Communication on Rounds

The role of rounds culture and communication in patient care and teaching

Background: The daily visit by the treating doctor or medical team at the bedside of the hospitalized patient («rounds») is essential for patient-centered care and interprofessional exchange.

Methods: This narrative review is based on pertinent publications (up to December 2024) that were retrieved by a selective search in the PubMed/Medline database.

Results: Bedside rounds are used to fulfill multiple tasks: medical, communicative, and educational. Complex social interactions, in particular, require precise and empathetic communication. 71% of patients say they primarily expect clear information about their medical situation. Information exchange can nonetheless be difficult, particularly with older and frail patients. So-called teach-back techniques improve patients’ understanding of medications and behavioral instructions (OR 1.84 [1.09; 3.12] and 1.83 [1.07; 3.13], respectively). Although many patients would like to take active part in discussions on rounds, the physicians explicitly encouraged them to do so in only 54% of cases. If the team discusses the patient outside the room before entering, the patient’s understanding of their condition is no different, but they are less likely to be confused by medical technology (21.3 versus 13.7); team satisfaction is higher (78.0 versus 68.3), and there is more opportunity to discuss sensitive topics (84.3 versus 59.3, each on a visual analog scale VAS 1–100).

Conclusion: Interprofessional discussion of the patient and suitable communication on rounds can improve patient care and are essential for undergraduate, postgraduate, and continuing medical education.

Cite this as: Gössi F, Becker C, Gross S, Arpagaus A, Bassetti S, Hunziker S: Communication on rounds: The role of rounds culture and communication in patient care and teaching. Dtsch Arztebl Int 2025; 122: 362–70. DOI: 10.3238/arztebl.m2025.0080

Ward rounds are a central instrument of inpatient medical care (1). The objectives of rounds are varied and include assessing the clinical course of illness and the patient’s well-being, reviewing diagnoses, and addressing relevant problems. They give the treating team the opportunity to discuss, coordinate, and document the next steps with the patient (2, 3).

Rounds are characterized by complex social interactions, and the question arises: what constitutes good rounds (4)?

Schmelter et al. (e3) have identified nine skills physicians should have when conducting rounds.

The two skills that are most frequently called upon are direct communication with the patient and communication within the treating team (e1, e2, e3).

The aim of this article is to highlight the importance of the structure of rounds for communication and teaching, to present the patient’s perspective during rounds, and to convey the key skills for successful rounds.

Learning objectives

This article should enable readers to:

• understand the central role of rounds in inpatient medical care and the different round structures (bedside, non-bedside) and their advantages and disadvantages for communication, teaching, and clinical thinking;
• apply the identified key skills for successful rounds, such as collaborative clinical group reasoning and the teach-back method;
• develop strategies that acknowledge and promote active consideration of the patient’s needs in decision-making processes during rounds.

Methods

This narrative review is based on publications up to December 2024 that were retrieved by a selective search in PubMed/Medline with the terms “ward round communication” (421 hits) and “ward round patient” (1,447 hits). After the titles, abstracts, and full texts of these publications were reviewed, 74 articles were retained for consideration, including 25 from the USA, 13 from Germany, 9 from Switzerland, 8 from the UK, 6 from Australia, and 13 from 9 other countries.

The role of rounds structure for communication, teaching, and clinical thinking

In the German-speaking countries, attending rounds and consulting rounds are usually structured with the initial discussion being held outside the patient’s room. The treating team then enters the room and continues the discussion with the patient (we refer to this as “non-bedside rounds”). In a large randomized trial that was conducted in three Swiss hospitals and included a total of 919 patients, this structure was found to be superior to bedside rounds with respect to certain aspects of communication. Patients in the bedside group more often stated that they were confused by medical jargon (mean bedside rounds vs. non-bedside rounds, 21.3 vs. 13.7 points on a 100-point visual analog scale [VAS]; adjusted difference 7.58, 95% confidence interval [3.67; 11.49], p < 0.001). There was no significant intergroup difference in the primary endpoint of the trial, the patients’ rating of the knowledge they had gained about their diagnosis and treatment. (79.4 vs. 79.5 out of 100 points, adjusted difference 0.09, [−2.58; 2.76], p = 0.95). The subjects were a broad sample of patients treated in general internal medicine wards; their median age was 69 years, and their most common primary diagnoses were cardiological (29%) and infectious (24%) (5) (Table 1).

Table 1

Studies on rounds in general

The main purpose of rounds is to optimize patient care. In an American study, 48 attending physicians and 31 medical students were asked about the goals of rounds in semi-structured interviews (6). Both groups considered rounds to be a valuable opportunity for training and continuing education, despite the amount of work involved, especially because they offer frequent opportunities for teaching. 218 statements on the purpose of rounds were collated: 30% related to training and continuing education, 34% to communication between the patients and the team, 16% to patient care, and 17% to assessment and feedback. This study highlights the importance of training and continuing education alongside the direct demands of patient care. Attending physicians must carry out the dual tasks of patient care and teaching in the limited time available (7, 8).

During rounds, physicians are often confronted with diagnostic and therapeutic uncertainties (9). A preliminary discussion outside the patient’s room lets attending physicians consider differential diagnoses, verbalize their thoughts, and discuss them with the interns and residents while out of the patient’s hearing (8).

This mode of information exchange, is sometimes informally called “talking to the room,” or, more formally, “collaborative clinical group reasoning.” The participants arrive at a shared understanding of the medical situation, followed by joint decision-making. It is an interactive thought process within the medical team in which the expertise and different perspectives of all team members are brought together for the optimal joint formulation of a diagnosis and a decision on treatment. As this is a team process, it requires good communication skills (e4, e5).

A clearly structured and concise case summary (“problem representation”) is the take-off point for diagnostic thinking. Non-bedside rounds let attending physicians give trainees immediate feedback on their case presentation, which is harder in the patient’s presence (8, e6). Unsurprisingly, attending physicians were less satisfied with rounds conducted entirely at the bedside (mean bedside versus non-bedside rounds 66. 6±21.8 versus 82.6±13.9 out of 100 points, adjusted difference –16.51, [–20.29; –12.72], p=0.002) (10) (Table 1). At the same time, teaching medical students under direct observation at the bedside is essential for learning clinical skills such as taking a medical history and performing a physical examination (11, 12). Supplementary teaching rounds with a didactic focus are desirable, and experience shows that they are also well received by patients.

Bedside communication

In a large-scale study conducted in Freiburg, Germany, the daily activities of 250 doctors in seven different hospitals over a period of 14 days were assessed (13). On average, they spent 46% (range, 35–60%) of their inpatient working time in direct contact with patients. No distinction was made between operating time and rounds, although there were clear differences between disciplines: surgeons spent less time with patients overall than internists. In a study from Rostock, Germany, this matter was examined in greater detail (14): it was found that internists (n = 3) spent an average of 62 minutes (50–73 minutes) per day with their patients, while surgeons (n = 3) spent an average of 18 minutes (7–28 minutes) with them, not including operating time. In a study from Lausanne, Switzerland, rounding times were examined more closely: 36 trainees in internal medicine working the day shift had an average of 198 minutes [177; 218] of direct patient contact, of which 142 minutes [131; 154], or 71%, were on rounds (Table 1) (15).

Rounds are important for communication between physicians and their patients. Studies have shown that the quality of this communication influences various clinically relevant outcomes, including understanding of medical information (16), readmission rates (17), and adherence to treatment (17, 18) (Table 2). In particular, the quality of the doctor-patient relationship is essentially determined by communication (e7).

Table 2

Studies on patient safety and adherence

Multiple studies have identified six core elements of doctor-patient communication (e8, e9, e10, e11, e12, e13, e14) that can be considered in the setting of ward rounds (Box).

Box

Six elements of physician-patient communication

The patient’s perspective

For many hospitalized patients, rounds are very important; they have even been described as the “most important minutes of the day” (19, 20, 21, e15). 211 patients on Swiss internal medicine wards (median age 67.6 ± 17.56 years) questioned in a survey expressed three key expectations of physicians on rounds: honesty, transparency, and reliability (22). 71% said they mainly wanted understandable information about their current medical situation. Intelligibility was directly correlated with patient satisfaction (22) (Table 1).

Elderly and frail patients are particularly vulnerable when it comes to communication. An acute illness causing weakness and fatigue to a degree that necessitates hospitalization can make it even more difficult to remember and understand information (23, 24, 25). In a Taiwanese study of 30 elderly patients (median age 80±6.8 years), it was found that medical information provided during rounds is soon forgotten. Of a total of 28 pieces of treatment information, patients were able to recall seven (25%) an hour later and only four (14%) four hours later (24).

Effective communication is clear and concise. It can be supported by deliberate repetition with regular checking that patients have understood both the content and the tone of the information provided. An effective communication technique is the “teach-back” method, in which patients are asked to summarize the information they have been given in their own words. This improves understanding and leads to better patient care, e.g., with respect to medication intake (16). (Table 2).

A Danish systematic review of seven studies concerning rounds on elderly patients reveals the importance of generational differences and asymmetrical (knowledge) relationships between physicians and patients. Patients may accept recommendations passively, especially if they are not actively encouraged to participate (“empowered”). (26).

On the basis of findings from 18 qualitative studies, a Norwegian research group recommends giving elderly and frail patients important information in written form and involving the family as an essential component of treatment, either by having family members present during rounds or by contacting them afterward (25).

Patient participation and control over decision-making

Another basic need of patients is active involvement (participation) in the consultation (22). In an Australian study, 113 consultations with 52 patients were observed. The doctors explicitly encouraged their patients to participate in only 54% of cases – e.g., by asking open questions about their concerns or worries (20).

Patient participation on rounds is not synonymous with shared decision-making. In a Swedish study semi-structured interviews were conducted with 15 elderly and frail patients (mean age 84, range 75–96). For the respondents, participation primarily meant receiving understandable information and being able to ask questions (23). The Australian study mentioned above showed that patients’ contributions to the conversation only influenced decision-making in 18% of rounds (20).

Patient’s Decisional Control Preferences (DCP) is a validated instrument, originally developed in 1997 for a study of patients with breast cancer, that is often used to assess the level of control that patients want to have in medical decision-making processes (e15, e16). The desired level is classified as active (the patient decides alone), collaborative (the patient and physician decide together), and passive (the physician decides alone). In a systematic review of the subject that was published in 2021, including a total of 13,247 cancer patients from 31 different studies over the period 2009–2020, active decision-making was preferred by 25% of patients, collaborative by 46%, and passive by 27% (27). A comparison with a study by Stock et al. published last year in this journal reveals how strongly such preferences can depend on patient characteristics and on the disease in question: in the latter study, only a minimal number of healthy women with the pathogenic BRCA1-/2 gene mutation preferred to take a passive role in decision-making (e17).

The DCP has not yet been extensively studied in the context of rounds on the internal medical ward, but a large-scale study from Switzerland (19) has revealed that most patients in this context prefer collaborative decision-making (62.2%, compared to 15.4% active and 22.5% passive). Patients who preferred active decision-making discussed sensitive topics more often than those who preferred passive decision-making (66.7% vs. 79.3% of rounds, adjusted OR 1.92, [1.1; 3.37], p = 0.022). (19). It remains unclear whether the preference for decision control can change over the course of a hospitalization, and to what extent the patient’s state of health influences the preference (20). The findings of two further studies from the USA (28) and Australia (29) are shown in Table 3.

Table 3

Studies on patient participation and patients’ preferences regarding their role in medical decision-making

Communication within the team

Merriman et al. conducted a qualitative study in an intensive care unit in England, examining 28 rounds on a total of 348 patients. Brief interviews of the medical team were carried out to put the observations in context. The investigators analyzed which elements of the rounds had worked well. In addition to medical expertise, they identified three key elements for successful rounds: medical expertise, time management, and effective team communication (4).

The desired result of effective communication within the team during rounds is that the decisions taken and the processes that are clearly defined should be understood by everyone involved. Effective communication also ensures that all participants know who is responsible for carrying out the measures that have been decided on (4).

Nurses and doctors appreciate the opportunity for discussion outside the patient‘s room during rounds. In a secondary analysis of the findings of the Swiss randomized trial presented above, teams that did not hold preliminary discussions outside the patient’s room reported that they more often felt uncomfortable when talking to patients (22.28 ± 26.60 vs. 13.68 ± 21.06 out of 100 points, adjusted difference 8.55, [5.69; 11;41], p < 0.001) and were less able to discuss sensitive topics (59.3 ± 30.4 versus 84.3 ± 20.9 out of 100 points, adjusted difference −25.67, [−28.87; −22.47], p < 0.001) (10)(Table 1).

There is a lack of research on the optimal team size and composition for rounds. Studies in English-speaking countries have shown, however, that large round teams with additional members, e.g., from social services or discharge management, can be perceived by patients as overwhelming (e18, e19). This is particularly true for elderly patients, for whom smaller teams are recommended (26).

The “team member” with the greatest continuity is the electronic patient record (e20). Inadequate and deficient communication during handovers from physician to physician or from nurse to nurse is a common cause of medical errors. In a study of 10,740 inpatients, the introduction of structured, checklist-based handovers among physician trainees lowered the frequency of medical errors by 23% (from 24.5 to 18.8 per 100 admissions), and that of preventable adverse events by 30% (4.7 versus 3.3 per 100 patients) (30) (Table 2).

Surgical rounds

In addition to operative skills, postoperative ward rounds conducted by the surgical team are essential for achieving good patient outcomes, as they enable the early detection of complications and timely intervention. The skills needed for surgical rounds are the same ones needed for internal medicine rounds (e23, e24).

In semi-structured interviews with 15 physicians at various hierarchical levels, five nurses, and five patients in a general surgery ward in the south of England, 92% (23/25) stated that they perceived significant differences in the quality of rounds. Lack of thoroughness (18/25, 72%) and poor communication (12/25, 48%) were the most frequently mentioned problems (31). In a randomized simulation trial, with 29 surgical residents participating, a half-day course in ward round management markedly improved performance: the intervention group showed better results in clinical patient assessment (79.8 ± 11.9% vs. 63.5 ± 8.1%, p = 0.002), patient management (72.2 ± 10.3% vs. 56.0% ± 19.7%, p = 0.014) and non-technical skills (including communication and teamwork) (23.3 ± 1.2 vs. 17.8 ± 2.1, p < 0.001) (32)

The duration of ward rounds varies depending on the complexity of the patients’ diagnoses and the medical specialty. In a Swiss study, the average ward round duration on an internal medical service was 14.1 minutes per patient (5). In contrast, a study conducted on a general surgery ward in Germany found an average time of 4.9 minutes per patient (e25). In a survey of surgical interns and residents and attending surgeons (n = 30) at the Munich university hospital, the average duration of rounds per patient was estimated at 4 minutes (e23). In other studies from Germany and New Zealand, the actually measured duration of surgical rounds was much lower, at 1.5 to 2.5 minutes at the bedside of each patient (e25, e26).

Traditional quality indicators, such as length of hospital stay, depend on many factors, and satisfaction surveys often suffer from a ceiling effect; thus, objective standards for the optimal duration of rounds are difficult to define (33). In a study from England, all important aspectsof internal medical rounds were defined, and rounds were then systematically carried out accordingly. These rounds lasted 12 minutes per patient (8 to 24 minutes) (34). This corresponds to observations from other, comparable studies of non-surgical rounds (5, 12, 35).

Postoperative care follows standardized processes and is strongly focused on patient safety, which is why the use of checklists is particularly suitable here (36). For example, one study showed that before the introduction of a checklist, peripheral intravenous catheters were discussed in only 9% of rounds and urinary catheters in 15%. Afterward, these figures rose to 72% and 76% (37).

Nursing staff, who spend a third (31–37%) of their working time at the patient’s bedside (e27, e28), also play a crucial role in patient safety. Studies show that the amount of time nursing staff spend directly at the patient’s bedside is inversely correlated with the rate of complications such as pressure ulcers, pneumonia, urinary tract infections, sepsis, medication errors, and even (in two studies) death (38, e29, e30). In a retrospective American study published in 2002, in which data from 6,180,628 patients in 799 hospitals were analyzed, the time spent by nurses at the bedside and the percentage of nursing services provided by registered nurses rather than licensed practical nurses were both found to be negatively correlated with the incidence of nosocomial infection. In hospitals with a higher ratio of registered nurses to licensed practical nurses (hospitals in the 75th versus 25th percentile), the increased use of more highly qualified nursing staff for medical patients was associated with a lower rate of urinary tract infection (−9.0%, [−6.1; −11.9%], p < 0.001) and nosocomial pneumonia (−6.4%, [−2.8; −10.0%], p = 0.001). These findings remained significant after adjustement for hospitals, diagnosis-related groups (DRGs), and comorbidities, among other factors (38).

Training in skills for rounds

Doctors who have completed medical schooland are at the beginning of their postgraduate training must be able to conduct rounds independently. A study conducted on 45 medical students in their final year at the university hospital of Heidelberg, Germany, revealed that they performed well in team and patient communication during simulated rounds, meeting 86% and 79% of learning objectives, respectively. Deficits were found, however, in the interpretation of electronic patient charts, initiating further diagnostic and therapeutic steps, medication adjustments, and documentation (49% of learning objectives achieved) (39).

In the German-speaking countries, trainee physicians (interns and residents) and attending physicians are responsible for teaching medical students in their final, practical year during ward rounds and preparing them for their future role (e31). Students should not just be passive observers; they should take over the care and ward rounds for some of the patients, under supervision. Some hospitals in Germany offer special ward round training for this purpose (40) or have even established their own training wards (e32, e33, e34).

Conclusion

Rounds require not only sound medical expertise, but also efficient procedures, good time management, and communication skills, both between physicians and patients and within the treatment team. Since rounds are a complex social interaction, more attention should be paid to their communicative dimensions in training, continuing education, and professional development. Open research questions concern the optimal size of the ward round team and the most effective way of conducting and structuring conversations. Qualitative and descriptive observational studies could provide valuable insights for the formation of hypotheses that could then be tested for causal relationships in interventional trials.

Conflict of interest statement
The authors state that they have no conflict of interest.

Manuscript submitted on 5 September 2024, revised version accepted on 2 May 2025.

Translated from the original German by Ethan Taub, M.D.

Corresponding author
Prof. Dr. med. Sabina Hunziker

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