Teaching Ward Rounds: what are the alternatives?

Abstract

Once upon a time I used to conduct a ‘‘teaching ward round’’ on Tuesday afternoons, prior to my Wednesday morning operating. There would usually be half a dozen pre-operative patients and perhaps some post-operative patients who were waiting to be sent home, or some patients admitted acutely from my last ‘‘on call’’. I call it ‘‘teaching’’ as contrasted with working ward rounds that are nowadays conducted in front of the white board with the patients’ names, and decisions that are made without actually seeing the patients. In those days the patients would arrive during the morning so that the medical students could spend an hour or more with the patients before they went for ECGs, chest Xrays etc and they would be back in the ward for our starting time of 2pm. The Ward Sister did not join us for the whole two hours duration but usually passed by to ensure that all was under control; junior nurses attended and were often asked to contribute to the discussion. Patients were informed beforehand and asked their consent to participate; the only patient I recall dissenting was the mother of one of the students. Some of the patients were anxious about what would happen, but almost uniformly agreed afterwards that they had learnt about their diagnosis and why they were undergoing such management. Each patient was presented by a student. The exercise was to compress the relevant details gathered over their hour with the patient (taking a history) and present it in the language we were teaching them to use (giving a history) in five minutes. They were encouraged to give important details first; some students could not resist the temptation of starting with ‘‘presenting symptoms’’ and rambling through every detail gleaned of the history, laying a few false trails and then with a flourish suggesting a differential diagnosis that included most of their knowledge of gynaecology. This was ‘‘patient-based learning’’ (PBL), and uncertain details were ascertained by the student asking the patient. The students were able to observe doctor – patient interactions as the senior medical staff on the ward round listened to the presentation, listened to the patient’s additional comments (listening for important answers is a skill difficult to teach in other environments), gave explanations that the patient could comprehend and participated in the ‘‘consenting’’ process. The next morning the patient was greeted in the anaesthetic room by the same student, who latter accompanied us to tell the patient of our findings and the procedures performed. Student learning was provoked by curiosity and some background reading overnight; they were amazed just what they had learnt and that they did not forget learning in such an environment. What has changed? Nowadays patients are seen as outpatients for pre-operative assessment, they arrive in the ward on the morning of surgery (even if they are transplant patients on a heap of immunosuppressant therapy, or have travelled some distance through the