Can we observe and teach better by changing the focus?

Jonathan Rabbs Anil GargConsultant Paediatrician Consultant PaediatricianMRCPCH , MSc FRCPCH, FRCPI, Dip Education

Department of Paediatrics, Worthing Hospital, West Sussex, UK anilgarg@doctors.org.uk

Traditional ward round is Consultant focussed. Changing focus to trainees improves their participation and allows performance to be

observed and enhanced.

Traditional Ward Round

Patient and Consultant in focus

Consultant does Ward round

Registrar, SHO and Sister

Admission History and examination presented

Findings confirmed, discussed with patient

Trainees not paying attention to consultation

Busy or look busy

Traditional Ward Round

Changed Focus to:

Patient and Registrar / SHO (trainee)

Consultant leads Ward round

With Registrar, SHO and Sister

Admission History and examination Discussed

Patient examined by

SHO or Registrar or Consultant

Others pay attention to consultation

Will have to comment on the consultation

Changed Focus to:

Current Ward round

• In practice since 2002• 80 trainees have been in department • SHO 0-2 year Paediatrics experience• Registrar 3-5 year Paed experience• Explain the ground rules to trainees

– Observe the clinical interaction– No writing when ‘talking with patient’– Will need to comment on the process

• Discuss patient details with likely ‘questions’• SHO / Reg carry out the consultation

– Introduce themselves and the team– Make ‘Comfortable and at ease’– Notes and details are available for results etc.

• If in ‘trouble’ intervene gently– Out of depth on inquiry by patient / relative– Not correct explanation– Encourage to say ‘I don’t know but will find out’

• After formulate the ‘gist’- Update notes.

• Discuss and feed back on Consultation– What happened and how could we do it better– All are encouraged to comment

• Registrar / SHO / Consultants can all WRITE and not only the junior most member of team

• Limited number of patients seen by juniors• Ward round is paced appropriately to try and finish in expected

time• All given feedback on performance • All gave back verbal feed back (comments)

• Structured written feed back from 45

RESULTS – Comments

• We learn by ‘observation’• ‘It feels strange to be observed.’• ‘I feel more involved in the ward round.’• ‘Why do we have to do it this way?’• ‘It is more time consuming’• ‘I think it prepares me for the exam and I will

not feel so tense.’

Registrar / SHO

• ‘It is like seeing myself in a mirror’• ‘I would rather not see this difficult mother’• ‘Yesterday we had more patients and we

finished half an hour earlier!’• ‘I would like to do it this way – sometimes.’• ‘Thank you for giving me the opportunity to

observe and feed back’

SHO / Registrars

• ‘It is like seeing myself in a mirror’• ‘I would rather not see this difficult mother’• ‘Yesterday we had more patients and we

finished half an hour earlier!’• ‘I would like to do it this way – sometimes.’• ‘Thank you for giving me the opportunity to

observe and feed back’

SHO / Registrars

• ‘It is like seeing myself in a mirror’• ‘I would rather not see this difficult mother’• ‘Yesterday we had more patients and we

finished half an hour earlier!’• ‘I would like to do it this way – sometimes.’• ‘Thank you for giving me the opportunity to

observe and feed back’

SHO / Registrars

• ‘Stethoscope – What stethoscope! I am usually the writer.

• ‘Didn’t feel like I’d be criticised for making a suggestion or giving answers that were wrong.’

• I learnt that with experience I will hopefully do, what to you comes effortlessly.’

WRITTEN FEED BACK FROM TRAINEES

Thank You