Dr Sue Crossland, consultant acute physician, explains the concept of the 'reverse ward round', and how it helps ensure good quality teaching.
At a recent RCP round table discussion, we were talking about team working in medicine. I am of the generation of young doctors who spent a significant amount of their time - including ‘off duty’ - with their team. We ate together, played together, knew each other’s strengths and weaknesses, but most importantly we learned from each other. Harking back to the ‘good’ old days is never productive. Modern medicine has demanded we change - and change we have. As consultants in acute internal medicine (AIM), we have the privilege of doing our ward rounds in the hospital's richest vein of learning - the acute medical unit (AMU). The downside is that it’s always busy. How can we ensure good-quality teaching, enabling colleagues in training to gain the abilities to become consultants themselves?
One of the consultants when I was a registrar was one of the first in AIM to try and improve teaching in the heady chaos of the AMU. She introduced me to the principle of the ‘reverse’ ward round, and as a consultant, I have continued to teach in this way.
Simply put, reverse ward round involve the registrar (or any grade of doctor, but I suggest it may be quite daunting for a less-experienced trainee!) taking the role of the consultant. She or he runs the ward rounds, listens to the presenting clerkings, discusses with and examines the patient, and proceeds to make a plan. The consultant can take a different role - scribe, jobs or just observing. It is important (and difficult) not to take over!
When you think about it, a consultant is like the conductor of the orchestra. A good registrar can manage a ‘sick’ patient as well, if not better, than a consultant. The registrar is the first violin - used to carrying the tune and ensuring that everything else is happening - but the conductor brings everyone together; keeping the players in time and in tune, and reaching the endpoint together. It is the element of the ‘bigger picture’ rather than the actual management of the symptoms that is the most difficult part of being a consultant, and it is not something that traditional teaching methods help improve.
There are many advantages - and some disadvantages - to the reverse ward round model.
From a positive point of view, it allows the registrar to start to learn more about the patient as a whole, aiding decision-making around capacity, resuscitation, bad news and chronic disease management. It is clearly important that the observing consultant does not interfere (obviously patient safety trumps this) as otherwise, any intervention from the consultant can leave the patient feeling less satisfied with the consultation. There must be a debrief, where different approaches can be discussed away from the clinical area. It also allows the registrar a safe place to start to develop their own ‘consultant’ style. From the observing consultant’s point of view, it is a great opportunity for learning (or refreshing) information and allows us to keep up to date (one of my registrars recently taught me about safe Apixaban use in older patients, for example). It also allows you to get to grips with the detail of work that your training doctors get up to every day - prescribing on EPR, locating ECGs, phoning referrals. This is a great way to build up teams - it is only by truly understanding others’ roles that we can work together efficiently. It is also useful for the other doctors present - presenting to the registrar may result in different feedback, and also the clerking doctor may be more likely to ask questions and generate discussion.
There are a few disadvantages, which I think are easily overcome.
Firstly, there must be a clear explanation to the patient as to what is happening, to avoid misunderstanding, and they have to be happy with this (I have never had a patient refuse). Secondly - it can be time consuming! Remember as an FY1 (or PRHO) when a clerking took hours? Learning to cover all elements of a post-take ward round in 15 minutes or less is a difficult skill, not always appreciated by our less experienced colleagues. Time constraints can be eased by doing a reverse ward round for a few patients - in our hospital, the bays are split into 4 beds, and 2 bays may be sufficient until the registrar becomes more confident.
Lastly don’t forget the debrief. Remember that everyone has their own style - and different to you isn’t necessarily bad. Discuss where different approaches could be used, which cases went particularly well (and why) and what changes could be made. Allow for self-reflection and consider the need for ‘homework’ - 5 minutes looking at the mental capacity act guidelines or DVLA recommendations for example.
What has this got to do with teams? It now seems that we function in pseudo-teams - like ships passing in the night (quite literally). It’s harder to have trust in a team you don’t know well - doing reverse ward rounds helps a team bond on a more horizontal level. Losing the hierarchical structures of old is, in my opinion no bad thing for teamwork. We need to make the most of what we have left.