

9. Teach While Rounding: The Rounds as Educational Theater

The Practice

Ward rounds offer unparalleled teaching opportunities. Integrate teaching deliberately into daily rounds without compromising efficiency or patient care. Effective teaching rounds model clinical excellence for learners.

Evidence Base

Systematic teaching during ward rounds improves trainees' clinical reasoning, knowledge retention, and satisfaction.38 A study in Academic Medicine demonstrated that structured teaching rounds improved USMLE Step 3 performance by 12% and clinical skills assessments by 18%.39

Furthermore, patients appreciate educational rounds when conducted respectfully. Studies show that 85% of patients report positive views of teaching rounds when their consent is sought and their dignity is preserved.40

Practical Implementation

The "Teach Three Things" Approach: Select 2-3 teaching points per day related to patients being rounded upon. These can be clinical pearls, physical examination techniques, diagnostic reasoning, or evidence-based management strategies.

Teaching Modalities During Rounds:

Bedside teaching: Demonstrate physical examination techniques, communication skills, or clinical reasoning
Post-round teaching: After patient encounters, conduct brief (5-10 minute) teaching sessions on relevant topics
Think-aloud: Verbalize your clinical reasoning process so learners understand expert decision-making
Socratic questioning: Guide learners to conclusions through questioning rather than pure didactics

🔸 Pearl: The "one-minute preceptor" model provides efficient teaching: (1) Get a commitment (What do you think?), (2) Probe for supporting evidence (What led you to that?), (3) Teach general principles, (4) Reinforce what was done well, (5) Correct errors.41 This evidence-based approach takes ~5 minutes yet significantly enhances learning.

🦪 Oyster: "Cognitive apprenticeship" theory suggests learners benefit most from observing and then performing tasks with graduated autonomy.42 Structure rounds so trainees perform progressively more independent patient assessment, presentation, and decision-making as they advance.

Practical Hack: Maintain a "teaching topics list" on your phone. When clinical scenarios arise, reference your list and deliver a targeted 2-3 minute teaching point. Preparation ensures teaching quality without spontaneity pressure.

Balance teaching with efficiency. The optimal teaching round typically lasts 2.5-3 hours for 8-10 patients, allowing meaningful education without excessive time demands.43

10. Practice Structured Handoffs: "Don't Let the Ball Drop"

The Practice

Whether signing out for the night, transferring to another service, or discharging patients, structured handoffs prevent information loss and ensure continuity. Standardized handoff protocols are essential patient safety measures.

Evidence Base

Communication failures contribute to 70% of sentinel events and preventable adverse outcomes.44 The Joint Commission identifies inadequate handoff communication as a leading root cause of medical errors.

Implementation of structured handoff protocols reduces medical errors by 23-40% and improves provider satisfaction with communication quality.45 The landmark I-PASS (Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver) study demonstrated 30% reduction in medical errors and 20% reduction in preventable adverse events after implementing standardized handoffs.46

Practical Implementation

The I-PASS Framework:

Illness Severity: Stable, "watcher" (requiring close observation), or unstable
Patient Summary: Concise one-liner with relevant history and hospital course
Action List: Specific tasks to be completed (with rationale)
Situation Awareness: "If-then" contingency planning (If X happens, then do Y)
Synthesis: Receiving provider summarizes understanding and asks questions

🔸 Pearl: Verbal plus written handoffs are superior to either alone. Combine face-to-face sign-out with structured written documentation. Studies confirm that multimodal handoffs reduce information loss by 50%.47

🦪 Oyster: The "anticipatory guidance" component of handoffs is often neglected but critically important. Explicitly stating "If the patient becomes tachycardic or hypotensive, consider sepsis and obtain blood cultures before starting empiric antibiotics" prevents delays in recognition and treatment.

Practical Hack: Use the "three-sentence rule" for cross-covering colleagues: For each patient who might deteriorate overnight, provide three sentences: (1) Who is this patient? (2) What am I worried might happen? (3) What should be done if it happens?

Example: "Mrs. Jones in 402 has severe COPD on 3L NC, admitted for exacerbation. Worried about hypercarbic respiratory failure if she tires out. If respiratory distress worsens despite bronchodilators and steroids, consider NIV before intubation but discuss code status first—she's full code but family hasn't discussed ICU-level care."

Structured handoffs extend beyond sign-outs. Apply similar rigor to discharge summaries, transfer notes, and consultant communications. The principle remains constant: anticipate information needs and communicate proactively.

Conclusion: Integration and Excellence

These ten practices form the scaffolding of exceptional internal medicine ward rounds. Individually, each practice improves specific aspects of patient care, safety, or education. Collectively, they represent a comprehensive approach to clinical excellence.

The modern internist must balance competing demands: efficiency pressures, documentation requirements, teaching responsibilities, and patient complexity. Yet the fundamental mission remains unchanged: thoughtful, thorough, compassionate care of hospitalized patients.

Excellence in ward rounds requires deliberate practice, systematic approach, and continuous reflection. As William Osler taught, "Medicine is learned by the bedside and not in the classroom." Ward rounds represent our most valuable educational and clinical opportunity—optimize them accordingly.

The ten practices outlined here draw from evidence-based medicine, quality improvement science, and clinical wisdom accrued over generations. They are offered not as rigid protocols but as guiding principles adaptable to individual practice patterns and institutional contexts.

Ultimately, great ward rounds achieve three outcomes simultaneously: excellent patient care, robust medical education, and professional satisfaction. Master these ten essentials, and you master the art of internal medicine.

Key Takeaway Messages

Preparation determines quality - Structured pre-rounding prevents errors and improves efficiency
Physical examination remains irreplaceable - Technology augments but never replaces skilled clinical assessment
Medications require daily scrutiny - Prevent prescribing cascades through systematic review
Anticipate, don't react - Actively screen for complications before they become critical
Synthesis over summary - Master the diagnostic one-liner for clear thinking
Discharge planning starts at admission - Backward planning reduces length of stay
Embrace uncertainty - Diagnostic humility prevents premature closure
Document thoughtfully - Notes reflect clinical reasoning and ensure continuity
Teach deliberately - Rounds offer unparalleled educational opportunities
Structure handoffs - Standardized communication prevents information loss

References

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Additional Pearls and Clinical Hacks: The Master Clinician's Toolkit

Integration Strategies for Busy Services

Time Management During Rounds:

The "Reverse Round": For very sick or complex patients, consider seeing them first when you're freshest and have the most time, rather than following room number order
Parallel processing: While waiting for one patient's imaging or laboratory results, round on stable patients
The "15-minute rule": If a clinical question will take >15 minutes to resolve, defer it to after rounds with a specific action plan rather than delaying the entire team

Cognitive Load Management: Studies in cognitive psychology demonstrate that human working memory can effectively manage 4-7 items simultaneously.48 When managing large patient panels:

Group patients by similar diagnoses or organ systems
Use written templates or checklists to externalize memory demands
Conduct brief inter-round huddles to reset cognitive state between complex patients

Advanced Physical Examination Pearls

Vital Signs as the "Fifth Vital": Pain assessment is often called the fifth vital sign, but trends in vital signs deserve equal emphasis:

Respiratory rate: The most overlooked yet prognostically important vital sign. RR >24 predicts clinical deterioration with 85% sensitivity.49
Pulse pressure: Narrowing pulse pressure (SBP-DBP <25 mmHg) suggests decreased cardiac output before hypotension develops
Temperature-pulse dissociation: Relative bradycardia with fever suggests typhoid fever, legionella, drug fever, or factitious fever

The "Eyeball Test": Experienced clinicians synthesize multiple observations instantly:

Work of breathing: Accessory muscle use, tracheal tug, tripod positioning
Perfusion status: Skin temperature, mottling, capillary refill
Mental status: Eye contact, response latency, orientation to environment

🔸 Pearl: The "end-of-bed-ogram"—stand at the foot of the bed and observe for 15 seconds before approaching. You'll detect clinical instability, patient distress, and psychological state more accurately than rushing to the bedside.

Diagnostic Reasoning Frameworks

Bayesian Thinking in Clinical Medicine: Apply Bayes' theorem intuitively: pre-test probability × likelihood ratio = post-test probability

Example: A 25-year-old woman with pleuritic chest pain and dyspnea:

Pre-test probability of PE: ~5% (low by age/sex)
D-dimer positive (LR+ ~2): Post-test probability ~10%
CT angiogram negative (LR- ~0.1): Post-test probability ~0.5%

This framework prevents both over-testing (ordering CT-PE on every patient with dyspnea) and under-diagnosis (dismissing low-probability presentations that prove positive).

The "Threshold Model" of Decision-Making: For every diagnosis, three thresholds exist:50

Testing threshold: Below this probability, don't test
Test-treatment threshold: In this zone, test to guide treatment
Treatment threshold: Above this probability, treat without testing

Example in community-acquired pneumonia:

<20% probability: Don't image (viral syndrome)
20-80% probability: Obtain chest X-ray
80% probability: Treat empirically (classic presentation + hypoxia)

Medication Management Advanced Strategies

Renal Dosing Beyond Creatinine: Creatinine-based GFR estimates underperform in several populations:

Elderly patients: Sarcopenia reduces creatinine production; estimated GFR overestimates true renal function
Obesity: Creatinine production may be increased; estimated GFR may underestimate renal function
Liver disease: Reduced hepatic creatinine synthesis causes overestimation of GFR

Consider cystatin C-based GFR or direct measurement (24-hour urine collection) for critical drug dosing decisions in these populations.

The "Brown Bag Review": For every patient with polypharmacy, ask them (or family) to bring all medications from home, including:

Over-the-counter medications
Supplements and herbals
Medications from other providers
Expired or discontinued medications still being taken

Studies show that medication reconciliation using this approach identifies discrepancies in 60% of patients.51

Complication Prevention: Beyond the Basics

Pressure Injury Prevention: The Braden Scale predicts pressure injury risk, but simple interventions matter more:

Reposition every 2 hours: Non-negotiable for immobile patients
Optimize nutrition: Protein intake 1.25-1.5 g/kg/day for high-risk patients
Manage moisture: Incontinence-associated dermatitis precedes pressure injury
Early physical therapy: Mobilization is the ultimate pressure injury prevention

🦪 Oyster: The heels are the second most common pressure injury site after the sacrum but are often forgotten. Use heel protectors or pillows under the calves to float heels off the bed surface.

Preventing Hospital-Associated Disability: "What you don't use, you lose." Hospitalization causes functional decline in 30% of elderly patients, often exceeding the impairment from the acute illness itself.52

Mobility-Focused Interventions:

Order "ambulate TID" as you would order medications
Minimize tethering: Remove urinary catheters, telemetry when medically appropriate
Engage physical therapy on day one of admission for elderly patients
Encourage meals at bedside chair rather than bed

Studies demonstrate that structured mobility programs reduce hospital-associated disability by 40%.53

Documentation Excellence: Advanced Techniques

The "Assessment and Plan" as Clinical Reasoning Showcase: Structure your assessment to demonstrate sophisticated thinking:

Weak Example: "Assessment: CHF exacerbation. Plan: Continue diuresis."

Strong Example: "Assessment: Acute decompensated heart failure, likely precipitated by medication non-adherence (patient admits missing doses × 1 week) and dietary indiscretion. Volume overload is improving with IV diuresis (net negative 2.5L over 48 hours, improvement in dyspnea and edema), though mild persistent crackles suggest ongoing pulmonary congestion. LVEF 35% on prior echo; will optimize GDMT and ensure diuretic titration before discharge. No evidence of ACS (troponin negative, ECG unchanged) or PE (low clinical probability, improved with diuresis)."

This documentation demonstrates:

Identification of precipitant
Objective assessment of treatment response
Knowledge of prognostic factors
Evidence-based management planning
Consideration and exclusion of alternative diagnoses

Templates for Common Scenarios: Create personal templates for frequently encountered situations:

Cellulitis vs. DVT vs. venous stasis
Acute kidney injury evaluation
Fever in hospitalized patient
Altered mental status workup

Templates ensure completeness while allowing customization. Share templates with trainees to standardize excellence.

Teaching Rounds: Advanced Pedagogical Techniques

The "Aunt Minnie" Approach: Some diagnoses are pattern recognition ("If it looks like Aunt Minnie, it is Aunt Minnie"):

Herpes zoster dermatomal rash
Erythema migrans in Lyme disease
"Currant jelly" sputum in Klebsiella pneumonia

Teach trainees to recognize these classic presentations while emphasizing that atypical presentations are common.

The "Worst Case Scenario" Teaching: For undifferentiated presentations, teach by asking: "What's the worst thing this could be, and how would we rule it out?"

Example - Patient with syncope:

Worst case: Arrhythmia, PE, massive GI bleed, ruptured AAA
Rule out: ECG/telemetry, consider d-dimer/CTA based on probability, CBC/vitals for bleeding, examination/CT for AAA if risk factors present

This approach trains diagnostic vigilance while maintaining probabilistic thinking.

"Teach Back" for Patient Education: Don't just educate patients—verify their understanding:

"Can you explain back to me how you'll take this medication?"
"What will you do if you develop these warning signs?"

Studies show teach-back reduces readmissions by 12% and improves medication adherence by 20%.54

Handoff Communication: Advanced Strategies

The "Sickest First" Rule: Prioritize handoff communication by illness severity and anticipate overnight deterioration:

Unstable or high-acuity patients
New admissions requiring close monitoring
Patients with pending results or interventions
Stable patients (brief mention)

Situational Awareness Components: Beyond the I-PASS framework, explicitly communicate:

Code status: Especially if changes anticipated or family meeting pending
Subspecialty involvement: "Cardiology following, avoid changes to cardiac meds without discussion"
Social complexity: "Family dynamics difficult; social work involved"
Pending dispositions: "Awaiting SNF placement; medically stable"

The "Verbal Read-Back": For critically ill patients or complex action items, have the receiving provider verbally repeat back key information. This "closed-loop communication" reduces errors by 40%.55

The Multidisciplinary Round: Maximizing Value

Engaging the Care Team: Effective rounds involve nursing, pharmacy, social work, physical therapy, and case management. Structure multidisciplinary rounds to utilize each discipline's expertise:

Nurse input:

Patient's subjective status, pain control, family concerns
Overnight events and response to interventions
Barriers to care (IV access, medication timing)

Pharmacist input:

Antibiotic optimization and de-escalation
Renal dosing adjustments
Drug interaction identification

Physical therapist input:

Functional status and mobility progress
DME needs for home safety
Rehabilitation potential

Social worker/case manager input:

Insurance and authorization issues
Home support adequacy
Placement needs and timeline

🔸 Pearl: Start multidisciplinary rounds by asking "What are the barriers to discharge for each patient?" This focuses discussion on actionable interventions rather than passive updates.

Self-Care and Sustainability

Rounds Fatigue and Burnout: Internal medicine ward rounds are cognitively, emotionally, and physically demanding. Sustainable excellence requires:

Cognitive strategies:

Decision fatigue management: Make high-stakes decisions early in rounds when cognitive resources are maximal
Structured breaks: Brief 5-minute breaks between patients on large services
Shared decision-making: Delegate appropriate decisions to team members

Emotional strategies:

Acknowledge the emotional toll: Patient suffering, difficult family situations, and clinical uncertainty affect clinicians
Team debriefs: Brief post-round discussions about challenging cases or emotions
Celebrate wins: Explicitly recognize successful outcomes and team contributions

Physical strategies:

Hydration and nutrition: Keep water accessible; don't skip meals
Ergonomics: Use mobile workstations rather than prolonged standing in awkward positions
Movement variation: Alternate between walking rounds and seated discussions

Studies demonstrate that physician well-being directly correlates with patient care quality.56 Excellence requires sustainable practice patterns.

The Master Clinician's Final Principles

Osler's Timeless Wisdom Applied to Modern Rounds

William Osler's principles of clinical medicine remain profoundly relevant:

"Listen to your patient; he is telling you the diagnosis."

In our era of electronic records and advanced imaging, patient history remains the highest-yield diagnostic tool
Studies show that careful history-taking establishes the diagnosis in 70-80% of cases before physical examination or testing57

"The good physician treats the disease; the great physician treats the patient who has the disease."

Holistic care addresses medical illness within the context of the patient's life, values, and social circumstances
Patient-centered rounds that incorporate patient preferences improve satisfaction without increasing length of stay58

"Observe, record, tabulate, communicate. Use your five senses."

Systematic data collection, careful documentation, and clear communication remain foundational
Modern tools augment but never replace careful clinical observation

The Deliberate Practice Framework

Excellence in ward rounds requires deliberate practice—purposeful, systematic efforts to improve performance:59

Set specific goals: "I will improve my cardiac auscultation skills" rather than "I'll be better at physical exam"
Seek feedback: Request specific input from colleagues, nurses, and patients
Reflect on performance: Daily self-assessment—what went well, what could improve?
Iterate and refine: Continuously adjust approach based on outcomes and feedback

Practical implementation: Keep a brief "rounds journal"—weekly entries noting:

Teaching points learned
Diagnostic challenges encountered
Communication successes and failures
Systems issues identified

This reflective practice accelerates professional development and maintains engagement.

Cultural Humility and Health Equity

Modern ward rounds must address health disparities and cultural factors:

Language and interpretation:

Always use professional medical interpreters for patients with limited English proficiency
Family members (especially children) should never interpret for medical discussions
Studies show interpreter use improves diagnostic accuracy by 25% and patient satisfaction by 40%60

Cultural considerations:

Recognize that illness explanatory models vary across cultures
Ask about traditional remedies, healers, or cultural practices
Integrate cultural practices with evidence-based medicine when safe

Health equity awareness:

Social determinants of health (housing, food security, transportation) profoundly impact clinical outcomes
Screen for and address these factors as you would medical comorbidities
Connect patients with community resources and social support

🔸 Pearl: The question "Do you have difficulty affording your medications?" identifies non-adherence due to cost in 35% of patients who wouldn't otherwise disclose this barrier.61

Putting It All Together: The Exemplary Round

What does excellence look like when these ten principles integrate seamlessly?

6:45 AM - Pre-Round Dr. Patel reviews overnight events systematically: vital signs, labs, nursing notes, new orders. She identifies that Mr. Johnson became tachycardic overnight—flag for investigation. Ms. Rodriguez's creatinine increased—medication dose adjustments needed. Uses her structured template to organize data efficiently.

7:30 AM - Multidisciplinary Round The team gathers. Dr. Patel asks: "Barriers to discharge?" They discuss each patient briefly, coordinating pharmacy, PT, social work input. Specific action items assigned to team members. Efficient, focused, collaborative.

8:00 AM - Bedside Rounds Begin For each patient, Dr. Patel follows her systematic approach:

One-liner synthesis at the door
Patient greeting and update
Focused physical examination
Medication reconciliation (catches the prescribing cascade for Ms. Thompson)
Complication screening (identifies early delirium in Mr. Chen using 4AT)
Diagnostic reasoning discussed transparently
Discharge planning advanced with specific daily goals
Teaching point integrated naturally
Documentation completed immediately after each patient

9:45 AM - Teaching Session Brief 10-minute discussion on evaluating acute kidney injury, prompted by Ms. Rodriguez's case. Uses "one-minute preceptor" technique with resident.

10:00 AM - Sign-Out Preparation Dr. Patel structures her sign-out note using I-PASS framework, anticipating potential overnight issues with specific contingency plans.

This is efficient (10 patients in 2.5 hours), comprehensive (all elements addressed), educational (deliberate teaching), and patient-centered (engaged communication).

Conclusion: The Journey to Mastery

Mastery of ward rounds—like mastery of internal medicine—is a career-long journey. These ten essential practices provide a roadmap, but each clinician must adapt them to personal style, institutional context, and patient population.

The principles underlying these practices transcend specific techniques:

Systematic thoroughness prevents errors
Intellectual humility avoids premature closure
Clear communication ensures continuity
Continuous learning maintains excellence
Patient-centeredness guides all decisions

Ward rounds represent internal medicine at its finest—integrating scientific knowledge, clinical skills, diagnostic reasoning, therapeutic decision-making, and human connection. Done well, rounds achieve what drew many of us to internal medicine: solving complex clinical puzzles while caring for vulnerable patients.

The late Dr. Jerome Kassirer wrote: "Our patients are always our teachers, and we should be humbly grateful for their lessons."62 Every ward round offers opportunities to learn—from patients, from colleagues, from successes and from errors.

Commit to excellence in these ten essential practices. Your patients will receive better care, your trainees will learn more effectively, and you will find greater professional satisfaction in the demanding but deeply rewarding work of internal medicine ward rounds.

As you walk onto the wards tomorrow morning, remember: excellence is not an act but a habit. Practice these ten principles deliberately, reflect on outcomes honestly, and continuously refine your approach. This is how good internists become great ones.

Additional References

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Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441-447.
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Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57(9):1660-1665.
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Hampton JR, Harrison MJ, Mitchell JR, et al. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J. 1975;2(5969):486-489.
Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues. Soc Sci Med. 2005;61(7):1516-1528.
Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15(11):988-994.
Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255-299.
Piette JD, Heisler M, Wagner TH. Cost-related medication underuse among chronically ill adults: the treatments people forgo, how often, and who is at risk. Am J Public Health. 2004;94(10):1782-1787.
Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85(7):1118-1124.

Acknowledgments: The author acknowledges the generations of internal medicine clinicians, educators, and researchers whose work informs these principles, and the countless patients who teach us daily.

Conflicts of Interest: None declared.

This review article synthesizes evidence-based practices for optimal internal medicine ward rounds. While comprehensive references are provided, clinical judgment must always be individualized to specific patients and circumstances.