Clean, Clear, and Consistent
For years, I was strongly against splitting our hospital medicine team structure into admitting and rounding teams. In looking at the competing values associated with this structural choice, I placed patient continuity at the top of the list. Letting go of that continuity seemed anathema to high-quality, patient-centered care. So I consistently argued against the split at our hospital medicine team meetings. But I was outvoted by the group. Then our structure changed, and I saw firsthand the many virtues of split rounding and admitting teams, particularly on direct-care hospitalist teams.
I think all of us who work in hospital medicine recognize that there is a certain amount of unpredictable chaos in our work that can never be eliminated. It may even be something that many of us found appealing when choosing this specialty: It keeps it interesting. But at a certain point, that invigorating unpredictability can become a liability—particularly when our dose of chaos becomes too high and crosses over into poisonous territory.
Admissions are inherently unpredictable in number and complexity. On mixed rounding and admitting teams, admissions loom over each day, encouraging rushed rounding, and producing increased stress driven by anticipation of the admissions, regardless of what actually comes our way. Planning a day around the possibility of a workload that may contain anywhere from zero to six hours of admissions work is inefficient and untenable.
And when the admissions do come, the disruption to care of rounding patients can be significant. It is a well-established fact that humans cannot be in two places at once. Pulling a rounding clinician off the floor to head to the emergency department at random intervals throughout the day is a significant disruption. And when there is a demand on the floor that requires the practitioner’s attention, the admission is interrupted, delaying and often degrading the care of that patient as well.
Contrast that with the relative serenity of a pure rounding team. At the start of the day, there is still that twinge of unpredictability: Will this patient discharge? Who might require additional medical attention? But in general, I have a sense of my day. I can develop a rounding order and commit to activities that contribute to rich, patient-centered care: complex multidisciplinary meetings, phone calls with family members, and time to linger at the bedside without the dread that I am spending time I will never get back if the admission fates decide to be cruel that day
On the admitting side, practitioners focusing on admissions can do just that—triaging the patients with the highest need to more expedient attention and often completing the intake from start to finish without significant interruptions. Importantly, being fully focused on admissions allows for an enhanced ability to engage in conversations with the emergency department about patient disposition in those situations where an admission to the hospital may not be the best plan for a patient.
I have not abandoned my appreciation for the value of continuity in hospital medicine. But I have found that there are other values worth acknowledging. In addition to the benefits outlined above, there is a direct benefit of disrupting continuity— an automatic second opinion. Modern medicine is a team sport, and I appreciate that my stellar colleagues are reviewing the patients I have admitted and honing the plan of care that I set in motion. And I am privileged to do the same for them.
I’m glad I was wrong in my stubborn attachment to mixed admitting and rounding teams, and I encourage you all to join me on the flipside.
Dr. Herrle is a hospitalist and physician leader with MaineHealth in Portland, Maine.
In Defense of the Messy Middle
My colleague makes a clean and appealing case for pure teams. Let some physicians admit all day, living at the front door of the hospital, mastering triage, diagnosis, and early management. Let others round, cultivating continuity, efficiency, and discharge expertise. It’s true, there would be fewer interruptions, clearer roles, and less cognitive switching. On paper, it’s elegant, and on spreadsheets, even better.
It’s a good argument, and I agree with much of it. Pure teams can be efficient; they can reduce burnout tied to constant task-switching, and they can standardize workflows while making staffing easier to model. In certain environments, such as high-volume emergency departments, surge conditions, or short-stay units, pure admitting or pure rounding teams may be exactly right.
But I fear that too much elegance can sacrifice excellence. Efficiency is not the same as responsibility. Hospital medicine is not a factory floor, even when it desperately wants to be one, and the work doesn’t divide cleanly into “before” and “after.” By having pure teams, we may end up quietly accepting losses that are harder to measure.
The strongest argument against pure teams, in my opinion, is accountability over time. When clinicians admit patients they will never see again, the incentives shift. Admission assessments can drift toward plausibility rather than precision, and diagnostic uncertainty will move forward. Plans are written in an environment where someone else will have to reconcile them later. To be clear, no one is acting in bad faith; the system is simply teaching that early decisions are provisional and disposable.
Rounding-only teams inherit those decisions without context and will spend time untangling assumptions made under pressure by people they may never meet. This is framed as continuity, but it is often archaeology. The rounding team becomes responsible for outcomes without having been responsible for the starting point. That is not continuity; it is custodianship.
Teams that both admit and round must live with their own thinking and remember what they were worried about on day one. As importantly, they can see which worries mattered. They recognize when an elegant admission narrative collapses by day three, a feedback loop that is not comfortable, but is instructive. It sharpens judgment in a way no protocol can.
Pure-team advocates often counter that feedback can be simulated through case review or handoff standards. In theory, this is true, but in practice, nothing substitutes for seeing your own plan fail at 6:00 a.m. on hospital day four. That experience changes future decisions; a checklist, not so much.
There is also a cultural cost to pure teams. Segmentation encourages quiet moral outsourcing. “That’s an admitting problem.” “That’s a rounding issue.” Over time, clinicians can become very good at their slice of the process and less invested in the whole. The hospital runs, the patients get better, but no one quite owns the whole story. When things go poorly, responsibility (and therefore feedback, which can shape learning) diffuses.
Hybrid teams resist that diffusion. They understand throughput and trajectory at the same time and feel emergency department pressure while also negotiating discharge barriers. Speaking from experience, this is more friction, but I believe this understanding also imparts better judgment. Not every admission needs a maximal workup, and not every inpatient day needs maximal optimization. That sense of proportion comes from seeing both ends of the pipeline.
Education matters here as well. If there are trainees on pure teams, they are learning task lists and non-contextual fragments. Admitting teams learn to start stories while rounding teams learn to finish them. Hybrid teams learn narrative medicine and see how an initial framing shapes days of care, and how small early choices echo downstream.
The pure-team model promises sanity through separation. The hybrid model offers something less tidy. Yes, the days are busier, and the interruptions are real. But medicine has always been interruptive, and the solution to that reality should not be to narrow professional responsibility until it fits in a rectangle on a scheduling app.
In sum, pure rounding risks turning physicians into very competent custodians of other people’s decisions, while pure admitting risks turning them into talented note-writers who never meet the consequences. The hybrid model is messier, but it keeps clinicians honest.
Hospitalists need efficiency, but they also need memory. Teams that both admit and round provide both, not because they are faster, but because they remain answerable to time. That, more than elegance, is what patients deserve.
Dr. Migliore is an assistant professor of medicine at Columbia University College of Physicians and Surgeons, and director of general medicine consult and perioperative services, as well as a medicine attending physician at Columbia University Medical Center, both in New York.