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. 2010 Feb;10(1):93–94. doi: 10.7861/clinmedicine.10-1-93a

The value of the post-take ward round

Andrew Medford 1
PMCID: PMC4954494  PMID: 20411612

Editor – Chaponda and colleagues recently highlighted the impact of shift working on patient care continuity and learning opportunities for acute medicine trainees (Clin Med August 2009 pp 323–6). One of the (perhaps) unexpected results they included in their table (but did not discuss), was the significant reduction in specialist registrar (SpR) diagnosis differences from the clerking diagnosis (from 35.8% in 2006 down to 24.3% in 2008, odds ratio 0.58 (0.40–0.83), p=0.002).

It would be interesting to know how this result is accounted for by the authors. Three possibilities come to mind. Firstly (the most favourable interpretation), an improvement in the diagnosis formulation skills of junior doctors in 2008; secondly (a less desirable scenario), a significant increase in actual SpR clerkings reflecting changes in working patterns between 2006 and 2008 and a shortfall of capacity in clerking junior doctors (ie below SpR grade); and thirdly (the least favourable scenario), a decrease in quality of the diagnosis formulation skills of SpRs in 2008 reflecting possibe changes due to working patterns.

The fact that there was no change in the difference between consultant diagnosis and SpR/junior doctor diagnoses in 2008 would not support the third or first scenarios and suggests no decrease (or improvement) in the diagnosis formulation skills of both junior doctors and SpRs over the time of the study. The reduction in SpR only reviews is, however, consistent with the second scenario of increased SPR clerkings. This may merit further analysis as, if confirmed, it will have implications for SpR training in the longer term. It is clearly important that SpRs have the opportunity to review a significant number of cases clerked by their junior colleagues as part of their own professional development and training.

Clinical Medicine. 2010 Feb;10(1):94.

The value of the post-take ward round

NJ Beeching 1, M Chaponda 1, DS Almond 1, M Taegtmeyer 1

We are pleased to respond to comments about our audit of educational aspects of post-take ward rounds (PTWR) in 2006 and 2008.

We voiced our concern that, in both audit years, the case notes of about half the patients contained no indication that results of investigations had been reviewed before the PTWR. Kendall et al (Clin Med December 2009 pp 544–8) commend the educational value of a structured consultant-led patient handover which might encourage the timely review of results, but this would still need to be recorded in the case notes. We suspect that the latter is most likely to occur during the PTWR.

In this issue, Medford noted the small drop in the proportion of diagnoses that were changed after specialist registrar (SpR) review of patient clerkings performed by more junior trainees, with no change in the number of diagnoses altered at consultant review (about 25% in each year). He wondered if the apparent reduction of changes in diagnoses made by SpRs was due to improving diagnostic skills of the junior trainees, or to a greater proportion of patients being clerked by SpRs. We found that, in 2008, 44.3% of patients were reviewed by both a consultant and an SpR, 45.4% by a consultant alone and 6.8% by an SpR alone, compared to 48.2%, 24.7% and 26.2% respectively in 2006. This does not directly answer the question, but suggests that there were fewer opportunities for SpRs either to review or to clerk patients themselves in 2008. We agree with Medford that the arrangement of medical on-call and PTWR should allow middle and senior grade trainees adequate opportunities to supervise more junior colleagues and to formulate their own diagnostic and management plans, followed by discussion with consultants. The challenge is to enable this to happen as near in time and place to the patient as possible during the patient admission process, so that the patient benefits from early senior review and trainees benefit from review of their diagnostic, therapeutic and management decisions.

Kendall et al state that ‘… this may require a paradigm shift in consultant working practices’. More simply, we need to rearrange work shifts and timings of PTWR in our trust so that trainees can attend more rounds at which patients they have just seen are discussed, and we are working on this and incorporating other suggestions such as those above.

Articles from Clinical Medicine are provided here courtesy of Royal College of Physicians

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