On Improving Ward Rounds (and Thus the Doctor-Patient Relationship) / by Muhammad Amir Ayub

This article was shared by a friend who has moved on to become a doctor in greener pastures away from Malaysia:

The sun is barely up when the curtain is pulled back, revealing a group of mostly strangers.

They are talking to each other. I understand every third word, I think.

It’s interesting that English-speaking people don’t understand full-blown medicine-speak. 

Patients — sleepy and confused, with un-brushed teeth and un-combed tresses — stood over by healthy figures in positions of authority wearing makeup, ironed clothes and swept-up hair.

We have no time to wait for you. Not in the developed Western world, and definitely not in a more resource-constrained environment. In Malaysia, housemen are expected to see patients before 7 am (what time do you think they woke up and drove to work?). Rounds may start by 8 (occasionally even 7.30 am). They have no time to know whether your favorite child is planning to follow the same career.

The moments when I stay behind and connect with the patient are small, but significant. Is there something I can get for you? How did you sleep? Is that sunlight in your face? Can you reach that glass of water? Would you like the door open or closed? How are you feeling?

Sometimes patients ask me who the person was just talking to them, not because they’re delirious, but because they just weren’t told. Sometimes they report a new symptom or ask a question. Once I even had a patient ask which specialty we were from.

We’re all guilty of rushing things. But when you’re rounding 40 patients in the general ward (as a specialist), general talk with patients is a luxury. Unless if you plan for rounds to finish at 1 pm, give HO's and MO's an hour or two to settle ward work (while others go for lunch breaks) and finish the PM rounds by 6 earliest, followed by 1-2 hour traffic (I'm very lucky to commute by public transport most of the time, with the option to just walk at times). But yes, we can do better to be more human in an efficient manner.

A 2005 study done at a hospital in New York City found fewer than half of patients discharged from hospital knew their diagnosis.

And fewer than one in five hospital patients could name the doctor in charge of their care, another study from the University of Chicago found.

This is a problem, for both patient and doctor (there are times when the patient's memory is the account of his/her medical history). With time at a premium, getting patients to read their discharge notes is a head start. Ensuring that patients know their diagnosis during the major rounds is probably effective too.

We can start with small changes like giving patients advance notice of when the team will be at their bedside, capping the number of staff present, seeking permission to begin the consultation, and providing clear introductions via the senior doctor.

During the visit the lead doctor should sit at the patient’s level, someone could take notes specifically to give to the patient, and genuine opportunities to ask questions should be created.

These seem like small steps. But for the person under the glare of scrutiny — sick, tired, bewildered — they are critical. Let’s reshape the hospital system and start each and every day with the patient at the centre of our care.

When our doctor-population ratio is better (senior doctor numbers, not just housemen and junior medical officers), this is definitely something that we should focus on as proper bio-psycho-emotional-spiritual treatment of patients. Not when rounds already take forever with the need to teach etc. Having more people means that 1 specialist has to see only less patients.

I’m so lucky that my “ward rounds” consists of seeing critically ill patients (the majority of whom can’t talk, of which one review typically takes 30 minutes-1 hour) or patients being managed specifically for their pain and not in charge of them as a whole. When new cases are referred for preop assessment in the ward, it’s not uncommon for the review to take more than an hour without other extracurricular talk. You need more manpower to treat patients as people and not as diagnoses.

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