Teaching on a ward round

Published 2 December 2008, doi:10.1136/bmj.a1930
Cite this as: BMJ 2008;337:a1930

Jean Ker1, Peter Cantillon2, Lucy Ambrose1

¹ Clinical Skills Centre, University of Dundee, Ninewells Hospital, Dundee DD1 9SY , ² Department of General Practice, National University of Ireland, Galway peter.cantillon@nuigalway.ie

Correspondence to: J Kerj.s.ker@dundee.ac.uk

A deliberate and planned approach to bedside teaching will make learning more effective

Teaching on a ward round has been compared to walking a tightrope. A clinical teacher has to balance the differing needs of undergraduate and graduate learners while providing a comprehensive and safe clinical service. Teaching in the presence of patients is an additional tension because the patient plays a central role and also is the most attentive member of the audience. Ward round teaching remains a powerful teaching context in medicine as it provides an authentic experience of the complexity of patient care and professional practice.^{1 2} The enduring value of the ward round lies in its potential to model professionalism, enhance clinical reasoning,³ and demonstrate the cultural norms of medical practice.^{4 5}

We have developed six questions that can routinely be used to plan and deliver effective bedside teaching on ward rounds (fig 1). The questions are derived from empirically based theories of experiential and situated learning.^{6 7 8}

View larger version (35K): [in this window] [in a new window] [PowerPoint Slide for Teaching] Fig 1 Six questions for planning a teaching ward round

What is the plan (for teaching and learning)?

Most clinical teaching is done on the hoof, but ward based teaching is more effective if it is planned. This can be difficult on a busy ward. When the senior clinician arrives for a ward round, there is usually a brief conference with team members and then "off we go." However, taking five minutes at the start to think about the learners, the teaching opportunities, the teaching goals, and the tasks will increase the efficiency and effectiveness of teaching enormously.

It is important to consider what sort of ward round it is. For example, a ward round that follows a night when team members were on call (a post-take ward round) will be longer than usual but may offer more teaching opportunities. As a clinician you will be more focused on ensuring optimum patient care. Taking time in advance to think about how to share and distribute the teaching tasks would be well worth while.

Practical points

• Estimate the amount of time that you will need for listening to presentations, making decisions, and talking to patients. Then work out how much time you have for teaching. Remember that discussing the patients will usually take longer than you think.
  
• Speak to the on-call team before you start to identify patients for presentations that might allow focused teaching about history, physical examination, or patient management.
  
• Know who your learners are: use their names. This simple demonstration of respect from you will make a big difference to their self confidence.
  
• If time is short, send learners to assess a new admission ahead of the ward round team so that time can be spent on the detailed study of one patient’s case rather than a superficial skim through many patients.
  
• Alternatively, ask the learner(s) to stay behind after the ward round has moved on to stay with a patient so that they can explore this patient’s understanding of his or her condition and its management. Follow this up by offering to meet with the students at the end of the round to discuss the encounter.
  

What do the learners know?

Empirical educational theory has established that the quality of individuals’ learning depends to a great extent on what they already know.^{9 10} Learners make sense of new experiences by using their existing knowledge. Your role as a clinical teacher is to help learners build new understandings, elaborate their existing knowledge, and tackle misconceptions. Ward rounds provide opportunities for learners as apprentice practitioners to think about their knowledge in the context of patients.¹¹

Practical points

• Identify learners’ level of clinical experience and knowledge by asking them about their stage of training, clinical rotations completed, and logged clinical experiences.
  
• Ask learners to summarise one or two patients from the last ward round they attended to get some sense of how sophisticated their understanding of patient care is.
  
• Ask learners if there are aspects of clinical practice that they find difficult to understand.
  

What can be achieved?

It is essential to agree in advance with learners what they need to learn. This provides a much needed focus to bedside teaching, which is often unpredictable. By using the learning needs that have been identified and taking cognisance of the learning opportunities that a ward round will offer, you can offer appropriate teaching for your learners.

Learning about team work
Ward rounds, whether conducted at the bedside or in the ward meeting room, provide opportunities for students to witness clinical teamwork and understand its value. Effective collaboration reduces hospital inpatient times and costs.¹²

Learning with and from documentation
Undergraduate students often have little understanding of how medical information is documented and stored. Preparing for and being involved in ward rounds gives them an opportunity to look through and understand healthcare records. You can ask students to write case notes based on their encounters with patients and give them feedback on the quality of their records.

Learning about safe decision making
Delivering care in a hospital setting has become more risky and complex in recent years.¹³ Ward rounds provide a powerful opportunity to both model and explain the risk assessments associated with every major decision.¹⁴

Learning professional behaviours
Clinical teachers should be aware that they are acting as role models for undergraduates and doctors in training as they work.^{15 16} Coaching, mentoring, and acting as a role model have been linked to error reduction and performance improvement within healthcare teams.¹⁷

Practical points

• Agree on the learning goals in advance. Aim to set a few, achievable goals, as less is more in clinical education.
  
• On the business ward round, set a theme to highlight, patient by patient. In this way, learning can be reinforced from patient to patient, maximising individuals’ learning.
  

Who will do the teaching?

It is essential to view the ward round as a unique opportunity for different teachers from different professions to participate in teaching. For example, including a pharmacist on the post-take ward round has been shown to be effective in improving the management of patients’ drugs.¹⁸ Including other health professionals as tutors reinforces learners’ sense of teamwork. By participating in this process, learners recognise the roles of different professional groups.

Practical points

• Before starting the ward round, agree to share your teaching role with other team members.
  

How can I help the students to learn?

The fifth question is deliberately worded to emphasise helping learners to learn, rather than the more traditional approach in which the teacher’s job was to transmit knowledge ("what do I want to teach?").

Directed observation
Rather than expecting students to know what to observe, tell them what to look for in clinical encounters: "Watch the way that I take a history from the next patient and tell me afterwards what you noticed." Experience has shown that this approach is especially useful with novice learners, who are often daunted by the ward round experience and do not know where to focus their attention.^{14 19}

Give learners tasks
Medical students often feel "in the way" in clinical settings. Giving learners tasks that benefit the team makes them feel involved and engages them in purposeful activity.

Organise dedicated teaching rounds
Most clinical teams organise dedicated teaching rounds for undergraduate and postgraduate learners. Dedicated teaching rounds can be enhanced if the goals of the teaching round are made explicit in advance; patients are carefully selected (or even invited to attend from home) to match the learning needs and abilities of different grades of learner; and the teacher observes and provides feedback on learners’ performance.

Stop and summarise the learning
Learning opportunities on ward rounds can come thick and fast. Learners can become overwhelmed unless some effort is made to stop between patients to summarise what was learned.

Practical points

• Always attempt to observe what the learner does and provide timely feedback either at the bedside or in a suitable location immediately after the ward round.
  
• Wait for learners to answer your questions (count slowly to 10 in your head). Silence can be an effective tool in enabling learners to think and contribute to a discussion.
  
• Use validated checklists (examples are given by Caldwell¹⁴ and Norgaard et al²⁰) to structure your evaluation of junior doctors’ performance on ward rounds.
  

How will I know what learning has been achieved?

Checking what has been learned is often the forgotten element of bedside teaching. It is vital to debrief learners after a ward round to highlight key points, uncover areas of uncertainty, and raise problems that could not be discussed at the bedside. It is also an important time to provide corrective feedback that might have been embarrassing to give in front of a patient.

Practical points
At the end of the ward round:

• Ensure that you or one of your fellow tutors reviews what has been learned with each group of learners. Use the learning summaries as your basis.
  
• Plan with learners what they need to look at or do before the next clinical encounter.
  
• Encourage learners to keep track of what they are learning by using a logbook or portfolio.
  

Goals for different grades of learner Medical student Presentation and discussion of history Demonstration of physical examination skills Comparison of current patient to previous experience Formulating differential diagnosis Prescribing Interpretation of common investigations Postgraduate trainees or residents Identification of salient points in history and examination Prioritising differential diagnosis Integration of clinical and investigative findings: clinical reasoning Treatment strategy Evidence for and against different management options Prognosis and follow-up strategies

Conclusion

Ward round teaching is here to stay, despite recent changes in doctors’ working patterns and the increasingly rapid turnover of patients occupying hospital beds. A deliberate and planned approach to bedside teaching will make effective learning much more likely. The critical success factors include establishing a safe learning environment, observing what learners do, and providing feedback in a timely fashion. Teachers should view each teaching ward round as an opportunity for both their learners’ and their own development.

Useful resources Task based learning Harden R, Crosby J, Davis MH, Howie PW, Struthers AD. Task-based learning: the answer to integration and problem-based learning in the clinical years. Med Educ 2000;34:391-7 Ward round checklists Caldwell G. Real time assessment and feedback of junior doctors improves clinical performance. Clin Teacher 2006;3:185-8 Norgaard K, Ringsted C, Dolmans D. Validation of a checklist to assess ward round performance in internal medicine. Med Educ 2004;38:700-7

Teaching points Take time to plan what you are going to teach and how it is to be done Base your teaching on a clear understanding of the nature and content of learners’ prior knowledge Be realistic about how much time there is for teaching on a ward round and plan accordingly. Share out teaching load among the team Ask learners to carry out tasks

Cite this as: BMJ 2008;337:a1930

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This series provides an update on practical teaching methods for busy clinicians who teach. The series advisers are Peter Cantillon, senior lecturer in the department of general practice at the National University of Ireland, Galway, Ireland, and Yvonne Steinert, professor of family medicine, associate dean for faculty development, and director of the Centre for Medical Education at McGill University, Montreal, Canada.

Contributors: All authors have given a substantial contribution to the conception and design of this article, drafted and revised the article, and have approved the final version of the article. JSK and LA are guarantors.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

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