The Fog of Wards

Abstract

Our department meets for Morbidity and Mortality meetings every quarter. The confidential discussions are non-judgemental and non-confrontational. We acknowledge the professionalism of all the clinicians involved in the cases being discussed and look for systems problems to review and address. As much as we try, we cannot prevent a spike in anxiety in the lead-up to our meetings. Everyone involved in the cases being discussed, especially the doctors in training, dread the meetings.

Medicine is hard. Inpatient medicine is especially hard. Dealing with sick children is a challenge. Emotional, distressed, anxious, or threatening parents are a challenge. Making informed, timely decisions is hard. Trying to manage a team of clinicians with differing levels of skill and enthusiasm is hard. Working in an often cramped and noisy office, focusing while there is a wall of noise from other teams handing over in the background, is hard.

We look to the evidence for guidance. Case reviews and case studies present clinical medicine as orderly and methodical. Data is presented in a logical sequence. The authors portray themselves as calm and professional. No one describes how it took three different people to do the lumbar puncture, or that the MRI was only performed after three calls to the on-call radiologist and two calls to the anaesthetist. The evidence often gives the false impression that clinical medicine is calm and efficient.

The expression ‘fog of war’ has been used to capture the uncertainty of the situation in war for more than a century. It aims to describe the uncertainty in situation awareness that soldiers experience in military operations.

We should acknowledge to our doctors in training that ward work is hard. The weeks of ward service are the most intense weeks of our year. Many of our colleagues fear their weeks on the ward. We discuss amongst ourselves the “fog of wards”: The difficulty in making time-sensitive decisions with incomplete data, of having to juggle two or three phones, the constant stream of ‘chat’ messages, the multiple interruptions and demands, the burden of the hundreds of clinical decisions, and the fear of making a mistake, of missing a critically ill child.

When we sit down at our next Morbidity and Mortality meeting, the opening slide, as well as acknowledging that the meeting is confidential and non-judgemental, will acknowledge the fog of wards. The cases will be discussed as bullet points, methodically and thoroughly. But, we will acknowledge that ward work is hard and stressful, and that no matter how many years we practise, the fog of wards never lifts.

We will also highlight what can be done to lift the fog: Minimise distractions on the ward. Find a quiet space to work. Treat the ward round with the respect it deserves and call people back who interrupt it. No one stops surgery to take a non-urgent call; you should not stop a ward round either for non-urgent interruptions. We should use our colleagues as mentors and sounding boards. They are a wealth of experience and perspective and can give clarity after many days of decision fatigue. In addition, take breaks. Weekends, holidays, sabbatical, and long service leave are essential to ward off the fog.

Gabriel Dabscheck and Nicola D. Fearn conceived and wrote this article together.

The authors declare no conflicts of interest.