Literature Review
"To have a group of cloistered clinicians away completely from the broad current of professional life would be bad for teacher and worse for student. The primary work of a professor of medicine in a medical school is in the wards, teaching his pupils how to deal with patients and their diseases."
Sir William Osler |
|---|
As we spread the philosophy behind family-centered rounds to more physicians at Cincinnati Children's Hospital Medical Center and other hospitals, physicians express five common concerns:
- Patient and family comfort
- Learner comfort
- Attending physician comfort
- Efficiency
- Teaching effectiveness
What the Literature Says
Research has shown that patients and families like bedside rounds. Data was collected to measure patients' and families' response to being included in rounds using satisfaction surveys, anxiety scales, clinical indicators, structured interviews and focus groups. With each research method, the result has been the same: parents want to know what is going on and have a voice in their child's care.
John Romano's observation that he included in "Patients' Attitudes and Behavior in Ward Teaching Rounds," published in 1941, are still relevant:
- Presence of nurse is reassuring
- Social history and physical exam require special care
- Most patients prefer to hear discussion
- Most patients don't understood medical jargon
- Brief explanations before and after rounds
- Rounds educate and reassure
Although patients and their families generally like to be included on rounds, there are things that can be done to improve their experience, such as:
- Change presentations - less jargon
- Provide opportunity to participate
- All physicians should be introduced
- Fewer physicians in room
- Physicians should be attentive
- Respect privacy more
- Ask permission to present at bedside
- Seated during presentation
For physicians conducting rounds at teaching hospitals, there is often the concern that learners will be uneasy about doing family-centered rounds. It is true that medical students, residents and other learners are uncomfortable about presenting at the bedside at first. However, with experience comes increased comfort. And learners who present frequently are more likely to prefer to do it in the future.
Conducting rounds at the bedside brings with it a certain amount of vulnerability for the attending physician. Learners and families might present issues or ask questions to which he or she doesn't know the answer. Conducting rounds outside of a classroom environment means a loss of control for the attending.
Studies have found that physicians who have been in the role of an attending for less than ten years prefer the conference room (57%) over people who have been an attending for more than ten years (18%). This illustrates that with time comes increased comfort and confidence in conducting rounds in front of families.
Rounds play an important role in patient care at hospitals. It is a time for information to change hands between caregivers and an opportunity for experienced physicians to teach students and residents. If rounds are done with patient and family present, it's also a time to answer their questions, which can mean more time added on.
In 1997 Lisa S. Lehmann, MD, published "The Effect of Bedside Case Presentations on Patients' Perceptions of Their Medical Care," in which she examined the length of rounds at the bedside versus in a conference room. She found that conducting rounds at the bedside did increase time spent with the patient from six minutes to ten. Multiplied by the number of patients seen during rounds each morning, this can add up. So why do it?
Our experience here at Cincinnati Children's has been that although more time is spent during rounds, there is much less time spent following up, carrying out orders and delivering information to families and staff. Because everyone hears the information at the same time, the plan of care can be executed much more quickly and efficiently. By investing time during rounds, time is saved later.
There has not been much research done on the effect of bedside rounds on teaching. Early studies indicate that moving rounds into the patient room shifts the focus from direct teaching to addressing things like the physical diagnosis and bedside manner.
Our Findings
Ultimately, family-centered rounds challenges us to move beyond our comfort zone and approach uncertainty at the bedside. Patients like bedside rounds but want doctors to use understandable language and allow them to participate. Learners don't like bedside presentations, but they become comfortable with experience with practice.
Bibliography
The information in this literature review on family-centered rounds referenced data from the following sources:
Kroenke K, Omori DM. Bedside Teaching. South Med J. 1997; 90:1069-1075.
Miller M, Johnson B, Greene HL, Baier M, Nowlin S. An observational study of attending rounds. J Gen Intern Med. 1992; 7:646-648.
Kroenke K, Simmons JO, Copley JB, Smith C. Attending rounds: a survey of physician attitudes. J Gen Intern Med. 1990; 5: 229-233.
Linfors EW, Neelon FA. The case for bedside rounds. N Engl J Med. 1980; 21:1230-1233.
Simons RJ. The physiologic and psychological effects of the bedside presentation. N Engl J Med. 1989; 321:1273-1275.
Wang-Cheng RM, Barnas GP, Sigmann P, Riendl PA, Young JM. Bedside case presentation: why patients like them but learners don't. J Gen Intern Med. 1989; 321:1273-1275.
Lehmann LS, Brancati GL, Chen MC, Roter D, Dobs AS. The effect of bedside case presentation on patients' perceptions of their medical care. N Engl J Med. 1997; 336:1150-1155.
Nair BR, Coughlan JL, Hensley MJ. Student and patient perspectives on bedside teaching. Medical Education 1997; 31:341-346.
Anderson RJ, Cyran E, Schilling L, Lin C-T, Albertson G, Ware L, Steiner JF. Outpatient case presentations in the conference room versus examination room: Results from two randomized controlled trials. Am J Med. 2002; 113:657-662.
Rogers HD, Carline JD, Paauw DS. Examination room presentations in general internal medicine clinic: Patients' and students' perceptions. Acad Med. 2003; 7:945-949.
Payson HE, Barchas JD. A time study of medical teaching rounds. N Engl J Med. 1965;273:1468-1471.
Orsetti KE, Willaims BC. "In-room" presentaion in the ambulatory setting. J Gen Intern Med. 1998;13 (Suppl):90.
Using Patient-Centered Care Principles to Improve Discharge Timeliness. Pediatric Academic Societies' Meeting Platform Presentation, San Francisco, CA., May 1-4, 2004. Pediatric Research 55:4; 2004.
Brinkman WB, Simmons J, Vossmeyer M, Muething S. "Family-Centered Rounds: Overcoming Barriers To Get Back to the Bedside." Educational Workshop at Pediatric Academic Societies Annual Meeting. San Francisco, CA, May, 2006.
Smith, A. G., Bromberg, M. B., Singleton, J. R., & Forshew, D. A. (1999). The use of "clinic room" presentation as an educational tool in the ambulatory care setting. Neurology, 52(2), 317-320.
