This article discusses the educational value of the “board round”, a clinical teaching forum introduced at Hope Hospital, Manchester, UK. At midday on weekdays all available consultants and middle grade doctors, and any other staff who can attend, meet to discuss a case selected from the patients currently in the department. As several experienced clinicians are available to discuss a clinical problem, the round allows a broad debate during which the merits of several management options are discussed. In addition, attending a board round addresses in part the concerns which senior clinicians may have about the balance of service delivery and protected teaching time. The paper describes several other advantages of this method of teaching, which has been adopted by other hospitals in the region.
- teaching methods
- board round
- situated case based learning
- teaching tool
- lifelong learning
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Finding “the time to teach” has become a relentless issue in the pressured arena of the emergency department. The educational constraints of meeting service targets are well recognised.1
Only fools learns from their own mistakes; a wise person learns from the mistakes of others.
It has been established that hospital consultants rate case discussion with colleagues as an enjoyable and stimulating aspect of their continuing professional development.2 Also, there is little dispute that the use of situated case based learning is a powerful teaching tool for junior staff in the emergency department. Within the emergency department, shift patterns dictate that trainees are working with no direct clinical supervision for significant periods of time. Any initiative that brings staff together for shared learning is therefore worthy of consideration. “Teaching One To One” (TONTO) has been advocated as a means for trainees and consultants to learn from one another in the clinical environment. Our experience of TONTO has been positive and we also advocate it as a tool for clinical teaching. However, it does have real and perceived limitations. In particular, it is labour intensive and both trainees and trainers have often commented that it does not happen as often as it should.
The “board round” at Hope Hospital, Manchester, UK, was introduced in an attempt to provide a clinical teaching forum for senior and junior staff to discuss and critique the clinical care of patients in the department at that time. We report our experiences of the “board round”.
THE BOARD ROUND
At midday on weekdays all available consultants and middle grade doctors meet at the majors end of the department. Midday was chosen as a second consultant and second middle grade doctor start at this time, as a result a minimum of four senior doctors are available. They are usually joined by other senior physicians who may be designated for administrative duties on that day. Although primarily aimed at the consultant and middle grade staff the round can include junior and senior house surgeons, nursing staff, sessional accident and emergency staff (for example, general practitioners), and representatives from inpatient hospital teams. An average of eight people attend. On rare occasions the meeting may be postponed due to the clinical pressures of the day.
All participants are encouraged to find a case from the patients in the department. On occasion, a case from a previous day is brought for discussion or further information from a previously presented patient is presented. There are no strict guidelines about what may be discussed although issues generally fall into three main areas:
A current clinical problem about which the presenting clinician is seeking advice as to how to proceed (What do I do today?).
An interesting or unusual case to share (You’ll never guess what I saw!).
A review of standard practice (Does everyone do this the way I do?).
The cases are supported using digitally acquired clinical images, electrocardiograms, radiological images, etc. We encourage participants to question all aspects of their clinical practice. For example, in patients with anterior shoulder dislocation the round has discussed (on separate occasions) reduction techniques, sedation techniques, immobilisation methods, sedation guidelines, discharge criteria, surgical anatomy, and the differential management of associated tuberosity fractures. The round is non-hierarchical as all participants are encouraged to share their opinions regarding patient management.
A number of outcomes can result from discussion:
a change in clinical management
a technique or skill may be demonstrated
an individual may be tasked to find further information and bring this back to a subsequent round
a best evidence topic (BET) question may arise
a written policy may be formulated (for example, management of patients who self-discharge following self-harm).
Table 1 shows a week’s worth of activity at the board round. The diversity of cases and outcomes is clearly demonstrated. The round usually takes 20 minutes and is strictly limited to 30 minutes. Following initial trials the board round has now been successfully implemented at other hospitals in northwest UK.
We believe that the board round has been an extremely effective method of teaching for several reasons. Firstly, it occurs during normal working hours and generally deals with current patients in the department. It is therefore perceived as an integral part of the working day rather than as an optional extra. Changes in treatment are demonstrable in real time on real clinical problems. This reinforces any new information learned and encourages all doctors to actively participate. Taking part in a board round addresses in part the concerns which senior clinicians may have about the balance of service delivery and protected teaching time3 by combining the two, since the decisions made during the round may enhance the care of a patient in “real time”. Secondly, several experienced clinicians tackle the clinical problem. This allows a broad debate to occur during which the merits of several management options are discussed. Finally, the participation of non-shop floor consultants allows them to be involved in clinical problems on a daily basis thereby maintaining their exposure to a wide range of problems.
Teaching in this way requires everyone to be open about their clinical decisions and to accept critique and challenge to their traditional practices. At times this can be difficult, particularly if the critique comes from a junior colleague. It is incumbent on the senior doctors to facilitate and encourage juniors to question their own practice as by doing this they demonstrate the need for lifelong learning. Developing the skills required to lead the board round and draw out the key learning points forms a key element of training as a clinical educator,4 since it combines aspects of small-group discussion, lecture delivery, and critique within a short period of time. The discussions allow different physicians to handle issues if there is clinical uncertainty, doubt, or error. It is an ideal opportunity for seniors to explicitly demonstrate their own practice and therefore to act as role models to other members of the clinical team.
By involving all available grades of staff in the shared discussion of a clinical problem, the board round fulfils the basic function of letting everyone “get together” with other colleagues, if only for a brief time. The way in which this facilitates learning is in itself invaluable. Having the opportunity to practise the skills of a focused presentation to colleagues is a key skill in professional development.5
Use of the board round could form a stimulating and rewarding part of the daily work in many emergency departments: it can be run with as few or as many staff as are available on a given day. The educational principles upon which it is based are longstanding and have stood the test of time—indeed, the wheel of reform is slowly bringing us back to the central role of “traditional” patient centered education once again.6