Matt Morgan: The ward round is broken

We need a new way of working, argues Matt Morgan


You are the director of a multi-million-pound coffee business. The working lives of your employees, not to mention your customers, are dependent on your actions today. For today, you have been tasked to visit ten of the lowest performing branches in your business. You will need to decide what is wrong with each branch and more importantly what to do about it. You may even need to close a store if the cause of their downfall cannot be rectified.

The method you have chosen to conduct this process is novel to say the least. You decide to drive from store to store throughout one morning with little or no prior knowledge of their problems. When you arrive, masses of unfiltered, unstructured data are plunged in front of your face. You are shown complex financial reports going back over the last few years, followed by masses of free text from customer comment cards. As you try to synthetize this, you have frequent interruptions from customers ordering new drinks and staff asking how to make them. You do all of this standing up in front of all the shareholders that surround you in the middle of the store. Then, ten minutes later, you announce your decision to increase the strength of the coffee by 10% in all drinks as part of the treatment. You then move on to the next store. By the time you get to the tenth store, you are tired having made a minimum of 200 decisions already that morning. This is known to be the volume limit of reasonable decision making. Then you do it all again tomorrow, and the day after, and the day after that.

When viewed through this lens, the way in which decisions are made in medicine seems crazy. First described by the Dutch physician Dr Herman Boerhaave in the 1700s, the ward round was a great innovative concept at that time. With very limited amounts of information to processes and a small team to communicate with, it was just what patients needed. However, today when I stand in a busy, noisy, critical care unit, presented with hundreds of pieces of data, surrounded by a multidisciplinary team of ten people, it is not what patients need.

Many doctors, including myself and my colleagues have recognised this. I often arrive early for work, sit down in a comfy chair, in a cool office, with a hot coffee. I review the history of patients using my two-screen computer set-up, while writing notes for the ward round on another. I review blood results and contextualise them by speaking to colleagues personally, by phone, and from the confidentiality of my office. I review complex scans while sitting down and examine them in detail. After this process is complete, I move out to the ward, prepared and forewarned. We then conduct a multidisciplinary ward round, with the help of a cognitive checklist, and spend important time speaking to patients, examining them when appropriate, and communicating with them, family members, and other members of the team. We have time to teach, time to reflect, and time to talk. We finish on time (mostly).

The old concept of the ward round is broken and needs to change. This fact needs to be recognised, researched, and taught. It is surprising that although I attend a compulsory resuscitation update annually, I have never been taught how to conduct a better ward round. We need technology to support this shift, and physical areas in which we can sit and review the complexity of patient care. The timetable of the day may need to change to reflect this. Modes of communication, such as using pager technology from the 1980s, need to support, not obstruct, contact. Overall, we need to recognise these issues and move to address them. Our way of working would not be accepted by businesses making decisions of far less impact than we, as healthcare professionals, make every day. The ward round is broken, let’s fix it.

Matt Morgan is an intensive care consultant, scientist, computer programmer, teacher and geek interested in machine learning, medical education and public engagement. Twitter: @Matrix_Mania

Competing interests: I have spoken at a number of education events for which standard travel expenses have been reimbursed. I received a research grant from Heath Research Wales and the Medical Research Council in 2016. I am paid as the lead clinical editor for BMJ’s onExamination.

  • Fredrik Baathe

    Hi Matt much appreciated your way of expressing the critical state of the ward round! While quick fix solutions is what we all long for, the complexity with the ward round should not be underestimated. Evolving complex phenomena is not a technical fix, but is about relations, power and identity. No fast and bump-free road, but the way to go to increase patient quality, professional and patient satisfaction, and get joy back in medicine. I have followed a medical department transforming their ward round and have two scientific papers where you can read more.

    Baathe F et al (2014). “Physician experiences of patient-centered and team-based ward rounding – an interview based case-study.”Journal of Hospital Administration 3(6): 127-142.

    Baathe F.et al (2016). ”Uncovering paradoxes from physicians’ experiences of patient-centered ward-round.”Leadership in Health Services 29(2): 168-184.

    http://wardround.net. has many more resources and a short clinical film of a new ward round

    So there is an existing model to be inspired from and a community of ward-round geeks ready to support…but the actual solution is a local journey and needs to be created by the people in your department to really integrate those local unique needs and wants to make things functional. This process needs a champion. I believe it might be you Matt? All best / Fredrik

  • Fredrik Baathe

    Hi Matt! Much appreciated your way of expressing the critical state of the ward round! While quick fix solutions is what we all long for, the complexity with the ward round should not be underestimated. Evolving complex phenomena is not a technical fix, but is about relations, power and identity. No fast and bump-free road, but the way to go to increase patient quality, professional and patient
    satisfaction, and get joy back in medicine. I have followed a medical department transforming their ward round and have two scientific papers where you can read more.

    Baathe F et al (2014). “Physician experiences of patient-centered and team-based ward rounding – an interview based case-study.”Journal of Hospital Administration 3(6): 127-142.

    Baathe F.et al (2016). ”Uncovering paradoxes from physicians’ experiences of patient-centered ward-round.”Leadership in Health Services 29(2): 168-184.

    http://wardround.net. has many more resources and a short clinical film of a new ward round

    So there is an existing model to be inspired from and a community of ward-round geeks ready to support…but the actual solution is a local journey and needs to be created by the people in your department to really integrate those local unique needs and wants to make things functional. This process needs a champion! Could it be you Matt?

    All best / Fredrik

  • Matt Morgan

    Fantastic resource – thank you!

  • Paul Moynagh

    I wholehertedly agree: what you describe is nothing new to me. As a young house physician in the 1960s I worked briefly for a chest physician whose ward rounds were conducted in a similar way. I vowed when I became the ‘boss’ I would do the same though I came across no one else who did. I never understood why.

    Since I started as orthopaedic consultant surgeon in the 1970s (now long retired!) I started my ward round seated in an office with a mug of coffee and all relevant staff (junior / assistant surgeons, nurses, physiotherapist, social worker etc) present and contributing with notes ready and a conveniently placed xray screen. No doubt nowadays there would be a computer screen Each patient was fully discussed, from scratch if just admitted, or just updating since the last round, and a provisonal management plan then proposed.

    We then went as a group to each patient’s bed in the manner of a traditional ward round, but being already well briefed we could from the start include and speak to the patient and their relatives instead of talking over them as otherwise too often happens. Where appropriate the patient would be clinically examined and the management plan then confirmed or amended. The overall time taken was similar to conducting the whole process at the patent’s bedside.

    I encouraged families to be present to help assess the home situation when planning discharge as well as acting as backup for patients who may find it hard to retain any information or advice. Fortunately for most of the time I practiced the hospitals I worked at had unrestricted visiting hours.

  • Matt Morgan

    Thanks for your wonderful insights, there are no new ideas of course only recycled ones! Hearing your perspectives from 1960 is invaluable! I encourage you to write this as a letter to the editor . . .

  • Matt Morgan

    I have been really enjoying http://wardround.net, thanks again.