CONTROVERSY
The Case for the Medical Grand Round
Med Teach Downloaded from informahealthcare.com by University of Otago on 12/28/14 For personal use only.
H . J. F. Hodgson, D M , MRCP, is Senior Lecturer in Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK. The medical grand round is under attack-not least by Dr Jack Gilbert (Medical Teacher, 1979, 1, 314-315).. The round forms a convenient symbol for the academic medical centre, for it fills a role as the showpiece of such institutions. It is impossible not to suspect that the assault on the round is a vicarious exercise: the real target is the academic centre itself, which must be exposed as an overprivileged, overspecialized ivory tower, lacking relevance to the community at large and diverting the medical student from the problems of primary health care. The attack, however, is not launched by a bold frontal assault, but by undermining and innuendo. The grand round, they say, is an inefficient teaching tool-it has never been demonstrated to be efficient. The grand round attempts to provide for both teacher and student obviously an impossible task. Most heinous of all -grand rounds are not what they used to be. Let it be clearly admitted at this stage that there is no evidence to justify the continued existence of medical grand rounds. Like most of the basic tools of medical education -clerkships, lectures, ward rounds -they ‘just growed’. One may, in passing, note that their continuing existence, indicating the willingness of a large number of physicians to appear weekly in the same place at the same time, implies a value; in these democratic days the useless and unwanted rapidly crumbles. Let us now examine in detail the potential value of such meetings. Potential Value-Something
for All
Consider first the consultant. In the institutions of which we speak, he is a specialist. He has enormous expertise in his chosen field, in which he researches, teaches and practises. His clinic is full of patients with the condition in which he has made his reputation. He reads extensively and travels widely to attend meetings on his subject. He is in line to meet the specialist’s job description -to know more and more about less and less. Clearly, when his own topic is discussed at the grand round he has a great deal to offer. But he also has a unique opportunity to learn when the case under discussion is not one of his. Few of us have the time or dedication to keep up with the most
98
advanced research of other specialties in our private reading. Meetings of general medical societies have fragmented into simultaneous subspecialty sessions; our own specialist societies discuss only the familiar. The domestic grand rounds, with their wide attendance, offer the specialist a rare opportunity to learn from what his other specialist colleagues are thinking and doing. Moreover, the resulting cross-fertilization of ideas bet ween specialist clinicians and laboratory scientists can lead to innovative research. Let us turn next to the registrar or houseman upon whom the task of presentation has fallen. He has to collate a clinical history, physical findings, investigations, diagnosis and treatment. In a well-balanced presentation he will place the case in the context of recent advances, and may draw attention to local research interests germane to the issue. I have no doubt that the presenter learns from his part in a grand round. Not only may this be the first occasion on which he has spoken publicly before a large audience (a useful skill which becomes easier with practice, although I have no evidence to support the latter assertion), but he must be prepared to undergo cross-examination. The questions that arise from the audience lack the predictability of those from other members of his own unit, so his background preparation must be impeccable. More than this, a wellpresented grand round case imposes a discipline of thought far removed from the easy pragmatism of much day-to-day clinical care. The prospect of being questioned in public is a great spur to logical thought, and the omitted investigation or unexplained anomaly becomes glaringly obvious in this context. Details of family history, occupational exposure or drug therapy may take on unexpected relevance during the presen tation of the case. If current research interests of the department are presented, the public examination of their value and originality offers a form of unofficial audit often more immediate and persuasive than that of editors or grant -giving bodies. And what of the medical student? To the antagonist, the medical student exposed to the grand round is forced to endure a lengthy discussion in which he cannot participate, and which is carried on far above his head about Medical Teacher V o l 2 No 2 1980
Med Teach Downloaded from informahealthcare.com by University of Otago on 12/28/14 For personal use only.
minutiae of little relevance. No doubt medical rounds can be carried out in such a fashion, but consider the ideal. No medical student - no physician either -will personally encounter all the obscure conditions of medicine. T h e round offers a means of sharing clinical experience. It is generally recognized (another un supported assertion) that clinical medicine is learnt from the patient; any physician recalling his first solo diagnosis in a n elderly patient with acute wheezing will remember how he learnt the difference between asthma and left ventricular failure. T h e generalized descriptions in textbooks provide only a background, but the case history of the medical grand round, leading the audience through the diagnostic process, can approach the reality of personal experience. In addition, in such presentations the student may see placed in context recent advances in diagnosis or treatment, and understand the relevance and limitations of modern research techniques. If his future lies in general practice outside hospital medicine, medical grand rounds may form his sole exposure to active medical research. How may one design a grand round that fulfils these objectives? There is unlikely to be one answer applicable to all institutions, but I will describe the format used in a major London postgraduate medical school, not because
I COURSESAND I
Audiovisual
Communication
in.
Medicine and the Life Sciences 9- 13 September, University of Stirling, Scotland A conference organized by the Institute of Medical and Biological Illustration which will be of interest to illustrators, teachers and researchers in the fields of medicine, veterinary medicine, biology, nurse education and health education. Academic Programme The academic programme will cover all aspects of audiovisual communication techniques including art, photography, films, television and sound recording. Workshops A comprehensive programme of small
Medical Teacher V o l 2 No 2 1980
it is ideal, but because it works. In 75 minutes three cases are presented, and in each the case history, illustrative material, radiology, a brief interview with the patient if appropriate, literature review and research considerations are restricted to fifteen minutes. T h e necessity to keep within this time limit causes even the most ponderous presenter to perform at a brisk pace, maintains the attention of the audience, and rarely leads to the omission of significant detail. Discussion is orchestrated by the Chairman of the Department of Medicine, or his most senior deputy. T h e varied offerings and rapid pace are designed to stimulate interest, and specifically to exclude the lecture format; they ensure that the audience will continue to attend not because it is expected of them, but because they are fairly sure they will be interested, stimulated a n d occasionally amused. T h e continued success and vitality of medicine rests upon three pillars: good clinical practice, research and teaching. In very few daily activities d o these three coalesce, but the medical grand round is the opportunity p a r excellence. No educational researcher has gathered any evidence that they ‘work’, and I would not encourage them to waste their time upon such a project. Whilst grand rounds survive and flourish, that will be the measure of their value.
practical workshops will run throughout the conference in 14 individual rooms where experts will present a personal approach to many aspects of medical illustration and encourage active participation by the delegates. Social programme A full social programme will be arranged to include visits to Stirling Castle, Falkland Palace and other places of historical and cultural interest. Ladies Programme A special programme of interest to delegates’ladies will be arranged. Further information from: The Conference Secretary 2nd International Conference Institute of Medical and Biological Illustration c/o Department of Medical Illustration Western Infirmary, Glasgow G11 6NT Scotland
Academic Staff Development
Workshops Sponsored by the Co-ordinating Committee for the Training of University Teachers (CCTUT) and the Swedish National Board of Universities and Colleges (UHA). The first three workshops will draw participants from academic staff in Sweden and the United Kingdom. The
fourth, which is being run in association with the Ontario Universities Program for Instructional Development (OUPID), will also draw membership from Canada. The language of the programme will be English. Research and Creative Teaching 8 -20 April, University College, Oxford. How may academic staff advance their personal development in the related areas of research and teaching? Evaluating the Academic Department 9- 16 April, University of Durham How does a department actually judge itself? Can we identify criteria of excellence? What are the values and priorities in a time of economic stress, and what are the criteria for survival? Teaching Chemistry in the 1980s 9 - 17 April, University of East Anglia How should research in chemistry influence undergraduate teaching? Should current knowledge be more visible in the curriculum? Continuing Education 10- 19 April, University of Manchester What are the current concerns and possible future problems in continuing education? Further information from: Dr David Mack CCTUT-UHA Programme istrator The Registry University of East Anglia Norwich NR4 7TJ
Admin-
99
The Case for the Medical Grand Round
Med Teach Downloaded from informahealthcare.com by University of Otago on 12/28/14 For personal use only.
H . J. F. Hodgson, D M , MRCP, is Senior Lecturer in Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK. The medical grand round is under attack-not least by Dr Jack Gilbert (Medical Teacher, 1979, 1, 314-315).. The round forms a convenient symbol for the academic medical centre, for it fills a role as the showpiece of such institutions. It is impossible not to suspect that the assault on the round is a vicarious exercise: the real target is the academic centre itself, which must be exposed as an overprivileged, overspecialized ivory tower, lacking relevance to the community at large and diverting the medical student from the problems of primary health care. The attack, however, is not launched by a bold frontal assault, but by undermining and innuendo. The grand round, they say, is an inefficient teaching tool-it has never been demonstrated to be efficient. The grand round attempts to provide for both teacher and student obviously an impossible task. Most heinous of all -grand rounds are not what they used to be. Let it be clearly admitted at this stage that there is no evidence to justify the continued existence of medical grand rounds. Like most of the basic tools of medical education -clerkships, lectures, ward rounds -they ‘just growed’. One may, in passing, note that their continuing existence, indicating the willingness of a large number of physicians to appear weekly in the same place at the same time, implies a value; in these democratic days the useless and unwanted rapidly crumbles. Let us now examine in detail the potential value of such meetings. Potential Value-Something
for All
Consider first the consultant. In the institutions of which we speak, he is a specialist. He has enormous expertise in his chosen field, in which he researches, teaches and practises. His clinic is full of patients with the condition in which he has made his reputation. He reads extensively and travels widely to attend meetings on his subject. He is in line to meet the specialist’s job description -to know more and more about less and less. Clearly, when his own topic is discussed at the grand round he has a great deal to offer. But he also has a unique opportunity to learn when the case under discussion is not one of his. Few of us have the time or dedication to keep up with the most
98
advanced research of other specialties in our private reading. Meetings of general medical societies have fragmented into simultaneous subspecialty sessions; our own specialist societies discuss only the familiar. The domestic grand rounds, with their wide attendance, offer the specialist a rare opportunity to learn from what his other specialist colleagues are thinking and doing. Moreover, the resulting cross-fertilization of ideas bet ween specialist clinicians and laboratory scientists can lead to innovative research. Let us turn next to the registrar or houseman upon whom the task of presentation has fallen. He has to collate a clinical history, physical findings, investigations, diagnosis and treatment. In a well-balanced presentation he will place the case in the context of recent advances, and may draw attention to local research interests germane to the issue. I have no doubt that the presenter learns from his part in a grand round. Not only may this be the first occasion on which he has spoken publicly before a large audience (a useful skill which becomes easier with practice, although I have no evidence to support the latter assertion), but he must be prepared to undergo cross-examination. The questions that arise from the audience lack the predictability of those from other members of his own unit, so his background preparation must be impeccable. More than this, a wellpresented grand round case imposes a discipline of thought far removed from the easy pragmatism of much day-to-day clinical care. The prospect of being questioned in public is a great spur to logical thought, and the omitted investigation or unexplained anomaly becomes glaringly obvious in this context. Details of family history, occupational exposure or drug therapy may take on unexpected relevance during the presen tation of the case. If current research interests of the department are presented, the public examination of their value and originality offers a form of unofficial audit often more immediate and persuasive than that of editors or grant -giving bodies. And what of the medical student? To the antagonist, the medical student exposed to the grand round is forced to endure a lengthy discussion in which he cannot participate, and which is carried on far above his head about Medical Teacher V o l 2 No 2 1980
Med Teach Downloaded from informahealthcare.com by University of Otago on 12/28/14 For personal use only.
minutiae of little relevance. No doubt medical rounds can be carried out in such a fashion, but consider the ideal. No medical student - no physician either -will personally encounter all the obscure conditions of medicine. T h e round offers a means of sharing clinical experience. It is generally recognized (another un supported assertion) that clinical medicine is learnt from the patient; any physician recalling his first solo diagnosis in a n elderly patient with acute wheezing will remember how he learnt the difference between asthma and left ventricular failure. T h e generalized descriptions in textbooks provide only a background, but the case history of the medical grand round, leading the audience through the diagnostic process, can approach the reality of personal experience. In addition, in such presentations the student may see placed in context recent advances in diagnosis or treatment, and understand the relevance and limitations of modern research techniques. If his future lies in general practice outside hospital medicine, medical grand rounds may form his sole exposure to active medical research. How may one design a grand round that fulfils these objectives? There is unlikely to be one answer applicable to all institutions, but I will describe the format used in a major London postgraduate medical school, not because
I COURSESAND I
Audiovisual
Communication
in.
Medicine and the Life Sciences 9- 13 September, University of Stirling, Scotland A conference organized by the Institute of Medical and Biological Illustration which will be of interest to illustrators, teachers and researchers in the fields of medicine, veterinary medicine, biology, nurse education and health education. Academic Programme The academic programme will cover all aspects of audiovisual communication techniques including art, photography, films, television and sound recording. Workshops A comprehensive programme of small
Medical Teacher V o l 2 No 2 1980
it is ideal, but because it works. In 75 minutes three cases are presented, and in each the case history, illustrative material, radiology, a brief interview with the patient if appropriate, literature review and research considerations are restricted to fifteen minutes. T h e necessity to keep within this time limit causes even the most ponderous presenter to perform at a brisk pace, maintains the attention of the audience, and rarely leads to the omission of significant detail. Discussion is orchestrated by the Chairman of the Department of Medicine, or his most senior deputy. T h e varied offerings and rapid pace are designed to stimulate interest, and specifically to exclude the lecture format; they ensure that the audience will continue to attend not because it is expected of them, but because they are fairly sure they will be interested, stimulated a n d occasionally amused. T h e continued success and vitality of medicine rests upon three pillars: good clinical practice, research and teaching. In very few daily activities d o these three coalesce, but the medical grand round is the opportunity p a r excellence. No educational researcher has gathered any evidence that they ‘work’, and I would not encourage them to waste their time upon such a project. Whilst grand rounds survive and flourish, that will be the measure of their value.
practical workshops will run throughout the conference in 14 individual rooms where experts will present a personal approach to many aspects of medical illustration and encourage active participation by the delegates. Social programme A full social programme will be arranged to include visits to Stirling Castle, Falkland Palace and other places of historical and cultural interest. Ladies Programme A special programme of interest to delegates’ladies will be arranged. Further information from: The Conference Secretary 2nd International Conference Institute of Medical and Biological Illustration c/o Department of Medical Illustration Western Infirmary, Glasgow G11 6NT Scotland
Academic Staff Development
Workshops Sponsored by the Co-ordinating Committee for the Training of University Teachers (CCTUT) and the Swedish National Board of Universities and Colleges (UHA). The first three workshops will draw participants from academic staff in Sweden and the United Kingdom. The
fourth, which is being run in association with the Ontario Universities Program for Instructional Development (OUPID), will also draw membership from Canada. The language of the programme will be English. Research and Creative Teaching 8 -20 April, University College, Oxford. How may academic staff advance their personal development in the related areas of research and teaching? Evaluating the Academic Department 9- 16 April, University of Durham How does a department actually judge itself? Can we identify criteria of excellence? What are the values and priorities in a time of economic stress, and what are the criteria for survival? Teaching Chemistry in the 1980s 9 - 17 April, University of East Anglia How should research in chemistry influence undergraduate teaching? Should current knowledge be more visible in the curriculum? Continuing Education 10- 19 April, University of Manchester What are the current concerns and possible future problems in continuing education? Further information from: Dr David Mack CCTUT-UHA Programme istrator The Registry University of East Anglia Norwich NR4 7TJ
Admin-
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