Grand rounds were the highlight of the week on the ward when the head of our department himself conducted them. They were fun, all bets were open, and the teacher would give youngsters in the team as well as the most experienced senior doctors a piece of his mind in equal measures. Although his tone was often slightly cynical, the procedure was always fair, and it was the same every week. Everybody was keen to participate because we all learned a lot, and the embarrassment of being singled out was considered less than the fun of participating.
Professor Hermann Heimpel (whom I congratulate on his 80th birthday) was the only teacher who asked a particular type of tricky question at the bedside. As the senior doctors on his team we could predict what he would ask over and over again – which was “why?” “Why do you want to measure sodium?” and “Why did you call the neurologist without asking him a precise question?” He almost never ordered additional tests or procedures. He may have asked if the candidate would agree to do a simple blood count in a patient with a suspicious “palmar-haemocytometer count” (nothing more than comparing the colour of the patient’s palm with that of the doctor’s).
The modern version of the “why” strategy (soon shortened to Y strategy) is the “Y nurse.” The Y nurse’s job is to ask: “Why are we doing this and that?” Well trained, highly experienced, and widely recognised, the Y nurse is an independent member of the team responsible only to the CEO. Their job is to support generation of optimal outcomes, i.e. the best possible clinical result for the least resource consumption. He or she has to identify questionable and poorly supported decisions of the team but should never make decisions. We learned from another project that medical students can function as valuable (and affordable) professional sceptics as long as they only register their scepticism but leave the final decision with the authority that will and can take the responsibility (1). To complete the role of a Y nurse, excellent clinical knowledge in the specialty is a prerequisite but not sufficient.
Attitude, skills, and knowledge of clinical epidemiology and basic microeconomics are also essential (2). The Y nurse can be expected to improve outcomes. He or she may not necessarily improve the patients’ survival rates but is very likely to improve patients’ quality of life, will almost certainly prevent unnecessary services, and save more money than her/his attractive salary will consume. This means that the Y nurse will definitely increase the efficiency of healthcare. We are working on a concise textbook and a first course for Y nurses.
Competing interests: I received no support from any organisation for the submitted work. I have had no financial relationships with any organisations that might have an interest in the submitted work in the previous three years and no other relationships or activities that could appear to have influenced the submitted work.
Franz Porzsolt is the head of clinical economics at the Institute of History, Philosophy, and Ethics in Medicine at the University of Ulm in Germany (www.uniklinik-ulm.de/clinecs)
- Porzsolt F, Braubach P, Göller A, Flurschütz PI, Sailer MB, Weiss M, Wyer P. The efficient contribution of medical students and the feed-back of their supervisors can help avoid the expert bias in medicine. Submitted for publication.
- Porzsolt F, Kaplan RM, eds. Optimizing health – improving the value of healthcare delivery. New York: Springer, 2006.