PERSONAL VIEW
The great unwashed nobodies, we ordinary
consultants and general practitioners,
need to question, challenge, and refuse to
cooperate Des Spence, p 37
Restore the prominence of the medical ward round
We should value it as much as patients do, writes Anthony Cohn, and resource it properly in terms of consultants’ time
P
icture the scene: cardiac theatres are
busy with patients listed for surgery. The
sternotomy is performed beautifully, the
patient is put on bypass, and veins are
deftly removed from the patient’s leg.
Being pressed for time, the surgeon realises that
she needs to prioritise, so only bypasses one of the
three occluded vessels. This takes a little longer
than expected so there is no time left to close the
sternal incision. The surgeon is neither quick nor
slow, but this is the only way that she can manage
the expectation of performing six such procedures
a day.
It sounds ludicrous and outrageous. Surely this
would never happen? Imagine the fallout for any
hospital that ran its surgical department this way.
Although for a surgeon surgery means operating, for a physician it means spending time with
the awake patients, understanding their problems,
and helping to provide possible solutions. In a hospital setting this is either in the clinic or during a
ward round, and we should take as much pride in
our bedside work as surgeons do in their operative skills.
From personal experience in several different
hospitals and speaking to colleagues in others, I
am surprised at how little priority is given to ward
rounds. While most hospitals have introduced
on-call physicians in some guise or other, all too
often their remit is unclear. Although some work
suggests that a safe but basic ward round could be
achieved dedicating about 12 minutes per patient,1
recent guidelines suggest that each patient should pital that admits 20 new patients daily should allobe allocated 15 to 20 minutes.2
cate five hours of consultant time to those patients
If this is so, why are patients not receiving this? alone, with added time for patients already admitIn many places the post-take round, though it hap- ted. Ideally this should happen seven days a week.
pens, is limited in time. Experience and anecdote As acute care becomes concentrated in larger but
indicate that it is typical that 20 or more patients fewer hospitals, having only one consultant doing
need to be seen in two hours—five minutes per the ward round is likely to be inadequate.
patient on average, assuming all notes, radioThis may require rethinking consultants’ job
graphs, and results are immediately to hand. This plans: I suspect that many of us have fallen into
compares poorly with the often quoted figure of the the trap of allowing necessity rather than desirabilseven minute consultation in general
ity to set our standards, allowing our
practice, which itself is generally con- What we think
expectations to fall even if those of our
of as a ward
sidered too brief.3‑5
patients have not. So what we think of
This must mean that corners are cut round, patients as a ward round, patients think of as
and standards of care fall. An effective think of as a
a “rush round.” Although some of our
daily ward round would help doctors “rush round”
skills may have improved—for examto focus on patients’ experience, limit
ple, our history taking and examinaunnecessary investigations and treatments, expe- tion—it is likely that others (often those most
dite discharge, and increase patients’ satisfaction. valued by patients, such as empathy and compasThe ward round should return to being the focus sion) will have been allowed to atrophy—and we
of hospital life rather than an inconvenience that may need to work to regain them.
disturbs the routine running of the ward and interOther changes may be needed to restore the
feres with doctors’ other commitments. In the same ward round to its rightful place—for example,
way that theatres should be equipped to maximise the composition of the ward round team; changsurgical efficiency, hospitals should be managed to ing the ward routine; considering how and when
increase ward round efficiency.
tasks generated by the round are implemented;
In an environment where everything is counted, accepting the round as sacrosanct; and disturbing
hospitals know approximately how many medical its participants only in cases of severe emergency.
patients are on their wards on a daily basis. It is
No hospital and no surgeon would tolerate a
therefore easy to calculate how much consultant reduction in quality in response to increasing
time would be required to deliver good quality demand. In the scenario I outlined above the surward rounds to these patients. For example, a hos- geon would be disciplined and the hospital pilloried. The medical ward round is the equivalent
of the surgical procedure and needs to be valued
and nurtured as such. The calls for strengthening
ward rounds have focused on perceived medical
shortcomings.2 But our biggest shortcoming is failing to protect our most precious and powerful tool,
which is spending quality time with our patients.
Individuals and institutions have to value this as
much as our patients do.
Anthony Cohn is consultant paediatrician, Department
of Paediatrics, Watford General Hospital, Watford,
Hertfordshire WD18 0HB, UK
[email protected]
Competing interests:None declared.
Provenance and peer review: Not commissioned; not
externally peer reviewed.
References are in the version on bmj.com.
Ward rounds: just as important now for coordinating hospital patients’ care as it ever was
24
Cite this as: BMJ 2013;347:f6451
BMJ | 23 NOVEMBER 2013 | VOLUME 347
LAST WORDS
FROM THE FRONTLINE Des Spence
Big pharma and big medicine in big trouble
Peter Gøtzsche, chief of the Nordic
Cochrane Center in Copenhagen, is
a tough guy, happy to push over the
apple cart of perceived wisdom right
in front of the vendors, wearing an
expression that seems to cry out,
“Come and get me if you think you’re
hard enough.” Like a Nordic police
investigator, in his new book Deadly
Medicines and Organised Crime: How
Big Pharma Has Corrupted Healthcare
he systematically sets out the case
against the drug industry.
It’s a classic courtroom drama, with
lies and corruption on a truly global
scale. The drug industry slits the throat
of health and watches on as society
bleeds. I want to slam down my hand,
shouting, “I rest my case, your honour,” clap the drug industry in irons,
and send it down. But the industry is
let off, gives the finger, and strolls off to
a waiting limo. It is acquitted because
it hasn’t broken the law. So the counterfeit research printing presses will
The drug industry
and big medicine
have mutual
financial conflicts
of interest in
making us sick
Twitter
̻̻Follow Des Spence on
Twitter @des_spence1
bmj.com/blogs
̻̻Former BMJ editor Richard
Smith reflects on Peter
Gøtzsche’s new book at
http://bit.ly/15MZohJ
keep rolling, representatives will keep
on selling pills, money will keep on
sloshing, and champagne corks will
keep on popping.
The medicine industry should be in
the dock too. Why have we allowed the
medicalisation of normality and the
march of overdiagnosis and overtreatment? Of course the drug industry and
big medicine have mutual financial conflicts of interest in making us sick. But
there is another problem. We have followed guidelines and done as we were
told even when we knew we shouldn’t
have trusted our presumed and so
called betters. Our professional deference conditions us to accept hierarchy.
Deference is about obedience, conformity, and demanding respect. But
deference is unintelligent, complacent,
conceited, and a poison to free thought
and innovation. The weapons of deference are titles, awards, gongs, white
coats, pinstriped suits, the arts, the
thesaurus, schooling, qualifications,
prestigious institutions, publications,
accent, manners, and mannerisms.
We have an untouchable and detached
international elite of networking medical so called “experts” and unethical
corporations. Deference means the
voices of the many are drowned out by
the voices of these few. Deference is the
authoritarian instrument of intellectual
oppression and stops us asking why.
But status and position should
not matter. The great unwashed
nobodies, we ordinary consultants
and general practitioners, need to
question, challenge, and refuse to
cooperate. Tear down the orthodoxy,
and deliver suffrage: a professional
intellectual democracy. We don’t have
any betters. All our opinions count.
Respect certainly; deference certainly
not. The case against deference is open
and shut.
Des Spence is a general practitioner, Glasgow
[email protected]
Cite this as: BMJ 2013;347:f6900
STARTING OUT Kinesh Patel
Sir David who?
“Have you met our senior manager?”
The question was put to the veteran
consultant, as an entourage of
important looking people swept
through the department. “He’s been
here for years.”
A polite handshake and the
customary pleasantries ensued, and
both parties asserted how lovely
it was to meet each other. I melted
obsequiously into the background a
couple of metres away, knowing my
place as a junior doctor. A minute
later and the encounter was over.
“I’ve never heard of him,” said
the consultant turning to me, with
a slightly puzzled look. “I’ve been
here a long time but no one’s ever
mentioned him to me.”
It’s a story all too familiar in the
NHS: managing is a dirty business best
done at arm’s length. There is no need
to get too near the grunts on the front
line. What proportion of staff working
in the NHS know the name of their
BMJ | 23 NOVEMBER 2013 | VOLUME 347
trust’s own chief executive or that of Sir
David Nicholson, boss of the £100bn
NHS in England? I’d bet most don’t.
Compare that with household names
such as Bill Gates, Willie Walsh, chief
executive of British Airways, or the
notorious Michael O’Leary, head
of Ryanair.
But why does any of this matter?
Shouldn’t we just go to work, do
our jobs, and go back home again,
suitably fatigued?
The NHS is going through difficult
times, and the changes tearing through
it are going to get more painful.
Without having at our fingertips at
least the names of those in command,
who are steering the organisations for
which we work, how can we expect
to understand the rationale behind
difficult decisions—let alone play a part
in shaping that change? Of course, this
is a two way street. Managers have a
duty to know who their staff are and to
use them to generate ideas for change.
It’s a story all too
familiar in the NHS:
managing is a dirty
business best done
at arm’s length
The reality is, however, that­—largely
through apathy—we prefer to live in
anonymity. Weakly, we rely on our
professional organisations to represent
our thoughts and then complain when
the views they espouse seem detached
from our own experiences.
The irony is that today technology
has enabled us to feel more connected
to people thousands of miles
away than the leaders of our own
institutions. The usual annual staff
conference “to meet the management
team” just won’t cut it these days: it’s
time for a more dynamic interaction.
British Airways, for example, has
350 000 people interested in what
it has to say each day on Twitter;
NHS England has fewer than 17 000.
Surely the world’s favourite health
service can do better?
Kinesh Patel is a junior doctor, London
[email protected]
Competing interests: see version on bmj.com..
Cite this as: BMJ 2013;347:f6899
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