LETTER TO THE EDITOR
Using Junior Doctor–Led Ward Rounds to Enhance Surgical Education Postgraduate medical training has evolved over the last decade, especially with the introduction of the European Working Time Directive.1 The recommended weekly working hours for doctors across Europe have been reduced to 48 hours, affecting the amount of time they spend in hospital looking after patients. Although there is a debate as to how much time juniors actually spend in hospital, it is generally accepted that this is much less than before the directive was actioned.2 Shift work is now a commonality whereby doctors are handed over patients who they may not have seen the day before but have to continue to care for them. Valuable learning opportunities are lost in terms of learning about the natural progression of a disease and maintaining continuity of care.3 This change has led to increased efforts to improve the quality of education for doctors in training. One area of interest is with regard to ward rounds as they are unique in their ability to convey the complexity of patient care, professionalism, and clinical reasoning.4 In the Foundation Programme in the United Kingdom, some doctors are exposed to the management of surgical patients for the first time. These patients may require thorough assessment for postoperative surgical complications and other parameters, such as nutritional status, stoma health, fluid balance, and wound healing. Juniors are expected to look after these preoperative and postoperative patients with minimal senior input. While on ward rounds with a Consultant or Registrar, it is easy to avoid active decision making and “blindly” follow instructions. This is not the case when Foundation doctors are reviewing patients before reporting to their seniors. Importantly, there is no way to ensure that the right steps are taken to expedite patient recovery in the latter or make this a worthwhile educational experience. One method that we have used to enhance the experience of junior doctors rotating through surgical rotations is the “junior-led ward round.” After 2 weeks of beginning their general surgical attachment, junior doctors are made to perform the ward round in front of their senior colleagues. After the junior doctor interacts with a patient, the Registrar or Consultant can supplement information that the junior doctor might have missed or conveyed incorrectly. In this way, important decisions about changing the feeding requirements of patients or discharge planning can be made in a safe environment and any queries can be answered immediately by the senior staff. This not only increases the 164
confidence and educational experience of the junior doctors in managing surgical patients when their seniors may be out of reach but also reassures the latter that their patients are obtaining optimal care. There is evidence supporting “junior-led ward rounds,” which makes it an appealing proposition for training all doctors. One publication showed the real-time assessment and feedback on medical posttake ward rounds improves clinical performance and that it can also be used as a continuing assessment tool for doctors.5 This active methodology of teaching juniors also improved knowledge acquisition of information regarding the conditions of patients.6 With the time constraints in very busy departments, it may not be possible to conduct entire junior-led wards rounds and it would be wiser to allow juniors to lead the ward round for 1 or 2 patients. However, the current state of affairs with reduced working times and training opportunities demands innovative methods of ensuring that our future Registrars and Consultants are well equipped to provide patients with highquality care. We believe that junior-led ward rounds are a step in this direction. Meher Lad, MBBS Darren K. Patten, MRCS University College London Hospital, NHS Foundation Trust, London, United Kingdom St. Mary's Hospital NHS Imperial Healthcare, London, United Kingdom E-mail address: [email protected]
REFERENCES 1. Doctors’ training and the European Working Time
Directive. Lancet. 2010;375(9732):2121. 2. Horwitz LI. Why have working hour restrictions appar-
ently not improved patient safety? Br Med J. 2011;342: d1200. 3. Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard
JD. Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review. Br Med J. 2011;342:d1580.
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.08.007
4. Bleakley A. Pre-registration house officers and ward-
6. Melo Prado H, Hannois Falbo G, Rodrigues Falbo A,
5. Caldwell R. Real-time assessment and feedback of junior
Natal Figueirôa J. Active learning on the ward: outcomes from comparative trial with traditional methods. Med Educ. 2011;45(3):273-279.
based learning: a “new apprenticeship” model. Med Educ. 2002;36:9-15.
doctors improves clinical performance. Clin Teach. 2006;3:185-188.
Journal of Surgical Education Volume 71/Number 2 March/April 2014
165
Using Junior Doctor–Led Ward Rounds to Enhance Surgical Education Postgraduate medical training has evolved over the last decade, especially with the introduction of the European Working Time Directive.1 The recommended weekly working hours for doctors across Europe have been reduced to 48 hours, affecting the amount of time they spend in hospital looking after patients. Although there is a debate as to how much time juniors actually spend in hospital, it is generally accepted that this is much less than before the directive was actioned.2 Shift work is now a commonality whereby doctors are handed over patients who they may not have seen the day before but have to continue to care for them. Valuable learning opportunities are lost in terms of learning about the natural progression of a disease and maintaining continuity of care.3 This change has led to increased efforts to improve the quality of education for doctors in training. One area of interest is with regard to ward rounds as they are unique in their ability to convey the complexity of patient care, professionalism, and clinical reasoning.4 In the Foundation Programme in the United Kingdom, some doctors are exposed to the management of surgical patients for the first time. These patients may require thorough assessment for postoperative surgical complications and other parameters, such as nutritional status, stoma health, fluid balance, and wound healing. Juniors are expected to look after these preoperative and postoperative patients with minimal senior input. While on ward rounds with a Consultant or Registrar, it is easy to avoid active decision making and “blindly” follow instructions. This is not the case when Foundation doctors are reviewing patients before reporting to their seniors. Importantly, there is no way to ensure that the right steps are taken to expedite patient recovery in the latter or make this a worthwhile educational experience. One method that we have used to enhance the experience of junior doctors rotating through surgical rotations is the “junior-led ward round.” After 2 weeks of beginning their general surgical attachment, junior doctors are made to perform the ward round in front of their senior colleagues. After the junior doctor interacts with a patient, the Registrar or Consultant can supplement information that the junior doctor might have missed or conveyed incorrectly. In this way, important decisions about changing the feeding requirements of patients or discharge planning can be made in a safe environment and any queries can be answered immediately by the senior staff. This not only increases the 164
confidence and educational experience of the junior doctors in managing surgical patients when their seniors may be out of reach but also reassures the latter that their patients are obtaining optimal care. There is evidence supporting “junior-led ward rounds,” which makes it an appealing proposition for training all doctors. One publication showed the real-time assessment and feedback on medical posttake ward rounds improves clinical performance and that it can also be used as a continuing assessment tool for doctors.5 This active methodology of teaching juniors also improved knowledge acquisition of information regarding the conditions of patients.6 With the time constraints in very busy departments, it may not be possible to conduct entire junior-led wards rounds and it would be wiser to allow juniors to lead the ward round for 1 or 2 patients. However, the current state of affairs with reduced working times and training opportunities demands innovative methods of ensuring that our future Registrars and Consultants are well equipped to provide patients with highquality care. We believe that junior-led ward rounds are a step in this direction. Meher Lad, MBBS Darren K. Patten, MRCS University College London Hospital, NHS Foundation Trust, London, United Kingdom St. Mary's Hospital NHS Imperial Healthcare, London, United Kingdom E-mail address: [email protected]
REFERENCES 1. Doctors’ training and the European Working Time
Directive. Lancet. 2010;375(9732):2121. 2. Horwitz LI. Why have working hour restrictions appar-
ently not improved patient safety? Br Med J. 2011;342: d1200. 3. Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard
JD. Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review. Br Med J. 2011;342:d1580.
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.08.007
4. Bleakley A. Pre-registration house officers and ward-
6. Melo Prado H, Hannois Falbo G, Rodrigues Falbo A,
5. Caldwell R. Real-time assessment and feedback of junior
Natal Figueirôa J. Active learning on the ward: outcomes from comparative trial with traditional methods. Med Educ. 2011;45(3):273-279.
based learning: a “new apprenticeship” model. Med Educ. 2002;36:9-15.
doctors improves clinical performance. Clin Teach. 2006;3:185-188.
Journal of Surgical Education Volume 71/Number 2 March/April 2014
165
