Monday, 21 January 2008

An example of Good Practise

Dear Bloggers

Having travelled to Hokkaido recently, I was able to see an example of good practise at the hospital to which I went.

The medical team who is headed by Dr Kaneko, run a Ward Round based system whereby all medical patients are reviewed daily by the senior physicians along with other staff doctors, junior residents, nursing staff and ancillary staff such as the speech & language therapist. This multi-disciplinary approach is excellent, as it is possible for all members of the team to understand the current clinical problems and of course, the social problems of patients to thereby be able to comprehend the full picture of the patient's current state.

This is an excellent example for learning at the bedside and making decisions based on history, physical and review of laboratory and radiological tests.

The fact that the patients are seen daily by senior doctors is a safe-guard for the patients in case errors are made by less experienced physicians or difficult-to-make decisions are required.

This is a very similar system to that of most UK hospitals whereby all medical patients are seen daily and where the Consultant will see the patients several times per week.

However, some hospitals in Japan do not have such a Ward Round based system whereby junior residents have to muddle through due to a lack of senior support. Moreover, medical meetings are held away from the bedside so that only history and physical, derived from perhaps an inexperienced junior resident, is heard, and decisions are then based on that plus the usual laboratory and radiological tests. There is of course no way to know if the resident has interpreted the history or physical findings correctly which thereby allows potential inaccuracies to become propagated through the inpatient stay unless the errors are identified early by a senior physician.

Such a no-hands-on approach can lead to errors which an experienced eye may pick up and soon avert.

In view that history taking and physical examination are not emphasized heavily in most Japanese medical schools, how can one expect junior residents to realistically pick up all the problems effectively?

Unless the emphasis of medical student training can be changed to reflect the changing needs of medicine, then the emphasis needs to be focused heavily on junior resident training.

Hence, a hands-on review by the senior doctors is essential to prevent mistakes being carried through into an admission and to teach the junior doctors appropriately to prevent the same problems occurring again in the future. A ward based approach is extremely important for the patient and for the resident training, rather than looking at numbers and pictures in a closed room. Some things cannot always be explained and it therefore requires a visit to the bedside to understand the problems.

Such senior doctor-led ward rounds of all the medical patients, a so-called 'business round' in the UK, is great for passing on 'gems' of information to the junior doctors with respect to history, physical, natural history of the disease and treatment plus how to understand the management of multiple clinical problems. Unfortunately, most books of clinical medicine deal only with distinct diseases rather than diseases in combination which a great number of patients have. That is the downfall of clinical books. However, the best teacher for this type of medicine comes from the Ward Round based teaching and discussion of evidence and experience of previous patient examples.

I, as a junior doctor, found it very helpful to also see the approach of the Consultants and how they dealt with difficult situations, such as telling bad news. To see how the different approaches worked allowed me to learn a great deal and to emulate the good examples. To see how the patients were treated with dignity and respect was also a good learning experience.

We do not start our lives as doctors and we are all human beings at the end of the day. Just because we become a doctor with a license does not mean we have all the necessary knowledge to manage patients at the start; far from it. We all need good role models to learn those things which are in no book, cannot be written down and can only be gained by approaching with a senior doctor to the bedside of the patient and seeing together. This is the basis of a medical vocation.

I think the experience in Hokkaido reminded me that there are many different ways to practise Medicine in Japan in addition to other good ways to learn medicine too.

Keep up the good job!

Have a great day....!

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