Grand Rounds, the practice of presenting a patient’s case and treatment to a group of clinicians, has been in existence for over a century. Such rounds have generally focused on examining obscure diagnoses, difficult cases, or some new technology, and on doing enough tests or procedures to catch even the most uncommon, unexpected problems. There is also a well-recognized tradition of rounds that focus on quality of care – most notably Morbidity and Mortality Conferences – but here again, case selection tends to focus on the surprising missed diagnosis or the unusual presentation. That model ignores the challenges of avoiding harm, contributes to the culture of overuse, and reinforces that the goal of medicine is to know, rather than to heal.
Grand Rounds in the 1920s (credit: National Library of Medicine)
The time has come to transform Grand Rounds into an opportunity to address the whole patient and the entire continuum of care. By exploring cases with complex patients, where there has been a critical failure in the patient-clinician relationship, a lack of patient involvement in decision making, or a failure of decision making around overdiagnosis and overtreatment, RightCare Rounds creates an opportunity for clinicians to consider innovative solutions and draw upon all parts of the health care system.
In this way, RightCare Rounds aims to better reflect the evolving challenges of modern medical practice, and to ensure that the lessons trainees and presenters learn are relevant to the realities they will face in the health care system of the future.
RightCare Rounds are built around the discussion of a single patient’s care. The patient has complex medical needs, often has multiple chronic illnesses, and has used large amounts of medical resources over a short period. A discussant who is deeply familiar with the patient’s care leads the process by outlining the patient’s medical, psychological, and social history, including the patient’s recent path of treatment and the clinical decision making and understanding of patient preferences that informed those decisions. The combination of traditional history, physical, and lab data with understanding the social, personal, and community issues the patient faces, provides a more complete context for the discussion and allows participants to pursue non-medical interventions that would not have been identified in a traditional model.
The case based approach allows participants to see, concretely, the myriad drivers of overuse better than read in case write-up or if presented on a slide. Further, the format provides a framework for thinking about what it would mean for that particular patient to get care that provides the greatest possible benefit, exposes them to minimal harm, uses medical and community resources effectively, and is tailored to the patient’s preferences.
Based on the presentation, which is organized around a structured analysis of the case, clinicians attending rounds develop an individualized course of right care for this patient. That conversation points out ways the situation could have been avoided, the patient could have been better served earlier in the process, or new programs or policies that could be implemented to improve care delivery.
Lown Institute board member David Bor, MD, a key member of our Medical Education Working Group and Chief of Medicine at Cambridge Health Alliance, has been our lead collaborator on this project. The Lown Institute has begun to pilot “RightCare Rounds,” and is in conversations with several potential clinical partners, including Cambridge Health Alliance, SouthCoast Health System, Beth Israel Deaconess Medical Center, and Lahey Hospital and Medical Center.
We will bring RightCare Rounds to other institutions in the coming months. If you are affiliated with a health care facility and are interested in partnering with the Lown Institute to host Right Care Rounds in your area, contact us at firstname.lastname@example.org.
32 teams of chief residents from leading hospitals across the nation have been accepted to the Lown Institute’s RightCare Educator (RCE) Program, an initiative designed to encourage clinicians to improve patient care by exploring and eliminating the drivers of medical overuse and promoting appropriate care for patients. The program provides chief residents with training and support to implement RightCare Rounds in their hospitals. You can access the RightCare Rounds toolkit to learn more about RightCare Rounds and the RightCare Educator Program under the LEARN drop-down menu on the Lown Institute website.