In the past, long before Covid, doctors used to openly discuss complex cases and unexpected deaths on an anonymous basis either in the doctors' mess or in medical grand rounds hosted by their hospital’s clinical education department. What's happened to these forums for learning? Are these clinical conversations alive and well, and helping doctors and nurses alike to learn from safety incidents? Or have medical grand rounds disappeared from practice?
At the Safety for All conference held at the Royal College of Physicians in December, I heard a huge number of experts call for new ways to improve safety. The event was hosted by Patient Safety Learning, a charity leading the way to galvanise people to take action on safety. I was prompted to ask about medical grand rounds as a way to discuss medical errors and a safe place for safety discussions.
These discussions may well have transformed into WhatsApp chats or video calls – but I hope the medical grand round with many different specialties joining in still takes place, even if it takes a virtual form for our new digital age. My interests when I was a junior doctor included medical evidence, how to communicate clinical risk and emerging threats to health. I was an active participant in medical grand rounds, which meant sitting in a lecture theatre in King's College Hospital.
I caught up with one of my alumni from King's College Hospital, Dr Raza Malik, now Chief of Hepatology, Lahey Hospital & Medical Center, Massachusetts, and he said: “I loved medical grand rounds at King's College Hospital with giants in medicine inspiring me to maximise my potential as a physician to enhance clinical care and improve human health”.
Dr Malik’s career has taken him to all corners of the globe, starting with the NHS in the UK, volunteering in Malaysia and Borneo through to Australia and finally landing in the USA as the Chief of Hepatology at one of the largest liver units in the world. He says this is “ironic because King's is where it all started and is itself the first and largest liver transplant unit in Europe.”
Dr Malik believes grand rounds are crucial for education, saying they “provide an academic forum to critically evaluate complex cases in a multidisciplinary format that is unique in medicine and critical for clinical care and education.“
Can grand rounds be a useful forum for learning from medical errors? I heard from Dr Phil Batty, President of the Independent Doctors Federation, who said: “The most important aspect in learning from medical errors is the culture of the doctor and the team or organisation in which they work. Recognising mistakes is the first step. The vast majority of caring doctors will find mistakes painful because they care. Overcoming the dissonance of denial is the first step”
Dr Batty said it works better when colleagues, family and a structure within an organisation support a learning environment. “Often mistakes are multifactorial and a safe learning environment facilitates learning for individuals and systems.”
In the private sector, medical grand rounds are alive and well. Dr Batty says “doctors learn from auditing their work, patient feedback, morbidity and mortality meetings” and that “ideally we learn from others' mistakes, but inevitably we make mistakes ourselves. Doctors are humans and nobody is perfect”.
Dr Batty is optimistic that sharing mistakes openly and transparently with colleagues is the most powerful learning tool, but a support network needs to be in place because it can be “challenging for the individuals concerned who need support.”
Discussing medical errors and sharing learnings from mistakes is a longstanding part of continuing professional education, highlighted 20 years’ ago by Dr Richard Smith, former-editor of the BMJ who said in a blog: "All life is mistakes. The more mistakes you make, the better." Mistakes are great teachers, but they also allow us to get through the day. Try to spend a day without making a mistake, and you’ll do nothing. So I find it hard as I survey 52 years of mistakes to pick my biggest. I’m spoilt for choice..."
The mistake Dr Smith chose to discuss was about deciding to not treat a patient and simply tucking him up in bed. "This was a mistake with wholly positive outcomes. The patient did well—and might not have done if we’d tried some heroic treatment. I learnt about the severe limitations of medicine and that I was a fool. Only unthinking fools could have decided to leave a man to die without learning more about him and talking directly to his relatives. I couldn’t claim now not to be a fool, but that mistake made me a wiser fool."
Doctors and clinicians need to be able to discuss cases and incidents for learnings openly. Medical grand rounds are a great way to bring a wide range of different specialists together to bring fresh perspectives to solve tricky cases. We need to encourage transparency and safe spaces for doctors and nurses to speak up. I hope that learning keeps evolving and grand rounds adapt for the digital age.
- Smith R. Tell us your greatest mistake and what you learnt from it. BMJ 2004. Accessed on 11 December 2023. https://www.bmj.com/content/suppl/2004/11/11/329.7474.DC3.
I'd love to hear from you. Do medical grand rounds still exist? What do you do in your organisation? Comment below. (You will need to be a member of the hub, and signed in. Membership is free and you can sign up here.)
About the Author
Dr Annabel Bentley originally trained as an NHS surgeon. She’s worked as a chief medical officer and a medical director across a range of healthcare organisations for over 30 years, spanning London teaching hospitals, large medical insurers and diagnostics providers and health tech start ups.
She’s provided evidence to the government’s Paterson Inquiry 2020 and was a member of the Department of Health’s Expert Working Group for the Information Standard, the first certification scheme for high quality health content.
She has been a Responsible Officer for seven years; established and chaired clinical risk committees. Her interests include evidence-based healthcare and patient safety. She is an independent healthcare consultant and charity trustee.