Nov. 24, 2009 Involving family members of pediatric cancer and hematology patients in medical rounds benefits both the family and the medical team, according to a new Indiana University School of Medicine study.
Riley Hospital for Children, where the study was conducted, is now one of only a small number of hospitals nationwide routinely offering the parents of pediatric cancer and hematology patients the opportunity to join their child's medical team as active participants in the discussion and planning of their son's or daughter's care.
Medical rounds in hospitals across the United States have changed over the years. They have evolved from formal didactic presentations conducted with great pomp in auditoriums with theater seating where the patient sat quietly on display; to bedside rounds as portrayed in television programs such as Scrubs, Grey's Anatomy and House. The current practice of sit-down team rounds physically removed from the family and patient have become standard due to heighted sensitivity to medical privacy.
The composition of rounding teams has evolved as well. At leading medical institutions, like Riley Hospital, the rounding team has expanded to include nurses, social workers, nutritionists, clinical pharmacists, and others in addition to the traditional medical students, residents, fellows and the attending physician. The more medical participants involved, the less likely parents were to participate as team rounds moved from the bedside to the conference room.
"Parents of children with cancer are often in an unsettling environment and are under a lot of stress. They frequently feel unable to communicate effectively with the many people who are taking care of their daughter or son. They may be reluctant to leave their child's bedside for fear of missing the opportunity to talk with members of the medical team," said Holly M. Knoderer, M.D., M.S., clinical assistant professor of pediatrics and clinical pharmacology at the IU School of Medicine and a Riley Hospital oncologist, who conducted the study and published its results in the November 2009 issue of Academic Medicine.
"The importance of the family's involvement in caring for children with cancer and blood disorders is as tremendous as the need to successfully educate our medical students and residents about the value of effective communication and family-centered care. Despite initial reluctance from fellows and nurses, having family members join in rounds was hugely successful and improved the standard of care," said Dr. Knoderer, who is a member of the Indiana University Melvin and Bren Simon Cancer Center.
Each weekday morning, patients' families are given the opportunity to sign up to attend sit-down team rounds when their child's case is discussed. Participation is voluntary, and family members can both ask questions and offer input. Together, medical students, residents, fellows, family members, and the attending physician formulate the treatment plan for that day. "Doctors are the medical experts, but the parents are the expert on their child. Treating parents as valued team members not only increases family satisfaction but improves care," says Dr. Knoderer.
"An unexpected benefit of the new style of rounds was that parents were less distracted in team rounds than at the bedside. In the child's room, parents and physicians often balance a ringing phone, computers, television/video games, a demanding sibling or a patient request. We observed that parents sitting in rounds were more focused and often came with a list of specific questions or concerns. Because the family understood that they had limited time in team rounds, they were more focused," wrote Dr. Knoderer. Additionally, parents were no longer afraid to leave their child's room in fear that they would miss an opportunity to talk with the attending physician.
The presence of family members in team rounds minimally prolonged team rounds. Overall, medical team work load was either unchanged or somewhat shortened during the study, as most families who attended team rounds needed far less time later at the bedside, and plans were less likely to change as a result of discussions made earlier in the day during team rounds.
One hundred percent of families who participated in the program indicated that family inclusion in rounds should be continued. For some patients, both the mother and father attended. Other days, one parent attended while the other stayed at the bedside. Older siblings or grandparents who were active participants in the patients' care often attended rounds. Teenage patients were also invited. In fact, it was often the teenage patients who attended most regularly. "Families reported increased feelings of inclusion, respect, and having a better understanding of their child's care," Dr Knoderer reported.
While medical students and resident physicians recognized the value of family inclusion for patient care and family satisfaction, some doubted the benefit to their own training. Yet, all acknowledged that parents should be allowed to participate in team rounds. Attending physicians indicated that parental inclusion in team rounds was an important teaching opportunity. It allowed attending physicians to better observe, evaluate, and give feedback on the trainees' communication skills.
"Parents of children with cancer become quite savvy. They reserve their toughest questions for the attending physician. When the attending makes rounds alone, the medical team can't witness these sensitive discussions. Allowing the medical trainees to witness difficult conversations about diagnosis, treatment and prognosis gives trainees a basis from which they develop their own practice style. Each interaction between parent and attending physician allows trainees to determine how the trainee can most effectively communicate with their patients. We hope that our trainees can use these interactions to model their own style of interaction with patients and families. We aim to provide the foundation on which each trainee can build effective communication skills," said Dr Knoderer.
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