Hospital working rounds. Talbot page 1______
Some Determinants, on the Hospital Working Round, of Experiential Learning in Postgraduate Medical Education
Dr Martin Talbot
Research Associate
Summary of presentation at the 3rd International Conference
"Researching Vocational Education and Training"
July 14-16 1999, Bolton Institute
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Division of Adult Continuing Education.
University of Sheffield
Sheffield
S1 4ET
UK
Correspondence: Royal Hallamshire Hospital, Glossop Rd, Sheffield,
S10 2JF UK Tel: 0114 – 271 3553 Fax:0114 –271 3408
e mail:
Key Words
Experiential learning – postgraduate medical education – Flanders interaction technique
Abstract
Recent policy in postgraduate medical education (PGME) has favoured a diminution of the experiential dimension of learning through reduced patient-contact time. In this changing learning environment, I describe research into the utility of the hospital working round as an instrument of learning in PGME.
I have shown that there is much teaching/learning discourse occurring in the course of the working round. I may have demonstrated that 1) while this experience can be of varying quality, depending on the trainer and on the learner, much of it is of merit, 2) juniors rate the round highly for demonstrating ‘professional behaviour’, 3) a profile of the good ‘teacher’ can be produced, 4) more experienced trainees find the rounds more educationally useful than do the less experienced, and 5) those with aspirations in surgery seem to learn more of the ‘technical’ aspects of the job than colleagues with medical aspirations.
In conclusion, I suspect that the working hospital round offers a considerable educational opportunity, to be neglected at peril.
Introduction
In the United Kingdom, recent changes in the nature of the junior doctor’s working pattern have tended to favour less contact time with patients and a more formalised and structured training (NHS Executive, 1992; Calman, 1993. SCOPME, 1992, 1993,1994). These changes might be at the expense of the trainee’s experiential learning. In order to explore this change, it is firstly necessary closely to study different aspects of the junior doctor’s day-to-day working and in doing so develop and evaluate tools for such study. I have started to assess the situation more fully by observing hospital working rounds and by asking junior doctors how they see the situation.
The working hospital ward round
In the training of the junior doctor, the ward round will be less frequently solely for the purpose of teaching than in the undergraduate years. It will be a structured event at which the consultant visits patients with the junior doctors; diagnoses are confirmed, management plans formulated. The patient should have the opportunity to enquire about progress. The lay public is unaware that much of the work of a working hospital round will have been undertaken by the junior staff prior to the round: the patients are ‘presented’ to the consultant who then acts as a yardstick in terms of approving or disapproving of management thus far.
The working round has the potential, then, for experiential learning, although some have suggested that it may involve a kind of facilitated experiential learning[1]. It is a formal opportunity to review the patient’s progress in the light of management decisions made earlier in the course of the illness. In terms of professional development, the trainee (the junior doctor) can reflect upon past experience and update his/her knowledge-base in the light of current experience. It is an opportunity for the trainee to observe the practised professional at work - to see how communication is undertaken, to see how thought processes proceed. More than this, however, it is an opportunity for the ‘trained’ to ask appropriate questions of the trainee and, in a more directive way, suggest alternatives and plans of action, also to allow the trainee to ask questions and test hypotheses. I have been interested to ask under what conditions is this kind of learning optimised?
Method
1) Direct observation of rounds
I have asked what is the frequency of teaching/learning events occurring on rounds and have adapted for this use the technique first described and then modified by Flanders and others (Amidon & Hughes, 1983). It has not, as far as I am aware, been used in informal learning situations.
Eight rounds of four consultant colleagues were studied in a teaching hospital. The participants were instructed to ignore my presence. They were ignorant of the specific interactions under scrutiny. Those which were implicit of patient care and diagnosis (and therefore potential teaching/learning interactions) were counted. I adjudged interactions as teaching/learning exchanges in that they were concerning only those aspects of patient care which could have contributed to experiential learning: questions of a housekeeping nature were excluded from the analysis. Categories of interaction are seen in table1. Grunting or nodding were counted as affirmatory transactions.
2) The semi-structured interviews.
I interviewed six trainee doctors, from within my own hospital, to ascertain their views on the topic of working rounds. These were ‘depth’ interviews, with some issues covered in detail informing later questions modified in the light of initial replies (Cohen & Manion, 1994). The subject was led through each previous positions as a junior doctor and aspects of work were discovered making working rounds satisfactory or unsatisfactory learning experiences. The interviews were semi-structured, utilising the technique which Robson calls ‘explanation building’ (Robson, 1993)
The interviews were tape-recorded and the subjects all were assured of confidentiality and anonymity. I have described the case histories of each subject and attempted to ‘tease out’ some common themes and the subjects’ insights on how they might conduct rounds were they themselves to be in the position of leader.
3) The questionnaire
After first piloting the questionnaire I contacted all of the senior house officers (SHOs; less experienced trainees) and a third of the specialist registrars (SpRs; more experienced trainees) at all of the hospitals in the North Trent Area. The respondents were requested to score their responses to four questions on a modified Likert scale (see sample questionnaire attached). The pilot suggested the questions to be unambiguous.
Using the Mann-Whitney U test (Moore & McCabe, 1993), data concerning the educational utility of rounds were analysed for statistical significance against, firstly, whether the respondent was an SHO or an SpR and, secondly, the career aspiration of the respondent. The career aspirations were simplified into 1) General practice, 2) Surgical disciplines (including obstetrics & gynaecology, accident & emergency and paediatric surgery), and 3) Medical disciplines (including oncology and paediatric medicine).
Results
1)Direct observation of rounds
The diagram shows that there were many interactions in the exchange categories and the cumulative totals of learning transactions observed per round was impressive. Table 1 shows the different categories of behaviour observed, over two rounds for each consultant.
Table 1: Incidence of Individual Categories of
Learning Behaviour
Consultant / A / B / C / DAttacking/defending / 0 / 0 / 0 / 0
Disagreeing / 0 / 1 / 4 / 0
Negative evaluation / 0 / 4 / 0 / 5
Testing learning / 1 / 6 / 13 / 2
Giving explanation / 8 / 7 / 10 / 4
Summarising/integr* / 10 / 17 / 7 / 6
Seeking information / 11 / 33 / 32 / 17
Giving information / 21 / 29 / 16 / 11
Giving instruction / 29 / 25 / 27 / 20
Cueing behaviour / 37 / 39 / 27 / 6
Giving direction / 38 / 60 / 34 / 26
Positive evaluation / 52 / 36 / 47 / 34
2) The semi-structured interviews
Individual interviewees
There were six interviewees of differing ages and grade, with wide experience of working rounds. They all felt that the round was a learning opportunity, dependant on the nature of the consultant to whom they were attached. Some clear, common themes emerged which are described in the next section.
Common Themes
Common themes were seen to occur with the frequency seen in table 2.
Table 2 about here
A clear profile emerged of the qualities necessary in a good teacher who:
- is interested in what you have to say
- is interested in the junior as a person
- is the kind of person to whom , as a doctor, one would aspire
- encourages questions
- encourages the learner to find out
- does not seem hurried
- is approachable
- is exacting; always asks ‘why’
- takes time to explain
- is astute and practical
- interested in the patient
- is ‘fun’
- takes a pastoral role with the learner
The subjects were asked ‘What would you do to make your consultant rounds good learning experience’. Responses included
- ‘Pre-round discussion’
- ‘Ask questions’
- ‘Turn up on time’
- ‘Encourage team spirit’
- ‘Be passionate’
- ‘Get juniors to present cases’
- ‘Make rounds fun’
- ‘The minimum you would have to do is to explain why decisions are made.’
- ‘Have time to discuss the patients’
- ‘Make efforts to summarise and integrate’
2) The Questionnaire Survey
143 of five hundred questionnaires were returned (29.2%). 110 respondents were SHO grade, in their mid-to-late twenties (mean time since qualification as a doctor of 4.2 years). 33 registrars were of varied disciplines, in their late-twenties to mid-thirties (a mean time since qualification of 7.6 years). The cumulative years since qualifying for SHOs and registrars were 462 and 251, making a total of 713 aggregate person-years of hospital practice.
Diagrams 1 - 4 show the scores for questions 1 - 4. The learning of professional attitudes (Qs 1 & 2) scored more highly than the learning of disease process (Q3) or of the nuances of ‘the Patient’ (Q4).
Respondents with aspirations to a surgical career were statistically more likely to have learnt more about disease and ‘The Patient’ than were those aspiring to medical careers. Other differences were not statistically significant (Table 3). Specialist registrars scored higher significantly more often, suggesting that they may have held the rounds in higher educational esteem.
Table:3 aggregated questionnaire responses, comparing grade
of respondent and some career aspirations (as examples)
U = Mann-Whitney U value
Z = z value
Discussion
There was clearly much ‘teaching/learning’ commerce occurring within the working rounds observed. Questions to be addressed include 1) have I studied enough rounds, 2) Did my presence on the round affect its conduct, 3) was the questionnaire response-rate satisfactory, and 4) can this kind of study be used in a practical way?
With respect to the first two questions, inspection of the data sets shows a high degree of pattern congruence, suggesting that a similar pattern might have occurred with more rounds: additionally, inspection of the individual category scores shows that although consultants were aware that I was studying the round, two obvious and simplistic ploys which they might have utilised to impress me, testing learning and giving explanation, were relatively under-utilised compared with other instructional tools suggesting that my presence was not such an intrusion after all. However, it would have been useful to have had validation by another observer viewing rounds or videotapes of rounds.
Regarding the interviews and questionnaire studies, small numbers render the results only preliminary. Nevertheless, the size of the interview panel was sufficient for common themes to emerge, and the respondents between them had over 700 person-years of hospital experience. Given this extent of experience I feel that my figures do achieve an acceptable level of face validity and may be worthy of discussion.
I believe that the questionnaire supported my feeling that there is good learning occurring. The respondents scored the round highly on modelling of professional experience. There were less high scores on learning about aspects of disease and of ‘The Patient’ but not to a statistically significant level. Respondents with aspirations for a surgical career scored higher on learning technical aspects of the job compared to those with aspirations to medical disciplines. Specialist registrars rated the educational value of rounds more highly than SHOs; this is unexpected since the SpRs are more senior one would have thought that the novelty aspect of rounds would have been less marked.
References
Amidon EJ & Hughes JB (Eds) (1983) Interaction analysis: theory, research and application. Reading, Mass. Addison-Wesley.
Calman, KC. (1993) Hospital Doctors: Training for the Future (The Calman Report) Department of Health. Misc. (93) 31.
Cohen, L & Manion, L. (1994) Research Methods in Education. London. Routledge
Kolb D (1984) Experiential Learning. Englewood Cliffs, NJ. Prentice-Hall.
Moore, DS & McCabe, GP (1993) Introduction to the Practice of Statistics. New York. WH Freeman & Company.
NHS Management Executive. (1992) Terms & conditions of service for hospital medical & dental staff AL (MD) 1/92.
Robson, C. (1993) Real World Research. Oxford. Blackwell.
The Standing Committee on Postgraduate Medical Education. Reports. SCOPME
(1991) Improving the Experience: good practice in senior house officer training.
(1992) a. Formal Opportunities in Postgraduate Education for Hospital Doctors in Training.
b. Teaching Hospital Doctors & Dentists to Teach: its rôle in creating a better learning environment.
(1994) Making the Most of Formal Educational Opportunities for Doctors & Dentists in Training.
Table 2: Learning Themes
Themes /Number
Good learning experiences
‘More senior’ juniors good for teaching / 6Keen consultants / 6
Consultant not seeming in a rush / 6
Questions encouraged / 6
Consultant modelling professional competence / 6
The firm was ‘fun’ / 5
Pre-round discussion / 5
Juniors felt valued / 5
Multidisciplinary rounds / 4
Exacting consultant / 4
Rounds felt non-threatening / 2
Bad learning experiences
Disinterested consultant / 6Hurried rounds / 6
Surgical rounds / 5
Academic and irrelevant rounds / 4
Frightening consultant / 4
Consultant not interested enough to test your knowledge / 3
Absentee consultant / 2
Appendix
Postal Questionnaire – the Working Round
Please annotate
Your age______yrsYears since qualifying______Your grade_____
Current specialty______Specialty to which you aspire______
(include general practice)
Please score these statements
by circling
Score
neveroftenalways
‘I learn a lot about disease on ward rounds’0 1 2 3 4 5 6 7 8 9 10
‘I learn a lot about “The patient”on rounds’0 1 2 3 4 5 6 7 8 9 10
‘I have learnt to emulate consultants’ good
practice as seen on ward rounds’ 0 1 2 3 4 5 6 7 8 9 10
‘I avoid bad practice by not emulating
consultants’ skills as seen on ward rounds’ 0 1 2 3 4 5 6 7 8 9 10
I really appreciate your help – thank you
Diagrams 1 – 4 follow
[1] Ken Nixon, personal communication.