Ward-rounds: role in clinical teaching and learning in contemporary medicine

Before we begin this commentary on ward-rounds, a brief overview on what makes learning more effective is appropriate. How do students learn? Firstly, there is surface or superficial learning which concentrates on learning the words for short-term memory whereas deep learning implies a comprehension of what the teacher wants to say or a process of making sense by delving into the ideas behind the words. Deep learning focusses on creating meaning and critical thinking, and it has its underpinning on a scientific principle of distinguishing, using deductive reasoning, the general from the particular and of applying concepts and methods to solving a previously un-encountered problem (1). It prepares one to deal with uncertainty, an attribute of a ‘good doctor’. Doctors today must be life-long deep learners and it is of paramount importance that teachers and trainers provide the opportunities for trainees to interact critically with what they are learning. Teachers can enhance deep learning by creating learning experiences which will facilitate the construction of meaning and the development of metacognitive skills. Metacognition refers to a person’s knowledge concerning his or her own mental process and also to the active monitoring and consequent regulation and orchestration of the processes (2). Information must be presented in a structured and organized manner for effective learning. It is difficult for the student to convert ‘amorphous’material into one which has a structure. Quality in learning entails the development of the students’ intellectual and imaginative capacities, their understanding and judgement, their problem-solving skills, their ability to communicate effectively, the ability to see relationships within what they have learned and to perceive their field of study in a broader perspective. Biggs described good teaching as creating a positive emotional and motivational climate, having students actively engaging in the learning, and by the provision of well-structured and integrated knowledge (3). The teacher’s role is thus not only to consider what is being taught but also how it is being learned. In this era of the cost-effective healthcare system, equal access, full coverage, integrated care, consumer satisfaction, ethics, population perspective in healthcare delivery, and promotion of healthy lifestyles have led to new paradigms in how we train doctors (4). Work-based teaching, learning, and assessment are one aspect of a mixed diet of learning opportunities for doctors. Ward-round, a form of work-based teaching provides an educational meal that not only satisfies but also nourishes. Furthermore, ward-rounds and bedside teaching provide the avenue for learning clinical medicine in perspective, around the patient. Other advantages of patientbased teaching include improved students’ motivation from contact with patients, stimulation of interest in the duties and responsibilities thereby associated, presentation of disease in a realistic manner, recognition of the importance of teamwork, variations in the clinical features of the same disease, individualization of treatment and communication of attitudinal aspects (5). Through this exercise, not only do they become part of the team but they also learn to anticipate the symptoms, signs and investigations the lecturer would need to make a diagnosis. To achieve the maximum benefits from ward-rounds, advanced preparation by the junior staff and the medical students by having case findings, laboratory and radiological results available is essential. Moreover, regularity, punctuality and fixed scheduling must be observed. Ward-round is unique in that learning is provided in a natural health-related environment; it is patient-oriented rather than disease-oriented; it has an inherent aim of facilitating the trainee’s problem-solving and clinical reasoning skills. Bedside rounds are the most patient-centred of all teaching avenues and they provide the most vivid and dramatic stage on which learning can occur (6). Apart from enhancing patient care, ward-rounds also provide a live and lively teaching experience related to the patients visited. Active involvement by the learner affords the opportunity to develop interpersonal skills while interacting with patients and team members, and at the same time to gain experience dealing with the problem of real patients with real medical and social problems (5). Stanley observed that all types of ward-rounds were avenues for teaching and learning but in different ways. In particular, post-call rounds provided opportunities to review diagnostic and management skills with a senior doctor; rounds led by registrars were valued because of their From: 1Department of Obstetrics and Gynaecology and 2Department of Surgery, School of Medicine, The University of the West Indies, St Augustine, Trinidad and Tobago.