Views And Reviews

The ward round is broken

BMJ 2017; 358 doi: (Published 25 September 2017) Cite this as: BMJ 2017;358:j4390

Who are "we"?

Dear Editors

I welcome Dr Faulds' contribution to this discussion

As Dr Matthew C Faulds FRCA FFICM did not fully declare he is a Consultant in Intensive Care Medicine and Anaesthesia in Newcastle Upon Tyne, I am uncertain who is included in the collective "we" in his response, particularly when he is suggesting significant changes to the work flow in various other specialties he is not directly part of.

I stress that there is nothing wrong about what Dr Morgan has described as his ward round in the Intensive Care Unit; it works for him and is enviable to other clinicians. But as reflected in my rapid response, the ICU medicine is also a high cost with very high staff to patient ratio environment (with a definite limit in patient load) well supported by technology and privileged priority access to pathology and imaging (like the Emergency Department).

As stated previously, to translate this quality of medical service would require a significant re-investment in logistics, technology and staffing practices, something the NHS can never afford sustainably in the past or future.

Dr Faulds' curious solution was to have a attending service structure without burden of other obligations for the day. Again it reflects the mindset of the ICU culture of cooperative responsibility but does not address medicolegal reality of the current system of admitting rights and responsibilities.

There may be a few circumstances whereby a patient is admitted into a hospital under the care of the intensivist or anaesthesist in the NHS, but by and large the majority of patients would have one doctor (or two at most), primarily a physician, surgeon or psychiatrist's name on the bed cart throughout their admission. As such if a problem or complaint arises, or a death occurs, the consultant named responsible for the admission episode bears ultimate responsibility to address any issues relating to this episode. When a writ is made, the consultant whose name is on the bed cart is most likely to be nominated to answer the charges.

Therefore the idea of handing over the control of ward round (and not directly involved in shared decision making) without handing over care (and ultimate responsibility) can be difficult if the caseload and conditions involved are highly variable and complex. No one likes to be responsible for a decision they are not involved in.

Hence such attending solution is only possible in limited scenarios outside ICU in which a standardised approach of care previously agreed upon by clinicians involved for a narrow range of conditions; for example, acute surgical services covering trauma and acute abdomen, or medical assessment units where the primary goal is to diagnose and stabilise/treat a range of defined conditions, and the rest directed to other medical specialties for care.

And regardless of how many clinicians are involved in the admission episode, when the patient is discharged, it will be under the care of one named doctor, and again most of the time it will be a physician surgeon or a psychiatrist.

Anytime the NHS decides to change the anarchic system of admission (and medicolegal) responsibility, then we can talk.

Competing interests: No competing interests

06 December 2017
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia