Ward Attending Skills

Ward Attending Skills

CDR John R. Holman, MC, USN

Faculty Development Fellowship

Madigan Army Medical Center

(edited for web page 21 July 1999)

Objectives

Role-play typical daily FPIT rounds
Contrast inpatient and outpatient teaching
Brainstorm challenges and success of MAMC FPIT
List attributes of good attendings
Formulate a common process for FPIT rounds
Develop a peer feedback system

Introduction

"If conducted properly, rounds are a joy to behold, but if done improperly they are a crashing bore and a waste of valuable time."

Ward rounds are an important aspect of clinical teaching for learners at all levels of training. Clinician-instructors are often concerned about their degree of success in conducting ward rounds. Such topics as

Combining patient care with teaching, assessment and feedback.
Meeting the perceived need to stimulate and entertain learners while transmitting up-to-date information.
Establishing the most desirable frequency and duration of rounds so as not to interfere with patient care by house staff.
Maintaining the interest of all members of the team, whose knowledge and skills are at various levels of development

are commonly mentioned as challenges to successful ward rounds.

What is the best way to conduct ward rounds? The answer is that depends on your institution, program and goals for learning. Together we will determine a framework for conducting FPIT rounds here at MAMC.

Role-Play Scenario

Typical morning rounds will be displayed. The team consists of the staff attending, a resident in each of the three-year groups and a third-year medical student. The team is reviewing the case of AA, a 79-year-old male with diabetes, CHF due to CAD, hypertension, dementia, arthritis and placement challenges. The patient was admitted 3 days ago after an exacerbation of his CHF due to not taking his medications. He is on digoxin, lasix, insulin, long-acting nitrates, an ACE inhibitor, aspirin, a stool softener, Tylenol with codeine and ativan at night for sleep. He has improved slowly during admission. His primary inpatient provider is the intern.

Inpatient vs. Outpatient Teaching

What are some similarities and differences in instruction between the two arenas for teaching in medicine? We will compare and contrast as a group.

Inpatient Outpatient

Unpredictable Patients scheduled

Experience differs by level Experience similar by level

Roles differ by level Roles similar by level

Many inputs to care Time limited

Large amount of data Time pressure

More time flexibility Case-based learning

More time compression Focused learning

Case-based learning

Desire in-depth teaching

More time to read

Family Practice Inpatient Teaching at MAMC

In small groups of 4-5, list the inpatient teaching successes we have at MAMC. Take 10 minutes and identify a spokesperson who will share your list with the group.

Take care of resident
Broad-based learning
Leadership opportunities
Appreciate whole patient
Practice medicine well
Opportunity to learn time management
Accessible attendings
Good at literature searching
Team works well together
Opportunity to evaluate performance
Opportunity for biopsychosocial teaching
Opportunity for socialization
Teaching occurs but can be variable
Variety of styles is a plus

In small groups of 4-5, list the inpatient teaching challenges we have at MAMC. Take 10 minutes and identify a spokesperson who will share your list with the group.

Continuity of care with PCM
Behavioral science issues
Teaching vs. service
Lack of complex care experience
Lack of standardized teaching experience
Different attending styles
Changeover every 2 weeks
Attendings with low comfort level with certain patients
Out of house attending at night
Bedside vs. conference rounds
Do attendings look at goals and objectives?

Attributes of a Good Attending

In your small groups, brainstorm the attributes of a good attending. List them on the flip chart. Contrast them with the list presented by the leader from the medical literature.

Attributes of a Good Attending

Brief

Approachable

Knowledgeable

Supportive

Malleable

Accessible

Positive mental attitude

Role model

Wisdom

Brave

Insists on teaching

Promotes autonomy

Team player

Good listeners

Respectful

Ward Rounds-Types and Purposes

There are two basic types of ward rounds: patient care or work rounds and teaching rounds. Teaching rounds are often the most worrisome for attendings. How do I stimulate them to learn? Did I select the right patients with interesting problems? How do I get the group to interact and not just listen to me talk? On the other hand, the students and residents are focused on getting their daily work done. For them, work rounds are critical. Shulman describes a survey of a pediatric inpatient service that indicates a need for consensus among faculty and residents regarding the purpose, content and process of rounds.
Work Rounds

McLeod suggests daily patient care rounds with the senior resident focused on the sickest patients only. The senior resident and staff see the patient together and plan further evaluation and management together. This allows for senior resident leadership of the junior members and allows the other residents to get daily work finished. These rounds should not last over 1 hour and should be conducted at the bedside.
Teaching Rounds

Shulman, McLeod and Goldman all agree that teaching rounds should be case-based, interactive, have a focused content and not last more than 2 hours. Teaching rounds occur two to three times a week and should involve three to six patients. The content may be pattern recognition, clinical skills, application of basic science knowledge or formal case presentation and discussion. Whatever the content, it should be focused and avoid trying to cover too much material. Patients who are reliable historians, have an atypical presentation of a common problem, have interesting clinical findings or challenging illnesses are ideal for teaching rounds. Teaching rounds should be conducted at the bedside to help link the teaching with patient care. It is important to teach approaches to problem solving and not facts as the learners need these to best perform their jobs.

In your small groups, design a process for work and teaching rounds for the FPIT.

References:

Goldman DA, Andrews SM, Pasternack S, Nathan DG, Lovejoy FH. A service chief model for general pediatric inpatient care and residency training. Pediatrics 1992;89:601-607.

Kroenke K, Simmons JO, Copley JB, Smith C. Attending rounds: a survey of physician attitudes. J Gen Intern Med 1990;5:229-233.

McLeod PJ. A successful formula for ward rounds. Can Med Assoc J 1986;134:902-904.

Shulman R, Wilkerson L, Goldman DA. Multiple realities. Teaching rounds in an inpatient pediatric service. AJDC 1992;146:55-60.

--------------------------------------Role Play Scenarios----------------------------------------

Staff

You are new to teaching. You’re not sure what the residents want or need from you in the form of teaching but you are willing to teach them whatever you know. You are uncomfortable with bedside rounds and tend to micromanage somewhat. You do not know the senior resident well. Your favorite subject is type 2 diabetes mellitus and are very well read on the latest medications.
Third-year Student

You have dispersed knowledge. You know a lot of stuff but have trouble putting it all together in a coherent plan. You just read an article in NEJM about a new beta-blocker call carvedilol that helps CHF patients live longer. You are convinced that this patient needs this medication and are not going to change your mind easily!
Intern

It is August and you are very insecure about your knowledge base and just about everything else. You are eager and willing to do what you are told, but it is hard for you to independently decide on evaluation or management plans for your patient, A.A. Your main question is how to start a sliding scale for your patient as his oral medications are not working well.
R-2

You just finished your internship and this is your first FPIT as an R-2. You feel comfortable as an intern but you are not sure what your role as an R-2 is. You also have clinic this afternoon and a bunch of notes and discharges to take care of so you need rounds to move quickly today (for a change!). You have a tough time looking ahead in the care of you patients for more than a day or two.

R-3

This is you first FPIT but you were the star intern and R-2 and are consequently a little overconfident. You do not read the literature that often but remember what your specialists attendings have told you about patient care. You want to increase the patients digoxin and lasix and get him to a SNF tomorrow. You remember a cardiologist telling you to max out dig and lasix for CHF patients before you do anything else. You believe his diabetes can be better managed as an outpatient.

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