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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
The ward round
Suggestions for improvement
Although the ward round was the culmination 
of every day, it was also the greatest
Thomas Bernhard
Moreover, there is no reasonable conversation
with patients on hospital wards; the chart
is allimportant.
Viktor von Weizsäcker, 1949
When the consultant came round this morning
with his assistants and attendants, he said
something that I did not understand to the
ward doctor.
Unknown patient, Damascus, 13th century
The ward round
The hospital ward round is the only regular chance for conversation between the inpatient and the doctor. Most patients have the greatest expectations before the round but many look back on it with great disappointment. Bliesener and Köhle (1986) neatly refer to the traditional ward round as a "handicapped dialogue".

The classical ward round takes place within a climate of conflicting interests, which are usually solved at the expense of the patient (Fehlenberg), as there are major differences between the team requirements and patient needs, that should theoretically be solved satisfactorily by the contact.

Westphale and Köhle analyzed the range of subjects raised by the doctors and by the patients during a general medical round, and contrasted them (see tables). Listing one against the other reveals that for the doctor, the major part of the round consists of concern for diagnosis, whereas the subjects that the patient broaches indicate his concerns about the effect of the illness.

During the round, the needs of the patient include those of information, of verbalization of emotional experiences, anxieties, general questions and the immediate aspects of how the disease will be treated. In addition, the ward round is also expected to meet the needs of the patient for contact.

The needs of the team however are concerned with a totally different area; checking diagnoses and results of therapy, consultation between the doctors, arranging the timing of investigations and treatment, as well as giving advice.

 Subjects raised by the patient (average)
Subject Absolute %


Diagnosis 1,33  21,6
Results of investigations 0,89  14,4
Results of examinations 0,73  11,8
Behaviour to the disease 0,71  11,5
Experience of the disease 0,51    8,3
Other 0,50    8,1
Psychological findings 0,19    2,4
Total 6,17 100,0
 Subjects raised by the patient (average)
Subject Absolute %

Experience of the disease

Diagnosis 0,54  18,3
Behaviour to the disease 0,48  16,3
Treatment 0,47  15,9
Results of examinations 0,32  10,9
Results of investigations 0,23    7,8
Other 0,13    4,4
Psychological findings 0,05    1,7
Total 2,95 100,1
Studies have shown that 90% of patients in acute hospital beds have a much greater need for information about their disease, which they do not consider satisfactorily met (Raspe, 1979).

This does not mean that the patient becomes more active in asking questions, even though his need for information is great. The opposite is true; the very patients in whom a high desire for information can be confirmed, do little or nothing which would provide the required information in the course of the contact with the doctor. There are various reasons for this (Raspe, 1980, Quasthoff, Hartmann, 1982):

Psychological reasons: conversation with the doctor is experienced as a stress situation, which inhibits the patient's free expression.
Cognitive reasons: the patient has not got the capacity to think through the information he is given during the course of the conversation. He is only able to put together certain questions and think through other options when the round is over; he then tries to work these out from inappropriate sources (other patients, relatives etc).
Organizational reasons: the patient is aware of the time pressure on the doctor, and does not have enough courage to enlighten himself by asking apparently unimportant questions.
Reasons dependent on the role that the doctor takes on: behaviour patterns implying absolute authority (with the inevitable strong directive role) inhibit the self-initiative of the patient. Kaupen-Haas have shown that 43% of all doctors presume that an authoritative role is appropriate.
Medical reasons: the patient may be so ill that he is no longer able to take part in a dialogue.
It is probably true that the major problem in every form of communication (the difficulty of finding a common reality) plays a particular role during the ward round.

Research into what really happens during the ward round goes back to 1970, when Siegrist found that, on average, the surgeon had one minute per day available for each patient. This severe time limitation imposes unusual pressure on the patient: he must be able to pose short and precise questions whilst receiving advice and information, often in an atmosphere of anxiety, expectation or stress. This often means that, although the patient is loaded with urgent questions, he cannot formulate them during the ward round. Siegrist: "I often found that patients who were able to tell me about their concerns and queries, were not able to bring them out in the course of the ward round ... I was particularly aware of the marked disciplinary nature of the ward round."

It was found (Jährig and Koch) that on average 3.5 minutes per visit were spent with a patient in a large Hamburg hospital. The doctor spoke for 2 minutes with only a third of this time directed at the patient (patient-oriented conversation time). The patient spoke half as much as the doctor. Whilst the doctor asked an average of six questions at each visit, the patient asked one.

Quantitative analysis of the doctor-patient conversation during the round revealed the marked asymmetry of this form of interaction. Nordmeyer showed that during the average 3.5 minute visit, compared to the patient, the doctor spoke more (63% of the time), asked more often (82%) and interrupted more frequently (87%).


Direction of the discussion of the consultant in a traditional ward compared to the psychosomatic ward, University of Ulm (Westphale and Köhle, 1982)

Raspe (1983) showed the majority of the doctor's questions were closed (10 closed to 1 open). Open questions were more likely to arise in conversation with private patients.

Engelhardt and his colleagues were especially critical (1973) of the large ward round. They wrote: "We believe that ward rounds of professors and consultants can have a particularly damaging effect if the doctors do not consider the effect of the way they act or their discussions at the bed-side of the patient. Even the description of the patient by the junior doctor does not mention the patient's symptoms in language that the patient would be able to understand but uses technical diagnostic jargon. There then follows a list of findings and their importance for the diagnosis. All of the discussion is carried out in an incomprehensible language. The patient lies quietly there in the bed, full of awe and more or less tense, and tries to catch something. Very often he understands none of it, but it is even worse if he misunderstands. He finds it particularly difficult and threatening if different opinions are expressed (perhaps heatedly)... The patient is left at the end of such a round, in which he has only been a bystander, not knowing whom he can trust."

From the point of view of the patient, the ward round should be the best chance to obtain information from his doctor, as well as to articulate his experiences, interests and desires. This is in contradiction to reality, as in fact the ward round usually rolls on without a contribution from the patient. This is based on the premise that if a dialogue is to take place, one of the two persons involved must be sure that it will take on certain quality. Nothdurft (as quoted by Köhle and Raspe) says: "The discussion must be perceivable. It must be transparent, which means that the thread of the discussion must be recognizable. Finally the direction must be so clearly defined that it is possible to extrapolate from it."

Perceivability, transparency, comprehensibility and clarity are however rarely the qualities found in ward round discussions. The patient, for example, cannot follow if the doctors suddenly start talking quietly to one another. The patient experiences this as obvious secrecy. There is a similar effect when the doctors discuss another patient. The conversation is often incomprehensible to the patient, as his background knowledge and understanding is far less than the others taking part in the round. Hospital personnel tend to take their previous experience so much for granted that some are simply unable to use words that the patient can understand. For the patient, an outsider, such conversation will be partly or totally incomprehensible. Finally the ward round conversation is not illuminating, as from his point of view, little is to be learnt from it. It is certainly true that patients rarely if ever rebel against the widespread ward round practices. This means that a certain vicious circle is set up, in which "the lack of transparency thus produces an apathy in the patient which in itself is a precondition of its effect" (Nothdurft).

Why is it that patients so rarely try to defy the course of the ward round, which, for them, is so unsatisfactory? There are various reasons for this. The rules which apply to normal conversation cannot be applied to the ward round interviews. The inhibitory influences of the traditional role behaviors are added and intensified by the asymmetry of the conversation per se. The ward round is for "specialists" who confront the "incompetent" patient with highly competent manners of speech.

Most of all, the patient is anxious about the negative effects of his medical or nursing care that might result if he defied the rules of this deeply entrenched and widely accepted ritual conversation.

The feeling of being "put down", which many patients are left with after the ward round, means that their initiative is consciously or unconsciously constricted or extinguished. As a result, marked asymmetry develops, which is to the detriment of the patient. Siegrist (1978) analyzed the typical reactions of a doctor to a patient's question:

1. Not to notice: the doctor ignored the patient's question.
2. Change of recipient: instead of giving an answer, the doctor speaks to another person taking part in the ward round.
3. Change of subject: the doctor develops a contending theme and introduces a new subject.
4. Evasion: the doctor rephrases the patient's question and moves his response to a side issue.
5. Uncertainty: he is not able to answer at that particular moment because not enough information is available.
6. Symmetry: the doctor clearly demonstrates that he is answering the patient's question to the best of his ability.

It is clear that the first four ways of answering will inevitably lead to an asymmetrical conversation.

Bliesener has described 12 strategies for putting down patient initiative: block, override, put off, trivialize, dismiss, appease, complicate, break off, shelve, filibuster, feign deafness, brush off. Bliesener and Siegrist (1981) have systematically examined which methods modern doctors and nursing staff use in order to prevent the patient initiating and carrying on a conversation according to his wishes and conditions. In these "inhibitory routines":

Personnel create the impression of being very busy.
Personnel do not speak to the patient.
Conversation between personnel is carried out in such as way that the patient cannot understand, and he is only involved if additional information is required.
Personnel speak softly, interrupt each other and use insinuations, abbreviations and specialized terminology or deal too quickly with the subject.
The subject under discussion is far removed from the subject that the patient would like to discuss.
Although nursing personnel involve the patient in conversation, this takes place as a battery of questions whilst his attention is distracted by the investigations that are being carried out at the same time (auscultation, pulse rate measurement etc).

The patient usually indirectly gleans information pertaining to the illness from the conversation of the team. This however leaves the door wide open for misunderstandings. Paradoxically, the worse the patient is, the more he is left to this sort of indirect route. Fehlenberg and his colleagues found that doctors evaded 36% of all questions of mildly ill patients but up to 92% in seriously ill patients.

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Suggestions for improvement
Analysis of the communication difficulties during the ward round makes the solutions obvious: the ward round should be centered around the patient (Westphale and Köhle, 1982, Fehlenberg, Simons and Köhle). This relieves the patient of the role of a more or less disturbing dummy and brings him into the focal point of the ward round. Not only does he receive the desired information, but his interests in communication are actively considered.

The ward round should be set up to allow dialogue. This is because this conflict- and person-orientated approach has moved away from the "monologue" into a "dialoguing" medicine (Balint). The ward round should fulfill both patient and team requirements equally. As well as taking into account the patient's need to understand the nature of his disease, in addition there is the need for communication for the patient, related to the emotional experience of the patient faced with disease and hospitalization. Sufficient time should be available at least for the initiation of genuine dialogue.

The discussion should be symmetrical. This means that the involvement of both doctor and patient should not differ quantitatively or qualitatively. The doctor should evade less questions, especially those of very ill or troubled patients. Symmetry also means that the doctor discusses the main implications of a question. The patient himself should be encouraged to pose more questions. Unasked questions should be recognized by active listening.

Patient information should be improved both in extent and quality. This aims for a greater proportion of "reactive information"; this means that more information should be provided than that either requested or suggested by the patient. "Implicit information" that the patient obtains by chance from personnel, or from conversations that he overhears, should be minimized.

Avoidance techniques should be avoided as far as possible, especially those of employing dismissing, putting off, deflecting, shelving and swamping the patient with information.

Fehlenberg et al. suggested that communications problems during the ward round arising due to the varying requirements of the patient and the team could be reduced by a functional dissection. One part of the round should be orientated to the patients, and take place at his bedside. The other (organizational and team-orientated), should take place elsewhere. This can be supplemented by daily discussions or ward-rounds. The doctor responsible for the ward should be prepared to sit at the patient's bed-side, whilst the other members of the round should maintain a respectful distance and follow the conversation, and usually need not be involved in it. If these guide-lines were to be followed, it is very likely that the ward round could create "a possibility to converse" rather than a "handicapped dialogue".

Guide-lines for ward round discussions
1. The round must be patient-orientated 
2. Conversation should be a dialogue
3. The needs of patient and team are equal, and should both be taken into account
4. The communication needs of the patient must be taken into account
5. Discussions should be symmetrical
6. The patient must be encouraged to pose questions
7. Avoid the need for implicit information
8. No avoidance techniques (putting off, dismissal, ignoring etc)
9. Separation of the patient-orientated from the organizational/team-orientated part of the round
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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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