Review article
Anatomy of the ward round

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Abstract

The ward round has been a central activity of hospital life for hundreds of years. It is hardly mentioned in textbooks. The ward round is a parade through the hospital of professionals where most decision making concerning patient care is made. However the traditional format may be intimidating for patients and inadequate for communication. The round provides an opportunity for the multi-disciplinary team to listen to the patient's narrative and jointly interpret his concerns. From this unfolds diagnosis, management plans, prognosis formation and the opportunity to explore social, psychological, rehabilitation and placement issues. Physical examination of the patient at the bedside still remains important. It has been a tradition to discuss the patient at the bedside but sensitive matters especially of uncertainty may better be discussed elsewhere. The senior doctor as round leader must seek the input of nursing whose observations may be under-appreciated due to traditional professional hierarchy. Reductions in the working hours of junior doctors and shortened length of stay have reduced continuity of patient care. This increases the importance of senior staff in ensuring continuity of care and the need for the joint round as the focus of optimal decision making. The traditional round incorporates teaching but patient's right to privacy and their preferences must be respected. The quality and form of the clinical note is underreported but the electronic record is slow to being accepted. The traditional multi-disciplinary round is disappearing in some centres. This may be regrettable. The anatomy and optimal functioning of the ward round deserves scientific scrutiny and experimentation.

Section snippets

Tradition and modernity

Traditionally the ward round was a parade led by the senior doctor (consultant, attending) with junior doctors, medical students, nursing staff and more recently other health professionals in train. All listened respectively to the consultant and the patient in a hushed ward. The junior doctor presented the “cases” being familiar with them because he admitted them the night before. No visitors loitered at bedsides and relatives respectfully waited until the round was over. The nursing ward

The core routine

The essentials of rounding are listed in Table 1. In the beginning was the history. This is still the case though the narrative is always subject to change. Best start with the referring doctor's letter (if available). The consultant correlates the admitting doctor's notes with the patient's latest account which may already have been told 3 or 4 times. Some histories improve with telling and some change! The repeat physical examination is still important as recently suggested [7]. Next come

Bed-side patient communication

How can we improve bed-side patient communication? The traditional multi-disciplinary entourage may be intimating. Geilser provides a moving analysis of the patient's perspective [1]. The parade arrives unannounced at the bedside sometimes catching the patient unprepared perhaps asleep, or even on a commode. Important issues may be discussed with token privacy which is inevitable in multi-bed rooms. The interview may be conducted over the din of TVs, cleaning and beeping medical equipment. Many

Inter-professional communication

How do doctors and nurses interact in the best interests of the patient? There may be unease between doctors and nurses as the latter may not feel they can have their say in care [2], [4]. There is diminishing clarity in the boundaries between the medical and nursing professions. The implicit assumption that doctors gave “orders” and nurses carry them out may no longer be acceptable to the nursing profession [15]. Most of the research is from a nursing perspective. The two professions occupy

The role of relatives and communication

When a person becomes hospitalised especially as an emergency they will find themselves surrounded by unfamiliar faces, procedures and perceived threats. Their family and friends become their natural advocates especially when the person loses autonomy or the ability to understand, make decisions or communicate. The physician must decide when it is best to have relatives present or not at the bedside. In paediatric practice it is often necessary and helpful. In adult medicine anxious relatives

Teaching

The word “doctor” means teacher. Bed-side teaching of students and doctors in training has been an important activity though now a declining priority for many consultants due to other commitments. Doctors and students may have felt that they were automatically entitled to learn their craft on patients in “Teaching Hospitals”. However most of these institutions began as charity hospitals for the poor who historically may not have had much choice in being “teaching” material (Fig. 2). Today a

The clinical note: good enough?

The medical and nursing notes are the tangible record of the round. They are crucial as legal documents. Yet important information in decision makings may not be recorded in the record [22]. How good is note making on ward rounds? It is an adroit clinician who can interview the patient, consult the support services, teach students and house staff and leave a record that reflects complex decisions. Even today, most inpatient medical records are handwritten. Notes tend to be telegraphic often

Conclusion

The ward round, which is central to hospital activity, lacks recognition as an important area for scientifically conducted research (Table 2). It is a complex wave incorporating multiple professionals in patient assessment and communication, diagnosis, prognostication, cost calculation, risk assessment, hospital-community communication, record keeping and teaching. It deserves study and reflection on its effects on patients and professionals alike.

Learning points

• The ward round encompasses a complex of activities in patient care, communication and decision making which have been insufficiently studied as a phenomenon.

• It is enriched by the input of the varied health professionals whose full potential may not be realised.

• Teaching, note taking and dealing with relatives and the complex of professional–patient relations needs further exploration.

References (24)

  • B.M. Reilly

    Physical examination in the care of medical inpatients: an observational study

    Lancet

    (2003)
  • ...
  • L. Birtwhisle et al.

    A review of a surgical ward round in a large paediatric hospital: does it achieve its aims?

    Med Educ

    (2000)
  • A. Busby et al.

    The role of the nurse in the medical ward round

    J Adv Nurs

    (1992)
  • E. Manias et al.

    Nurse–doctor interactions during critical care ward rounds

    J Clin Nurs

    (2001)
  • ...
  • ...
  • Making the best use of the department of Clinical radiology: Guidelines for doctors

    (2003)
  • A.S. Elsteine et al.

    Clinical problem solving and diagnostic decision making: selective review of the cognitive literature

    BMJ

    (2002)
  • S. Eeichart et al.

    Physicians' attitudes about prescribing and knowledge of the costs of common medications

    Arch Intern Med

    (2000)
  • C. Ham et al.

    Hospital utilisation in the NHS, Kaiser Permanente and the US Medicare programme: analysis of routine data

    BMJ

    (2003)
  • A. Hickey et al.

    Prevalence of cognitive impairment in the hospitalised elderly

    Int J Geriatr Psychiatry

    (1997)
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