Professional III Exam Preparation: How to Gain Benefit from Ward Round

This article is a expansion of previous article: "Early Preparation for Professional III M.D" [link]

Ward round is not just 'round around the ward' which is commonly done by medical student.

They are not to be blamed as they unable to fully understand the concept behind the ward round, hence preventing them from gaining benefits from it.

If they fully understands it, then it will be a good medium for them to learn effectively so that they will have easy moment during the working day.

The problem arise when the number of medical students increase dramatically. So, the number of student joining the round would be increase as well. This will reduce the effectiveness of learning and student will easily get lost along the way. When the focus is shifted from the patient to their own fantasy world, then nothing will get into their head. In other word, it means useless and wasting of time.

Worst of it is when the attending doctor or specialist will find their presence as annoying. It is not suppose to happen because teaching medical student is part of their job if they are in teaching hospital. But in non teaching hospital, they are not to be blamed for the action. Most of the time, this labeling happen when they find out that medical students are not interested with what they are presenting and discussing. And sometime, they are being disturbed by the action of medical students who chat among themselves about things that are un related to the patient care

In order to gain benefits from ward round, we need to understand what is ward round. In a guideline produce by the Royal College of Physician and Royal College of Nursing in 2012 entitle "Ward rounds in medicine Principles for best practice", they defined ward round as a complex clinical process during which the clinical care of hospital inpatients is reviewed.

Round is usually joined by a team consisting of medical officers or house officers in charge of the patient, specialists, nurses, pharmacists and other related parties including medical students.

The structure of the round usually take part in few steps. The first steps would be the case presentation by the in-charge doctor. He will briefly present the data of patient, initial chief complaint when patient being admitted and the working diagnosis as well as differentials. It is then followed by the progress of the patient, any relevant investigation finding and response towards medication or procedures.

Since time is limited, it has to be done fast, pointing out relevant issue, not missing out the crucial point and well structured.

In the guideline that I point out earlier, it states that ward round process involve few steps and functions.

First is regarding the diagnosis of the patient. as a general rule, the diagnosis has being established after the patient being admitted. However, it was like arranging the puzzle. The more time we take, the puzzle will grow more bigger and we will have more clearer idea. Therefore, the diagnosis may be refined, or changed.

Then, patient's progress is being reviewed back based on the result of available investigations, any changing or additional history and physical examination and patient's observational chart of vital sign, drug chart, any relevant chart like dengue chart, input/output chart, drain chart, GCS chart and many more.

The next step is to make a decision based on the previous two steps. The team will decide on further investigation and options of treatment as well as patient's care.

During this point, the team will identify and triage patient whether he is stable to be discharged, need to escalate or de escalate the treatment, or to be referred to multidisciplinary team for opinion and further management. If patient is found stable to be discharged, then the team will decide on discharge plan; medication, discharge advise and arrangement of follow up.

Apart from that, it is crucial to identify any new threat to the patient, possible harm from the management and pitfall in the management.

This whole process need a lot of effective communication, team work and leadership skills.

So as a medical student, how would you get benefit from this process?

Now that you already understand the anatomy and the purpose of ward round, next is you need to make use of this structure for learning purpose.

You know that time for ward round is limited, so you must know when to interrupt, asking question or keep quiet.

The most crucial step that you should do is to know about the case in the ward. It is a bit easier for the fresh case rather than ‘old’ patient who being treated in ward for quite some times. Because you will always able to see active management by the treating doctor or you can see the response of treatment in that patient. In order to know about the case, you can choose the short cut and the long cut. The short cut is by reading the case note and the long cut is by re clerking the patient.

But, the essential point that you should know is the demographic data of patient, presenting complaint of the patient. What brought the patient to the hospital and clinical finding during the initial presentation. Then you have to digest or understand why certain diagnosis has being made by the attending doctor at that time. Usually it is being formulated after combining the history, physical examination and investigation. Sometime, initial diagnosis consist of more than one differentials. So you should also pay particular attention to the investigations ordered by the doctor in order to narrow done the diagnosis.

Then, look at the medication ordered for the doctor and have a guess why it is being choose. And the next is to know the response of the treatment and other progression. After that, you should do your homework at home. Make sure you read about the case and management of the case so that you would have rough idea about it.

For example; A 10 years old boy presented to the emergency department with complaint of high grade fever associated with chills and rigor, shortness of breath and productive sputum. Initial diagnosis was community acquired pneumonia and you can see that the acute management would be oxygen therapy, prop up the patient, vital sign monitoring or cardiac monitoring, keeping patient nil by mouth with intravenous drip support, medications like broad spectrum antibiotic and analgesia was started. You will take a look at the initial investigation which is Hb 8.4, total white 26.0, platelet 673 and hematocrit 42%. Na+ 120, K+ 4.2, Urea 17.4, Creatinine 220. Chest X rays show right lobar pneumonic changes.

At this step, you should be able to generate few learning points. Differential diagnosis would be pneumonia, pulmonary tuberculosis, meliodosis or he could probably have underlying chronic lung disease but exacerbate by acute infection. Your next learning point would be the active management. You will learn what type of oxygen therapy given to this patient, why he was kept nil by mouth and put on IVD. What is the type of IVD and how to calculate the fluid requirement. What is the abnormality of the blood and radiological examination.

After two days, patient condition is still not improving. Something is not right about this patient. So you would ask yourself. Is this patient in severe sepsis that his kidney function test is not good. Hyponatremia would be due to SIADH from the active lung infection. Why he did not improve? Is the antibiotic working for the patient. Why is that patient still dependent to oxygen.

Then you will find out at the investigation chart that blood C&S come back and shows that patient is resistant to the antibiotic that has being prescribed. So you change the antibiotic and patient is responding well. No more tachypnoeic and was allowed orally. Total white blood count normalized and Hyponatremia resolve. So patient’s active management would be lesser now. Only to complete antibiotic.

Few days later, patient condition suddenly deteriorate. Somehow becoming very tachypnoeic and cannot breath. There was a hyper resonance of the affected lung field and reduce air entry. Somehow, he develop pneumothorax and chest tube was inserted. So you will notice that the doctor will now cover another new problem. One is the pneumonia with sepsis and acute renal failure which is improving but develop pneumothorax. There’s no need to change antibiotic because it’s working. Pneumothorax could be complication. Since chest tube already being inserted, the focus now is to off the chest tube.

Finally after four days, lung already expands back but still there is haziness at the affected lung. Air entry is improving. Chest x rays show no more pneumothorax so the doctor decided to remove the chest tube. But you will be asking yourself, why did the opacities still there? Then you will learn that the consolidative changes on chest x ray will remain at least two weeks.

So now, you will understand about the case, so you will not going to be blur during the round. So you can ask relevant questions to the medical officer or specialist if having free time, for example; 1) what are the criteria that we look for to decide when to insert chest tube and remove it?, 2) is there any scoring system to predict mortality in this patient?, 3) Decision for intubation, 4) markers for infection and so on. Furthermore, you can you this time to clarify your understanding. For example you are not sure whether the chest x ray finding is consolidation or collapse, regime of antibiotic for adult and pediatric pneumonia and so on.

Furthermore, by having reading about the patient, you may also prepare yourself with future questions ask by lecturer. If you can answer it, their impression on you will be better and you will have more teaching session and knowledge from him. For example, like this case; he might be asking you about landmark for chest tube insertion, history and clinical examination to suggest that this patient having pneumonia, how would you monitor patient’s response on antibiotic or medication that has been serving to the patient and also complication of the disease.

Trust me, if you truly able to grab the principles behind this ward round concept, you will learn more effectively. Wards round and reading the patient’s progress will help you to pass the clinical papers.