Why We Still Need Medical Grand Rounds
Medical Grand Rounds has been the premiere education event of Departments of Medicine since the foundation of the modern Department of Medicine. Historically, patients were presented and their cases carefully dissected, in their presence, for the edification of the audience: a mixture of trainees and faculty members. Grand Rounds was a mixture of show and tell, how-to and meet the expert. The wisdom of the experienced physician was distilled into one hour and consumed by the medical house staff. Of course, Grand Rounds was always about much more than education…there was pageantry and ceremony which was at once conserved amongst Universities and yet, like Darwin’s finches, unique in each micro domain. In most centers, the gray-haired senior faculty sat at the front, always in the same seat; decades would pass without Dr. Big Bottom moving chairs. Higher up in the auditorium the faculty sat and higher still the students and interns. Grand Rounds was also a great place for people watching: Who has sleep apnea? Who are the opinion leaders? Who are friends (or enemies)?.....Go to Grand Rounds. The personality traits of individuals and the culture of the Department are on display for all to see. Jokes are told, heart sounds are imitated, important events in the life of the Department are celebrated, new colleagues are welcomed and the departed remembered. Some days, Medical Grand Rounds is High Science, some days it is Great Medicine and other days, it's Theater of the Absurd. Another interesting occupation of some of the audience is, broadly termed, unrelated work. Some physicians are locked on their iPhones and others bring stacks of EKGs to rounds, emerging from apparent oblivion to ask cogent questions of the unsuspecting speaker. Grand Rounds is also a watering hole and we physicians are its wild beasts. Grand Rounds has evolved to be more scientific, with a greater focus on results from randomized clinical trials. As Science and Medicine have consummated their marriage, Grand Rounds more often features the application of basic science to Medicine, and vice versa. This translational science can be challenging to present without losing the audience but when a master of the art guides the journey from bench to bedside, such talks are inspirational. I have no concern about this evolution of Grand Rounds. Dr. Lawrence Altman published an excellent piece about the changes in Medical Grand Rounds in the New York Times in 2006. This article focuses on the change in style of Rounds, from the Socratic method with patients on display at the front of the room to a didactic style with PowerPoint. It is easy to understand the appeal of the historical model for Grand Rounds. It was compelling and practical and entirely captivating see the painting below of the first use of anesthesia during a surgery to remove a neck mass in the Ether Dome at Massachusetts General Hospital. The patient reported no pain, the audience looked on in rapt attention and the media subsequently praised the event. This is the kind of GRAND Rounds we would all like to host (admittedly it was Surgical not Medical…but you get the point).
Above, left: View of the Ether Dome Above, right: Dr. John Collins Warren used ether to painlessly remove a neck mass, Oct 16th, 1846
While a stylistic change in Grand Rounds has occurred, I believe the true challenge of Grand Rounds is the existential struggle for audience. I have given Grand Rounds in institutions high and low around the world, in Harvard’s iconic Ether Dome, in Munich (to the thumping of desks which follows a successful lecture) and in rooms so poorly attended that the awkwardness can only be deflected by humor. Indeed the propensity of dwindling audiences at Grand Rounds inspired the following apocryphal tale: A Professor is invited to give Medical Grand Rounds at a Prestigious University. At the appointed hour he sits alone in a cavernous auditorium with only one other physician in the front row. He gives his speech, rather deflated. After the lecture he leaves the podium and thanks the audience of one, saying “I really appreciate your having stayed for the whole thing”. Whereupon the sole audience member replies, "I had to stay, I’m the second speaker”. Shortly after assuming my role as Head of Medicine at Queen’s University, I was confronted with the concern that Medical Grand Rounds in the Department of Medicine at Queen’s University had become moribund. The reasons offered for the decline in attendance (masked, for a time, by use of a smaller auditorium) were multiple. The time, 11:30am, was inconvenient. It conflicted with clinics, faculty were too busy, attendance was not incentivized; clinical productivity was the coin of the realm, the number of visiting speakers was in decline and the audience had shrunk (or was it vice versa?). Our Grand Rounds had become like one of my favorite plants that survived for years in a corner of my house but did not thrive (some apparent requirement for sunlight). How best to bring the drooping plant back into bloom? Faculty engagement? A new time? Coffee? All reasonable sources of sunlight. I am not the first to be faced with the challenge of fostering a successful Grand Rounds. A former Chair of Medicine at the University of Alberta, now Dean of Medicine at Dalhousie University, Dr. Tom Marrie once asked the faculty whether they cared to have Grand Rounds at all, so frustrated was he at the poor attendance. With this gentle prompting, the rounds attendance improved. Another Chair of Medicine at the University of Alberta, Dr. Paul Armstrong made it clear that Grand Rounds was an expectation - and a place where you could catch him for a quick question. Dr. Armstrong understood that Grand Rounds had a value beyond education. It was an ideal venue to show the institution to the world. His efforts ensured that the best and brightest visited his institution. Medicine has undergone a hyper-evolution in the last 3 decades. At an accelerating pace, familiar structures and even the rhythm of the profession have changed. Physician lounges are gone, work hours are circumscribed, and specialties have retreated into themselves so that like talks to like. It can be hard to encounter colleagues, especially those in other Departments or Divisions, as pressure mounts for productivity. Your Department Head, if you are unlucky, is more likely to ask you how many RVUs you have generated (or discuss your billing penetration) than they are to chat about the interesting radiograph, lab test, research discovery or patient. Do we not still need a forum in which we can enjoy the game of differential diagnosis and sharpen Ockham’s razor? Is there time in our busy days to sit with colleagues and talk about the research, education and medical practice that is the core of our profession? Hopefully, the answer is yes and, assuming so, the place and time must surely be Medical Grand Rounds. However, faculty vote with their feet and many apparently believe that Medical Grand Rounds has gone the way of the LP album, the rotary telephone and ….gasp, the white coat! My experience suggests many reasons why we need Medical Grand Rounds more than ever in 2013: 1) To educate: To expose trainees to the best of Medicine and Science. This is the oldest of reasons and remains valid today. Medical Grand Rounds remains the cheapest and most effective way of obtaining CME, which is a requirement for physicians. A good Grand Rounds calendar arguably offers more true education than any CME meeting in an exotic location. The scenery may not be as exotic but, with planning and an attention to speaker selection, Grand Rounds can certainly be entertaining. 2) To knock down the walls of science and medicine: Medical Grand Rounds is one of the few venues left in which one can present medical and scientific problems using a trans-departmental approach. A vibrant Grand Rounds program should engage not only the faculty and trainees in Medicine but also appeal to Pathologists, Surgeons, Basic Scientists, Ethicists and Medical Historians. The very best Medical Grand rounds often are combined efforts with faculty from several Departments exploring a problem in a comprehensive manner. There are few other venues in which faculty from different Departments assemble and discuss problems of mutual interest. 3) To socialize: There is no better way to build esprit de corps than a vibrant Medical Grand Rounds. Walk through the door into Rounds and you are rubbing shoulders with the young and old, the iconic and the average. House Staff learn the art of articulate presentation and how to disagree without being disagreeable. They see good slides and bad, they learn to understand and respond to a question with aplomb. When one listens to the banter around a case at Rounds, one is often humbled by what one’s colleagues know. Medical Grand Rounds, when led by a dynamic Head and championed by a faculty leader and supported by all Divisions, is a paean to the beauty of the confederation that is a Department of Medicine. 4) To do business: If you want to have a quick word with a colleague, lobby the Head of the Department, talk with a resident…what better place than Grand Rounds? Some of the most important negotiations are initiated or consummated with a quick word at Medical Grand Rounds. In addition, the visitor or recruit gets their first impression of the depth and cohesiveness of the Department at Rounds. 5) For the “after party”: When there is a visiting speaker in town, the tradition holds that they are wined and dined. Gossip is exchanged. You think it’s bad here? ….Let me tell you about my University. How are your House Staff? Do you have someone I can hire for my lab? How is Dr. X? The busy bees that flit around the world giving Grand Rounds provide a degree of connectedness amongst Departments at different institutions. By engaging the residents and fellows in the hosting Medical Grand Rounds we invigorate the process and not infrequently establish connections that may lead to job offers or collaborations for our junior colleagues. 6) To support undergraduate and postgraduate education: The art of differential diagnosis, the curiosity of the gray beards, the chance to hear the inside story about a discovery, trial or invention. These opportunities uniquely present themselves at Medical Grand Rounds. Residents, interns, students and clerks all can benefit (and participate). The smorgasbord that is Medicine is laid out for their hungry minds each week. A Medical Grand Rounds curriculum, if developed with input from each Division and informed by a needs survey, is an inspirational educational tool. 7) To engage the interprofessional team: Grand Rounds is (or should be) friendly to nursing, pharmacy and other health professionals. In my prior life as a Cardiology Chief, I tried to ensure that nurses, pharmacists and others felt welcome at Rounds. We work in inter-professional teams and we need to share this great experience with our teammates. Whatever the genesis of the problem, the attendance at Queen’s was poor (<1/3 of the faculty). Changing this was not simple. The first step, faculty engagement, took time but paid dividends. A survey of the faculty confirmed commitment to Grand Rounds and, in a vote, they approved the use of funds to support this and other academic development activities. After scrutinizing room schedules at a busy Medical School and considering clinical commitments, the time was move to 7:20am. This early hour raised concerns about accessibility for faculty with young children (the time will be moved to a slightly later hour in the fall). Nonetheless, with funding in place for a robust speaker’s series, a faculty that committed their resources and made the commitment to attend, we held our first Grand Rounds of the new series on Thursday, Jan 10th in Etherington Auditorium….and the room was full. With a new time, funding and faculty support, the next step was recruitment of a champion, in addition to myself. I recruited a talented young faculty member, Dr. Mala Joneja, Associate Program Director of the Core Internal Medicine Program, to reinvigorate our Grand Rounds. This week I take the stage as a speaker, discussing Mitochondrial Dynamics as a Therapeutic Target in Lung Cancer and Pulmonary Hypertension. Hopefully there will be adequate coffee in the room to energize the crowd. I look forward to the thoughts of readers of the blog on how our Grand Rounds can be improved.