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Restore the prominence of the medical ward round

BMJ 2013; 347 doi: (Published 31 October 2013) Cite this as: BMJ 2013;347:f6451

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Re: Restore the prominence of the medical ward round

Osler wisely observed that 'A good physician treats the disease well; a great physician treats the patient who has the disease well.' Geriatricians have (where possible) incorporated this into their practice, and indeed it is enshrined in the central - and evidence-based - tenet of our work: comprehensive geriatric assessment.[1]

With the increasingly prevalent case of patients who have delirium and/or dementia, the other crucial component is obtaining information from someone who knows the patient well. I encourage such advocates (whether family, friends or others) to be present at my ward rounds.

Sadly now, this often presents the only continuity of information provision between recurrent hospital admissions, where the only constant seems to be repeated discontinuities in care. The procrastinating gambit of writing in the notes 'need collateral history' often simply wastes time. With the information to hand from an advocate - even if only in outline form - one can both establish a feel for the trajectory of the patient's illness, and also get a feel for their context and the risks involved in their return home. This enables a strategic view to be taken about where things are heading, what the priorities are, and the relevant time scales. Arrested suspects have the statutory right to an advocate during questioning; admitted patients on the ward are often systematically denied this right outside visiting hours!

All too often, listening to, and explaining to, the family or other advocate seem to be perceived by senior doctors as a time-consuming optional encumbrance. Retrieving important information, explaining what is going on, and building a therapeutic relationship are key components of good medicine in my view.

Perhaps, given the prevalence of delirium and dementia in the current acute medical take, Osler's other well-known saying might now be better rendered as "Listen to your patient's advocate, s/he is telling you the diagnosis."

Reference: Comprehensive Geriatric Assessment for Older Hospital Patients. Ellis G & Langhorne P. Brit Med Bull. 2005; 71: 45-59

Competing interests: No competing interests

27 November 2013
Kit Byatt
consultant general physician & geriatrician
Hereford County Hospital
Union Walk, Hereford HR1 2ER