|Although the ward round was the
|of every day, it was
also the greatest
|Moreover, there is no reasonable
|with patients on hospital
wards; the chart
Viktor von Weizsäcker,
The ward round
The hospital ward round is the
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".
|When the consultant came round
|with his assistants
and attendants, he said
|something that I did not understand
Unknown patient, Damascus,
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)
to the disease
of the disease
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,
Subjects raised by
the patient (average)
Experience of the disease
to the disease
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,
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.
reasons: conversation with the doctor is experienced as a stress situation,
which inhibits the patient's free expression.
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).
reasons: the patient is aware of the time pressure on the doctor, and
does not have enough courage to enlighten himself by asking apparently
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.
the patient may be so ill that he is no longer able to take part in a dialogue.
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."
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:
to notice: the doctor ignored the patient's question.
recipient: instead of giving an answer, the doctor speaks to another
person taking part in the ward round.
subject: the doctor develops a contending theme and introduces a new
the doctor rephrases the patient's question and moves his response to a
he is not able to answer at that particular moment because not enough information
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":
create the impression of being very busy.
not speak to the patient.
between personnel is carried out in such as way that the patient cannot
understand, and he is only involved if additional information is required.
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
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
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.
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
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.
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 must be patient-orientated
should be a dialogue
of patient and team are equal, and should both be taken into account
needs of the patient must be taken into account
must be encouraged to pose questions
the need for implicit information
techniques (putting off, dismissal, ignoring etc)
of the patient-orientated from the organizational/team-orientated
part of the round
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
of this page: http://www.linus-geisler.de/dp/dp22_ward.html