How team clinical reasoning occurs on ward rounds: Implications for learning.

Background: Ward rounds offer a rich environment for learning about team clinical reasoning. We aimed to assess how team clinical reasoning occurs on ward rounds to inform efforts to enhance the teaching of clinical reasoning.

Methods: We performed focused ethnography of ward rounds over a 6-week period, during which we observed five different teams. Each day team comprised one senior physician, one senior resident, one junior resident, two interns and one medical student. Twelve 'night-float' residents who discussed new patients with the day team were also included. Field notes were analysed using content analysis.

Findings: We analysed 41 new patient presentations and discussions on 23 different ward rounds. The median duration of case presentations and discussions was 13.0 minutes (IQR, 10.0-18.0 minutes). More time was devoted to information sharing (median 5.5 minutes; IQR, 4.0-7.0 minutes) than any other activity, followed by discussion of management plans (median 4.0 minutes; IQR, 3.0-7.8 minutes). Nineteen (46%) cases did not include discussion of a differential diagnosis for the chief concern. We identified two themes relevant to learning: (1) linear versus iterative approaches to team-based diagnosis and (2) the influence of hierarchy on participation in clinical reasoning discussions.

Conclusion: The ward teams we observed spent far less time discussing differential diagnoses compared with information sharing. Junior learners such as medical students and interns contributed less frequently to team clinical reasoning discussions. In order to maximise student learning, strategies to engage junior learners in team clinical reasoning discussions on ward rounds may be needed.