Thoughts about Teaching Ward Rounds on a Medical Service

There is considerable anecdotal evidence that teaching ward rounds has deteriorated. This article discusses current impediments to the performance of teaching ward rounds and what the attending physician teacher and trainee can contribute simultaneously to improve patient care and teaching. Patients, who are the center of activity, gladly participate in teaching ward rounds and, when carried out properly, enjoy and profit from it. Because this teaching patient care exercise is extremely important, considerable effort must be expended to create an environment that exudes excellence.

J. Willis Hurst, MD, MACP,

Active Consultant to the Division of Cardiology, Candler Professor and Chairman, Department of Medicine Emeritus, Emory University School of Medicine, Atlanta, Ga

Many observers of medical education believe that teaching ward rounds have changed and that they are no longer viewed as a learning exercise by students and by house officers. Seasoned true teachers of medicine place the value of properly conducted teaching ward rounds as the second most important teaching activity offered by the usual training programs.¹ Teaching activities, listed in order of their value, include self learning, teaching ward rounds, morning report, conferences involving a specific patient, seminars, grand rounds in which a specific patient case is presented and discussed, and lectures.² Note that lectures are listed last.

Because of the uncontested teaching value of properly conducted teaching ward rounds, it is appropriate to discuss current impediments to the implementation of excellent teaching ward rounds and suggest ways to restore them to their rightful place as second in usefulness in a teaching program.

Impediments and Suggestions for Their Removal

1. Teaching-attending physicians may not know what their teaching responsibilities are. They may believe that their only duty is to point out that the patient needs a certain technical procedure. They may fail to remember that students are only introduced to skills, including cognitive skills, in medical school and that they should try to perfect them during house staff training. Accordingly, the teaching-attending must check the trainees' skills. If this is not being done, the attending physician should enroll in a seminar that addresses thinking, how people learn, how to evaluate trainees, and how to correct deficiencies.

2. The beepers carried by trainees and attending physicians frequently interrupt teaching ward rounds, often with issues that could and should have been dealt with earlier in the day. When this occurs frequently during the ward rounds, the chief of service should review the organizational structure of the day's work so that nonemergency patient care duties can be implemented before teaching ward rounds. It may also be possible to discontinue nonemergency calls during the rounds.

3. Attending physicians must deliver the very best in medical care and teach at the same time, keeping in mind that trainees save them a great deal of time when they "work up" patients. Remember, attending physicians can be held legally responsible for the care they provide and the care they direct, as well as for inadequate supervision.³ They can also be held "vicariously libel" for the actions of their trainees. Resident physicians, too, can be sued for malpractice.³

Years ago, a floor nurse made ward rounds with the attending physician and trainees. The current nurses shortage can be partially overcome at the end of ward rounds, when the attending physician discusses certain aspects of patient care with the appropriate nurse. When done properly, this prevents misunderstandings and points out to the trainees the importance of nurses in delivering patient care.

Suggestions for Effective Teaching

The group involved in teaching ward rounds includes patients, attending physicians, and 3 or 4 trainees. Each element plays a specific role in making the activity a successful teaching exercise.

The role of the patient

Patients in public hospitals accept the trainee and attending physician that happen to be scheduled to see them. They trust both because, over the years, the hospital has served its patient population well. Because the attending physician and trainee are the only ones that care for the patient's medical needs, kindness, respect, and caring must be the core of their activity. Studies have shown how important respect is to patients. A survey of 288 patients showed that those treated by attending physicians were more satisfied than those treated by resident physicians, primarily because the former treated them with more respect.⁴ Patients trust those who care for them, and the attending physicians and trainees must never let them down.

Patients in a private teaching hospital almost always appreciate that the attending physician and trainees are striving to offer them excellent care. It is important for the attending physician to discuss the role of the trainee with the patient and explain ward rounds. Many patients are excellent teachers who bring to life their stories of angina pectoris, multiple sclerosis, or other conditions that can be more revealing in real patients than in textbooks. Patients may also ask the trainee questions about their illnesses, forcing the trainees to look up the answers.

Regardless of whether patients are in a private or public facility, those who care for them must realize that it is a privilege. Doctors were "invented" to serve patients, so the needs of patients always come first.

The role of the trainee

House staff programs were created to help trainees develop their skills under the tutelage of skilled true teachers. Trainees must develop the habits of learning during the few years they have with teachers, and teachers must help them.

Teaching ward rounds is not where attending physicians, using poor handwriting, simply cosign ill-contrived medical notes that have been written, also in poor handwriting, by trainees. Rather, it is where the teaching-attending physician actually checks the trainees' examination of the patient and the written account of their examination. The goal is to make certain that what is written and what is said about the patient are the same. The attending physician must also assess the trainees' analytical skills and determine if they are developing appropriate learning habits.

Above all, house officers must remember that they are still in school and that 3 to 6 years of training is needed to attain the skills to function alone. The true teacher's job is to help trainees become independent thinkers who can solve medical problems, determine the reaction of individual patients to their diseases, and are skilled in the delivery of health care in a compassionate manner. Punctuality must become a habit for life. Being late is disrespectful to patients and colleagues.

Before ward rounds, the trainee creates a Complete Problem List on patients, to be presented to the teaching-attending physician. The list is created by analyzing data collected on a patient and reorganizing it into problem statements. This process is known as thinking. The trainee must be prepared to answer 2 questions that the attending physician should always ask: "What data did you use to formulate this problem?" and "Are all the significant data you collected accounted for on this problem list, as a separate problem, or as an attribute of a diagnosis?" The answer to the first question helps determine if the trainee is developing analytical skills. This is how a true teacher discovers if the trainee knows the criteria required to make a diagnosis, or if the trainee has copied the diagnosis from an old record, or was simply told the diagnosis by someone. The second question is asked when the attending physician discovers that a significant problem (ie, any condition that influences the patient's health) has been omitted from the problem list.

Trainees should read about certain aspects of the patient's illness and be prepared to share the information with the attending physician and their peers. Trainees should also be prepared to ask the attending physician about any aspect of the examination of the patient, from checking for aortic valve regurgitation to interpreting the chest x-ray or electrocardiogram (ECG).

The role of the teaching-

attending physician

Teaching-attending physicians perform perhaps the most important teaching activity in medical school and the teaching hospital. This is because teaching ward rounds challenge trainees to translate their medical knowledge into the care of the patient in a humane manner.

When the attending physician meets the rounding group, the entire chart for each patient should be available. If that is not possible, a photocopy of the Complete Problem List must be available for discussion. Ideally, each member of the rounding team has a copy. The chest x-ray film and ECG should also be available.

The attending physician should review the Complete Problem List with the group before entering the patient's room, and then ask the trainee to present the data used to formulate several of the patient's problems. Any trainee who attempts to give a long dissertation should be stopped, because this shows a lack of understanding of how to analyze data and formulate a problem statement. Trainees are functioning at a junior medical student level, where the use of data that have been collected is not always emphasized. The attending physician must recognize this deficiency, point out the error, and help the trainee learn how to select the appropriate data needed to make a diagnosis. The teaching-attending physician should stress that copying a diagnosis from an old record is not acceptable. Even a patient's statement about a previous diagnosis must not be accepted unless there is specific supportive information.

Before the group enters the patient's room, the attending should ask the trainees if there are any specific areas that they would like checked. The attending physician may also want to review the ECG and chest x-ray film because many patients will want to know what the physician thinks about their results.

When the group enters the patient's room, the attending physician should greet the patient and introduce the members of the group. The same courtesy is extended to the spouse or any other family members. It is rude to ignore the members of the patient's emotional support system (family and others). A skilled teaching-attending physician can sense if the patient and/or spouse is unduly anxious or uncomfortable and attempt to reassure them.

The attending physician then elicits the important points in the history and physical examination and, if the trainee has overlooked anything, demonstrates the abnormality to the group. This is very important, because the trained attending physician who has more experience should see, feel, and hear abnormalities that are not discovered by the trainee.

The attending physician discusses routine laboratory work, including the chest x-ray film or ECG with the patient, as well as the diagnosis. If no diagnosis has been established, the attending describes the differential diagnosis and what is needed to identify the specific diagnosis. The attending also discusses other medical problems with the patient and points out that one problem and its treatment may affect other problems and that the admitting problem and other problems will be discussed in detail with the patient before discharge.

The attending physician should leave the room with a word of encouragement. An excellent physician must not be visibly unhappy and almost never leaves the patient feeling there is no hope. The visit should be reassuring, pleasant, and, when possible, rewarding to all concerned, especially the patient.

If a discharge date can be anticipated, the attending physician should say, "I will discuss your medical problems with you in detail the day before you go home. The morning of your discharge, I will ask you to repeat what I have said. At that time, I will show you the updated problem list that summarizes what we have found."

The purpose for these comments is to show the trainees that communication with patients is not simply telling them the diagnosis and what to do about it. A physician must hear patients repeat what they think the physician said and, if it is wrong, correct them.

After leaving the room, the attending physician continues to discuss selected aspects of the patient's condition with the trainee. The following discussion is a good example of a discussion related to a cardiac patient.

"Joe, I wish to congratulate you. Very few doctors would know to ask the patient if he had pain in the lower jaw when he exercises. Many would not have identified the patient's angina. Furthermore, you recognized that the angina was unstable—that too is a superb achievement. Joe, I would like you to do 2 things. Will you ascertain later if the others in your group know how to identify unstable angina pectoris and how it differs from stable angina pectoris? Remember, every trainee must teach. Also, I would like you to have a 1-minute discussion with our group tomorrow on why the discomfort of myocardial ischemia may be located in the chest, jaw, arms, or little finger. Such radiation seems strange but is easily explained. Remember, we get smarter when we ask ourselves questions about our patients and look up the answers."

To the whole group, "I want to point out how important it was to identify the abnormal V wave in the deep jugular vein pulsation, because it indicated the presence of heart failure. I will ask one of you to discuss this abnormality tomorrow."

"Notice too, that the computer readout of the ECG was wrong. This, of course, is common. Remember, the patient stated that 1 of the episodes of jaw pain and chest discomfort persisted for 2 hours. That is too long for angina and the ECG shows a large ST-segment vector pointing to the right and anteriorly. Accordingly, the patient originally had unstable angina and then developed a right ventricular infarction. If he had come for help sooner, rather than 2 days after the prolonged pain, he would have been treated differently. Now, Joe, we must recast the problem statement you made to match the findings of right ventricular infarct preceded by unstable angina."

The attending physician may also say, "Joe, what questions did you ask yourself about this patient and did you look them up?" Joe responds, "I noted that his serum potassium level was 2 mEq/L and, when I looked it up, I discovered that it might be caused by the potassium-losing diuretic he was taking for essential hypertension. I also learned about the effect of hypokalemia on the ECG."

The attending physician asks, "How long did it take you to read about that?" Joe responds, "About 10 minutes." The physician points out, "Joe, you just learned an important lesson. When you state a problem clearly, it usually takes little time to find the answer. There are 2 types of reading—the quick read, as you demonstrated, and the long read, where you try to understand more complex problems, such as the cause of atherosclerosis. By the way, Joe, you should add hypokalemia and essential hypertension to the problem list. Remember, no significant problem should be omitted."

Teaching-attending physicians must serve as a bridge between the basic sciences and clinical medicine. Accordingly, they must lead the trainees to think in terms of basic mechanisms that are responsible for normal and abnormal phenomena. This is easily accomplished when the attending physician uses simple things to emphasize this method of learning. For example, asking, "What are the basic mechanisms involved in the production of edema of the lower legs?" or "Why is the blood pressure higher in the legs than the arms?" or "When during the mechanical cardiac cycle is the T wave produced in the ECG?"

The attending physician must determine if the trainees really understand what happened to the patient. Accordingly, before the patient is discharged, the attending should ask the trainees to describe their understanding of the patient's problems and correct any misperceptions.

Final Thoughts

The teaching-attending physician must check trainees' data collecting skills, analytic ability, understanding of the basic mechanisms that are germane to the normal or abnormal phenomena they discover in a patient, ability to understand the patient's reaction to disease, and ability to solve problems and deliver what they know in a caring manner. Attending physicians must also check the trainee's written notes and write their name so it can be read easily. We are not celebrities who scribble illegible hieroglyphics on pieces of paper presented by their fans. As physicians, our writing must be legible. Teaching-attending physicians must never cosign a trainee's notes that they believe can be improved. Trainees must remember that they are still in school and should expect their teacher to guide them until they can function on their own.

Some attending physicians will say they do not have time to teach as it has been described here. They must remember that trainees save them considerable time when they work up the patients assigned to them. To be fair, the attending physician should spend an equal amount of time reviewing the trainees' work and examining the patient, while teaching every step of the way.

Above all, the attending physician must determine if a trainee exhibits the habits of a physician who knows how to learn medicine and how to deliver excellent service to patients before they leave the comfortable arms of the teaching hospital.

Teaching Medicine: Process, Habits, and Actions

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