Internal Medicine

Ward rounds – ideas for making them better

A leader must be able to define an ideal state and get people enthused about moving towards it” said Dr Prab Prabhakar, a consultant paediatric neurologist at the Great Ormond Street Hospital (GOSH), as we sat down together in my office.  I had met Dr Prabhakar a few months ago in London and was pleased that he was taking a day out of his vacation in India to visit us.

“Would you feel comfortable raising an issue if you noticed something wasn’t quite right?  How do we, as doctors, learn to see things from the patient’s perspective?  How do you develop a culture where you feel responsible for what happens in the whole hospital, not just your unit?”  These were some of the questions he asked members of our paediatric unit before hearing a presentation on ongoing quality improvement work in the department.

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Before long we were in the auditorium to hear his talk on improving ward rounds.  Dr Prabhakar related examples from his actual ward rounds at GOSH.

LISTEN and SILENT have the same alphabets

“A 3.5 year old child with a serious genetic immune disease had been admitted to the hospital over the weekend and I had to see him on Monday to talk to the family about the possible causes of the current acute deterioration; the differential diagnosis included three possible reasons…. How long do you think this consultation is going to take?” asked Dr Prabhakar.

Estimates from the audience ranged from 20 minutes to a full hour.

“It took me 2 and half hours!” said Dr Prabhakar. “I thought it would take between 30-45 minutes.  But no one had told me that both parents were lawyers.  The father had a notebook and was documenting everything.  The parents had already put in a complaint against the hospital. And most importantly the father was depressed!  How can you ever prepare for this?”

“In the first one hour I hardly spoke.”

“Should I have just given them the differential diagnosis and told them about the tests that need to be done?  Is it my responsibility to listen to their complaints?  Should I have terminated this conversation and simply told them about the neurological condition of the child?”

I think the one hour I spent was the golden hour. It said to them that this doctor cares, he is willing to give his time to listen.  If I had stopped them and told them what I had to say, I bet nothing would have gone in.  Because I took 2.5 hours on Monday, it took me 15 minutes on Tuesday, 10 minutes on Wednesday, and on Friday before I left it took only 5 minutes.  By Wednesday and Thursday the writing stopped!  Not so with other specialists – writing is still going on, still having one hour conversations.”

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What I learnt is you never know what you are going to encounter.  But by taking time to listen to the family, the narrative from their point of view, hearing their story, their anger, and their feelings, we can meet our fundamental duty of empathizing with them and clearly communicating what we were trying to say.”

You have to go where the mother is to be heard

The next case that Dr Prabhakar picked was of an 18 year old single mother with a seriously ill child in the hospital.  She sat withdrawn on her chair, unaware that her child had lost half his brain.

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“She is sitting in a place of safety, where she knows what is happening, she doesn’t know what is happening in the rest of the room. We can’t talk to her from this space, we have to go to her, acknowledge she is in a different place. Looking someone in the face is quite a powerful thing to do.

Taking responsibility for decisions as a team

As a third case, Dr Prabhakar discussed a 3 year old who had come in for an angiogram.  This child had an experimental treatment and now was now suffering serious side effects that had left him blind and unable to walk without help.  He was needle phobic; all he knew was that people held his hand and then there was a big poke.  The healthcare team had sited a canula after much screaming and shouting and 10 minutes later the child had pulled out.  Dr Prabhakar had to decide whether they needed to re-site the canula?

He decided that they didn’t need the canula!  And he asked why did they had put in a canula in the first place?  The decision had been taken by a colleague five months ago, in different circumstances, and this time around there was no one senior to check the plan before executing!

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“How do you communicate and take responsibility for such decisions as a team?” asked Dr Prabhakar, highlighting an important problem in care delivery in hospitals.

Placing equal importance on showing respect as on making a clinical diagnosis

What struck me most about Dr Prabhakar was how he embodied the qualities of an ideal consultant – he seemed to be not just an expert clinician but also outstandingly empathetic towards the patient, family, staff, junior doctors and colleagues.  I found myself thinking that this was different from how even some of our best doctors come across in India.  While clinical skills for diagnosing diseases and performing procedures are often highly developed in our better consultants, their ability to communicate and empathize with different stakeholders often leaves much scope for improvement.  This may be because of high pressure of volumes in teaching hospitals and as Dr Rinku Sen Gupta Dhar, consultant obstetrician-gynaecoligst, pointed out, “It’s hard to display compassion when you have to see 45-50 patients in two hours in the OPD”.  But undoubtedly there are other reasons too.  Prof Vinod Paul, head of paediatrics at AIIMS said, it could be related to how we select doctors – relying on multiple-choice questions.  And Dr Prabhakar pointed out, it could be because “we have never been told that showing respect to a man from a village is as important as finding a mitral stenosis murmur.”

The dignity of the consultant that Dr Prabhakar displayed in his examples was made possible not just by his personal qualities but by being in a system that permitted such behaviours to be practised.  If medicine has to live up to the expectations of its stakeholders – patients, families, doctors, and others –senior consultants will have to provide clinical leadership that values courtesy and care as much as diagnosis and treatment.

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  • Rajni Sharma

    There is no doubt that communication and empathy are very important, perhaps as much as clinical care diagnosis and treatment.
    “The dignity of the consultant that Dr Prabhakar displayed in his examples was made possible not just by his personal qualities but by being in a system that permitted such behaviours to be practiced.” I fully agree with your statement; the need and importance of these qualities has to be recognized by our system first and by the medical community in India, before it can be brought into practice.

    • Was great to have you attend! I think being on the faculty of a prestigious teaching institutions like AIIMS puts you in a good position to sensitize students and trainees towards these issues.

  • Anil Verma

    Great blog

    I believe it’s not only the academic institution but private institution physicians go through this
    In our day to day activities we forget patients are not bed number or room number but human beings and need to be treated with respect and compassion

    In my profession a common mistake is not discussing the procedure before hand and the results of it in a comprehensive detail manner. I have to say at times in my hurry to get things done and see more patients I am guilty of this but still make efforts to provide compassionate care

    Anil

    • Great to have you reflect on your own practice. I am willing to bet that your patients are very happy – they have an outstandingly well-trained and sensitive physician!

  • Rajesh Bhardwaj

    Very enlightening.
    from my perspective, there are some factors to be considered – especially regarding the first example
    1. the key words in that narrative were ‘lawyer parents’, ‘notebook and documenting everything’, çomplaint against the hospital’. it indicates a high level of ‘medical literacy’ as well as threat of litigation. strong incentives to continue to engage the parents in a lengthy dialogue. it is evident that dr prabhakar had someone stand in for him for that day to cover his OPD or any other engagement he might have had. In an OPD that automatically slots 15 minutes per consultation – an international practice- imagine the number of complaints management would get if the physician took two and a half hours over one consultation.Schedules have to be kept – not so much for your sake as much for the other patients waiting to be seen. i would have arranged to see the parents in my chambers after the round ad after finishing other commitments. it was just a discussion – not a medical emergency.
    2. in the third case there is a hint of censure against the junior doctor in the team – it is an anecdotal incident – juniors will take time to understand to take independent decisions – usually it is safer to go with ‘what was done before’. it is a common situation – the senior doctor takes responsibility for the collective misdeeds of the team and the junior doctor learns. happens all the time, in a thousand different ways.

    As a clinician i am always happy to engage and empathize with the patient, without losing objectivity, but my frustration comes from lack of ‘medical literacy’ in a vast majority of our lay population, as well as a language barrier – i had a patient of Mikulicz disease recently, in a lady who came from the nearby Vasant Gaon – how do i explain it to her? All she wanted to know was whether there was ‘pus in it?’
    There is no Hindi word for Tonsillitis.

    But it’s an interesting presentation, and always interesting to hear when clinicians ‘bare their soul’ and let us share their more significant moments.
    regards
    rajesh

    • I wish you could have attended – I’m sure you would have enjoyed and added to the discussions. Dr Prabhakar was asked what he would do if he didn’t have the possibility of spending so long with the family at the time of the ward round. He replied that he sometimes has to tell the family “I don’t have the time to fully hear your concerns now but I will be back at such and such time”. He said that most families respond to that quite well.

      Thanks for you comment.

  • Neha Joshi

    Brilliant capture of his visit ! Another thought provoking insight that I found extremely valuable from his experience was -chanellizing energy towards learning from those practice’s that deliver success in the system 98% of the times instead of always s attempting to change practice’s that bring failure 1-2% of the times .
    I strongly believe our system is burdened by volumes and thereby succumbs to rushed moments, rushed body language , sometimes blindsight to patient’s agony and needs overhauling at multiple levels ranging from our communication skills during training to our burdened work environment . As we stand at crossroads of change , perhaps we can pick our learning’s from many successful interventions world over , as well as from that ” something ” in our healthcare practices that helps us serve huge numbers inspite of these challenges.

    • I loved his point about focusing on what’s working too!! He had so many great insights – it was impossible to remember all of them and difficult deciding what to leave out!

  • Arpita De

    The session we all had with Dr Prab Prabhakar was truely inspiring. Our journey started from a medical case and went on to the multiple roles of a consultant in the rounds- a listener, a counseller and a trainer.
    Talking of volumes I agree it is a huge problem, but we get a good training because of the huge number and variety of patients coming to the medical colleges. A polite tone and empathy dont always take a lot of time. A constant sensitisation of trainees and creating a culture of politeness and sensitivity is vital for adding to the human element of treatment. This is all the more relevant in obstetrics where a lot of pain and anxiety is there.

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