From the Residency Vault: L&D Sign Out Styles

The EMORY OBGYN Class of 2010 - Not shown because she is taking the picture (why?) is Martina Badell

As I gear up for the "Channeling Doctor Manners: L&D entry" I was reminded of my list of OBGYN signout styles and thought I would share.

As a 3rd year resident on L & D, you are in charge of "running" labor and delivery." Pretty much every patient is your responsibility and in the post-duty hours world of Graduate Medical Education (GME) communication is essential. But everyone has a unique style of communication.

I did my OBGYN residency at Grady Memorial Hospital - the GRADYs as the nurses like to call it. When you came on to start your shift, both day and night teams would sit (stands) and listen to the 3rd year resident present the board. 

The point is to provide "inventory," so-to-speak, on all the patients and their issues on Labor and Delivery. The goal is to be concise-yet thorough-logical, and coherent. Obviously, the more experienced one got, the smoother things were. 

Labor and delivery signout is where the true personalities of OBGYN residents shine. As a result I always tell medical students who are on away rotation sub-I's to spend time on labor delivery because the signout is one place where you can capture "the pulse" of the program.

While every obstetrician (and physician for that matter) has his/her own personality, it quickly became evident to me that there were certain signout styles that were common. Hit the jump for the most common L&D signout styles and let me know if I am missing one or need to qualify one further.

1. The adjective only signout.

This is exactly what it sounds like. "24 yr old, G2P1, 37.6 wks, spontaneous labor, 4/50/C/-1, clinic patient, epidural, pitocin..." Adjectives only. In fact there are no full sentences here. Just obstetric buzzwords that resonate with any OBGYN resident going about things with a "just-the-facts-ma'am" approach. Obviously these are suitable for low risk patients but some have mastered this signout with even the most high risk patients without missing critical facts. 

2. The Tangential signout.

Again, exactly what it sounds like. Things start off logical and coherent, but before too long the resident has steered the "audience" into a soliloquy regarding a detail that is not exaclty germaine to the obstetric plan going forward. Mostly done with good intentions, this signout requires someone to real the presenter back in.

3. The Pat-myself-on-the-back signout. 

We have all done this and sometimes it comes when we are looking for a bit of recognition after a tough day/night. Usually these signouts involve you going the extra 100! miles, double checking a colleagues' work, finding an oversight and reminding them (in front of everyone) that you are the BOMB.COM because had you not noticed the oversight, the patient and all of LABOR and DELIVERY would have gone to hell in-a-handbasket!

Again, good intentions here but often these signouts are peppered with phrases that can parlay some degree of conceit: 

"...had I not confirmed the AROM..." or 

"...its a good thing I have all that ONC experience...(because I knew what to do during that repeat x4)" or 

"I personally called the SICU attending and he [begrudgingly] accepted the patient."

4. The defensive signout. (a.k.a The WORLD-is-Against-me signout)

The last 12 hours were, frankly, not too kind. Nothing seem to go right. 

-The patient is still closed/thk and high from this morning. 

-You have been trying for what seems like an eternity to get Ms Jones adequate. 

-Everyone's pitocin seems like it is still at 6 and people are telling you its becuase the bags were probably "poorly mixed" by pharmacy

-None of the sections were straightforward and you have 2 patients in the back with midtrimester losses who still have retained placentas. 

-The night supervisor disagreed with your plan to call a section and you know the day person is going to question you "why?" (and conveniently your chief has slipped out right before signout!) 

In the defensive signout, nothing is YOUR fault. EVERYONE else is to blame. You tend to hear phrases like, 

"the nurses wouldn't turn the pit up quick enough" or 

"that was the dispo given from the night attending/chief" or
"every patient weighed 400 lbs" 

or 

"we must have gotten a bad batch of pitocin." 

5. The Unnecessary Detail signout

Another one that we are all guilty of. This is where you learn everything about the patient, that has nothing to do with her plan of care for the next 12 hours, but for some reason the off-going team seems to think that telling these stories is worth the risk of a duty hours violation.

6. The unorganized signout 

Again, one we all have fallen prey to, particularly early in the beginning of the year. A cousin of the tangential signout, the unorganized signout out typically involves a illogical flow of patient historical information (+/- an actual plan of care) and usually correlates with a poor understanding of the patient being discussed. 

Usually full of "oh yeah and's" or "ummm, yeah's." For example, "Ummm, this is a 34 yr old with pre-eclampsia, she came in 2/25/C/-3, she wants an epidural, she is getting mag...umm...looking at computer full of strips...she is in room 12, she had 2+ on her UA, and she is on mag...oh yeah, and she is 29 weeks...looking at chief resident who is staring at the floor trying to decide if they should just jump in"

I remember coming up with the list as a part of a skit for our end-of-the-year resident celebration but I couldn't get it together the way I wanted to so it has been relegated to this space. Residency is tough when you are going through and humor and self-deprecation helped me get through it. While one might try to extract a teaching point from here, my intent is purely entertainment. Please give me your feedback on any signout "styles" that I am missing.