Bedside Rounds are not always Patient-Centered

Multi-disciplinary Patient and Family-Centered Bedside Rounds are featured in Nance’s “Why Hospitals Should Fly,” touted as a best practice in the ideal hospital that has virtually eliminated all medical errors. I agree with the principles: the patient and family should be informed and not only kept at the center of all clinical decision-making but should be the decision-makers. Furthermore, the multi-disciplinary team should be involved every step along the way, all voices equally heard and involved for the safety and coordination of the patient’s care. However, I have found that I sometimes disagree with the application I’ve seen of these principles in practice. I had the opportunity to discuss this in a small group yesterday: It sounds like there are groups out there that are taking steps to avoid the pitfalls I describe here, and undoubtedly, there are ways to overcome them. Nevertheless, I feel the need to express my concerns to help others be vigilant. Furthermore, I would argue that there are likely alternative mechanisms to accomplish the same goals.

My concerns may be best summarized with a generally hyperbolic example based on my perception of the patient’s reactions who suffered through a version of Multi-disciplinary “Patient-Centered” Bedside Rounds: A team of 12 individuals enters Mr. Jones’ room: the attending physician, chief resident or fellow, the resident caring for Mr. Jones plus 2 other residents, a medical student, a nurse, a respiratory therapist, a pharmacist, a pharmacy student, a social worker, and a representative of the spiritual care team. The team members line the walls of the room, surround the bed, and loom over the patient and his devoted wife, who sits concerned at the bedside. The attending physician introduces himself, explains the “rounding” process, and encourages the patient and his wife to participate. Each team member contributes to report as appropriate. The patient listens, but is too overwhelmed and intimidated by the large group to speak up unless specifically prompted–and even then responses are brief. The team generates excellent clinical questions and receives input from the multi-disciplinary members. The Jones’ have started to tune out: They understand only a small percentage of what is said because the language used is academic, specialized, and calculated to facilitate precise communication between medical professionals. The team acknowledges that the patient may not understand by specifically addressing the patient and saying, “We’re going to talk shop for a minute.” The team goes on to discuss the most recent bench research that may one day be applicable to Mr. Jones’ care (but not quite yet), and reviews some basic pathophysiology and pharmacology at the expense of the medical student who couldn’t quite remember that chapter. The medical student (and the patient) aren’t entirely sure what the attending’s questions had to do with Mr. Jones’ care, and Mrs. Jones wonders why they were giving the medical student such a hard time. Otherwise, Mr. Jones and his wife catch snippets of the high level, academic discussion that scare them and create more questions than answers, but they really don’t know where to start asking questions. After the discussion, the attending summarizes the plan of care in patient-centered language, and elicits questions from Mr. and Mrs. Jones before the team leaves the room. The team stands outside the room for another 10 minutes continuing their discussion: mostly out of audible range from the patient and his wife, who feel mostly overwhelmed by the whirlwind that had just descended upon them. But they wonder what the team is now talking about just out of earshot: what are they hiding?

I would argue that the language used in front of the patient should always be patient-centered language. Teaching and academic discussion is undoubtedly important and pivotal to both patient care and medical education, but the bedside may not be the time nor place for that discussion unless all content is directly related to the patient’s care and presented in language that the patient would also be able to understand. It is difficult to maintain that high fidelity of patient-centered language and too easy to slip back into speaking in specialized medical terms. The appropriateness of language and content at the patient’s bedside is only one issue I raise. You can gleam additional concerns by the hyperbole I employed in my exam as the team “descends upon and looms over” the patient and his family.

Does this mean that Multi-disciplinary Patient and Family-Centered Bedside Rounds should be abandoned? No, of course not. This can be a very powerful tool. However, the implementation should be thoughtful, with bedside content remaining centered on the most important focal point: The Patient.

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