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.

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“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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