The Journal of Pediatrics
Volume 155, Issue 4 , Pages 466-468, October 2009

What's New Is Old: Maximizing the Benefits of Parental Presence at Bedside Rounds through 100 Years of Insights from the Literature

  • Jeffrey M. Simmons, MD, MSc

      Affiliations

    • Corresponding Author InformationReprint requests: Jeffrey M. Simmons, MD, Cincinnati Children's Hospital Medical Center, 333 Burnet Ave ML 7035, Cincinnati, OH 45229.
    • ,
  • William B. Brinkman, MD, MEd

Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

Article Outline

 

See related article, p 522

Advocating for bedside rounds, in a commentary published nearly 30 years ago, Linfors and Neelon1 describe an account of Sir William Osler's bedside technique: “Usually Dr. Osler made some examination himself and demonstrated and discussed salient features, all the time mingling his discussion with remarks and explanation to the patient so that he would not be mystified or frightened.” Linfors and Neelon, 1 lamenting the “pervasive translocation of teaching activity away from the bedside,” ask rhetorically, “how can this have occurred, without any obvious policy decision to do so and without regard for the implications of the move.” Ironically, Cameron et al2 reference the commentary by Linfors and Neelon in their report in this month's issue of The Journal. Cameron et al2 express concern about recent pressure to include parents in teaching rounds “despite limited information on the potential impact on parents, teaching, and patient care.” Separated by 3 decades, both authors describe perceived nonevidence-based pendulum swings (in opposite directions) in how clinical care and teaching are blended in academic centers. However, the rich existing literature, now including findings from Cameron et al and our 5 years of clinical experience with a model of family-centered bedside rounds at Cincinnati Children's Hospital Medical Center lead us to hope the pendulum will not again swing away from teaching and care blended at the bedside.

Spanning nearly 60 years, multiple investigators have documented that adult and pediatric patients and families strongly prefer to have rounds conducted at the bedside.1, 3, 4, 5 In a randomized, crossover design in which families experienced both bedside presentations and rounds away from the bedside, Landry et al5 documented that 81% of families preferred subsequent days' rounds to occur at the bedside. These families also strongly preferred to have resident teaching occur at the bedside. Cameron et al2 found that participation in rounds increases parents' perceived satisfaction, understanding, and involvement in decision-making.

Importantly, in most studies, patients and families identify similar key aspects about how to implement bedside rounds to maximize the experience for the patient and family, including prerounds preparation, introductions to medical team and their roles, inclusion of patient/family in discussion, avoiding unexplained medical jargon, and presence of the bedside nurse.3, 4, 5, 6, 7 Cameron et al2 suggest in their closing recommendations on how to invite parents to rounds that “parents are most likely to make a meaningful contribution to rounds if they understand that their input is valuable and welcomed.”

In terms of educational impacts of bedside case presentations, the existing literature is less robust, but does contain several important insights. First, although several studies document that both trainees and attending physicians initially prefer to present cases away from patients and parents (as noted by Cameron et al2), these same studies and others show that once both groups have had some experience with the practice, their comfort and preferences change.5, 8, 9, 10, 11 In addition, the most commonly cited reason by physicians for their preference is that patient and families will be uncomfortable with bedside presentations, a perception that these same studies refute convincingly. Another commonly cited reason for resident preference for conference room presentation is loss of credibility or perceived lack of competence when presenting in front of patients or families. In contrast, Landry et al5 found that parents perceived residents to be more competent when presenting at the bedside. However, perhaps most important when considering the findings of Cameron et al2 is the insight from several prior studies that bedside presentations lead to a qualitative shift in what gets taught and learned compared with conference room presentations. Several authors have described that residents and attendings feel bedside presentations lead to more opportunity to teach and observe physical examination and observe and model bedside manner and communication skills.10, 12

Although we applaud the effort of Cameron et al2 to comprehensively evaluate the effects of including parents in teaching rounds in the pediatric intensive care unit, we believe their findings and conclusions should be considered carefully because of bias in their methods and in their reading of the literature. For example, the claim that prior work demonstrates that “house-staff and attending physicians overwhelmingly prefer to round separately from patients” does not fully reflect the impact of experience on perceptions as noted previously, nor the limitations of the initial perceptions themselves (ie, physician perceptions that families will be made uncomfortable by bedside presentations). In terms of methods, Cameron et al2 were unable to blind the subjects (parents, resident and attending physicians, and nurses) to the presence of the observer of rounds, and that same observer also performed all the interviews of parents and shared in the coding and analysis of the qualitative data. However, we believe the most important limitations of this work were the potential impact of attending physician bias and the framing bias of the questions asked of each subject in the primary evaluation tool, the “individual rounding assessments.”

Our belief that there was likely attending physician bias against parent inclusion on rounds during the study is founded on 3 findings noted by the authors: first, that nearly double the proportion of residents and nurses believed that “parents should be routinely invited to rounds” than did attending physicians (71%, 79%, and 40%, respectively); second, that only about half the time a parent was present for rounds did they elect to participate (48/91)—in our experience approximately 85% to 90% of parents elect to participate in rounds when asked13; third, only 31% of the time that a parent elected to participate did they ask at least 1 question. We conclude that parental presence on and participation in rounds was not encouraged by the attending physicians, and we speculate this atmosphere may have affected the opinions of other health care providers.

In terms of framing bias of the questions asked of health care providers in the “individual rounding assessments,” the questions asked whether parental presence “limited educational questions” or “limited discussion.” Although, nurses, residents, and attendings were asked whether “the parent provided new, pertinent information,” they were not asked whether parental presence generated new educational questions or enhanced discussion. In other words, the questions themselves were not neutral and potentially led subjects to respond in 1 direction. It is not possible to determine how these 1-directional frames that were asked immediately after each rounding event may have biased the subsequent more open-ended questioning of both parents and health care providers.

Our final concern about the conclusions by Cameron et al2 is their assertion that “parental presence on rounds. . . likely has a negative impact on house-staff education.” Because this claim is primarily based on perceptions of the attending physicians about how they “limited” their teaching in part to “avoid exposing gaps in house-staff knowledge,” at a minimum it ignores the multiple aspects or competencies of medicine that residents must learn (communication skills, for example). Furthermore, the assertion assumes that exposing gaps in resident knowledge on rounds always leads to positive impacts on house-staff learning.

The work of Cameron et al2 confirms prior findings—particularly that parents find bedside rounds useful and that most staff agree parents should be given the option of participating—and adds important new information about parental presence on rounds, most objectively that parental presence may not significantly increase the length of rounds. In addition, this work raises some important questions: how to invite parents on rounds—encouraging participation without subtle coercion; the potential for producing anxiety in parents during bedside presentations—and interestingly, how a key reason parents may opt out of rounds is because of this potential anxiety; how best to balance the additional information gleaned from parents during rounds (reported 57% of the time by Cameron et al2) with the potential for limiting discussion about sensitive issues that may impact decision-making (reported 10% of the time by Cameron et al2); and, how to balance the potential loss of disease-process focused teaching and learning described by Cameron et al2 with the potential gains in observation and modeling of physical examination findings and communication skills that were not measured by Cameron et al2 but have been described by others. Ultimately, these questions will be best answered through studies that attempt to measure patient and educational outcomes as opposed to just changes in perceptions, which has been the dominate method of work to date.

Finally, we conclude by emphasizing the importance of how bedside rounds are implemented in realizing their many benefits and limiting their potential problems. In a systematic review, attempting to define “family-centered bedside rounds,” Sisterhan et al14 concluded that such rounds should be “a planned, purposeful interaction that requires the permission of patients and families as well as the cooperation of physicians, nurses, and ancillary staff.” Conversely, Cameron et al2 note for their study “there were no changes made in the way the medical team conducted rounds.” Sticking to business as usual can produce undesired consequence such as the parent comment that rounds are “like a foreign language. . . very technical. . . very detached. They don't sound like they are talking about your family member.” Such sentiments lead Cameron et al2 to make some important recommendations about implementation of parental presence on rounds, including that this should be considered “in a carefully thought out manner.” These summary points are a valuable contribution to our understanding of this most recent swing of the pendulum in academic centers. We hope that Osler's words in 1903 will serve as pause to any future push of the pendulum away from the bedside: “It is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself.”15

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References 

  1. Linfors EW, Neelon FA. Sounding boards. The case of bedside rounds. NEJM. 1980;303:1230–1233
  2. Cameron MA, Schlein CL, Morris MC. Parental presence on pediatric intensive care unit rounds. J Pediatr. 2009;155:522–528
  3. Romano J. Patients' attitudes and behavior in ward round teaching. JAMA. 1941;117:664–667
  4. Simon RJ, Baily RG, Zelis R, Zwillich CW. Occasional notes: the physiologic and psychological effects of the bedside presentation. NEJM. 1989;32:1273–1275
  5. Landry M, Lafrenaye S, Roy MC, Cyr C. A randomized, controlled trial of bedside versus conference-room case presentation in a pediatric intensive care unit. Pediatrics. 2007;120:275–280
  6. Lehmann LS, Brancati FL, Chen MC, Roter D, Dobs AS. The effect of bedside case presentations on patients' perceptions of their medical care. NEJM. 1997;336:1150–1155
  7. Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study. Acad Med. 2008;83:292–297
  8. Nair BR, Coughlan JL, Hensley MJ. Student and patient perspectives on bedside teaching. Med Educ. 1997;31:341–346
  9. Wang-Cheng RM, Barnas GP, Sigmann P, Riendl PA, Young MJ. Beside case presentations: why patients like them but learners don't. J Gen Intern Med. 1989;4:284–287
  10. Rogers HD, Carline JD, Paauw DS. Examination room presentations in general internal medicine clinic: patients' and students' perceptions. Acad Med. 2003;78:945–949
  11. Kleiber C, Davenport T, Freyenberger B. Open bedside rounds for families with children in pediatric intensive care units. Am J Crit Care. 2006;15:492–496
  12. Baker RC, Klein M, Samaan Z, Brinkman W. Exam room presentations and teaching in outpatient pediatrics: effects on visit duration and parent, attending physician, and resident perceptions. Ambul Pediatr. 2007;7:354–359
  13. Muething SE, Kotagal UR, Schoettker PJ, Gonzalez del Rey J, DeWitt TG. Family-centered bedside rounds: a new approach to patient care and teaching. Pediatrics. 2007;119:829–832
  14. Sisterhan LL, Blaszak RT, Woods MB, Smith CE. Defining family-centered rounds. Teach Learn Med. 2007;19:319–322
  15. Osler W. On the need of a radical reform in our methods of teaching senior students. Medical News. 1903;82:49–53

PII: S0022-3476(09)00621-0

doi:10.1016/j.jpeds.2009.06.061

Refers to article:

  • Parental Presence on Pediatric Intensive Care Unit Rounds , 25 June 2009

    Melissa A. Cameron, Charles L. Schleien, Marilyn C. Morris
    The Journal of Pediatrics October 2009 (Vol. 155, Issue 4, Pages 522-528.e1)

The Journal of Pediatrics
Volume 155, Issue 4 , Pages 466-468, October 2009

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