Show-and-tell for doctors Making the rounds: In a tradition that began at Hopkins Hospital, doctors learn from patients and each other

September 23, 1995|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

Precisely at 8 a.m. every Friday, Hopkins doctors in starched white coats converge on a small, oak-paneled amphitheater, finding seats on the long wooden benches to take part in a medical tradition that began a century ago.

Interns and residents peer over the balconies. World-renowned specialists are sitting in the audience of more than 200 doctors. A huge portrait of Dr. Henry Mills Hurd, superintendent when Johns Hopkins Hospital opened in 1889, stares out over the steep rows. Latecomers stand in the back, craning their necks to see.

With the words, "May I have the first slide, please?" the lights dim, and the ritual of grand rounds is under way. The teaching session, built around physicians presenting their patients' cases to their peers, has its roots at Hopkins and is practiced nationwide by medical schools and hospitals.

"At Hopkins, medicine is sort of a religion," said Dr. David Hellmann, deputy director of Hopkins' Department of Medicine, who has been a key organizer of the rounds for the past decade. "These buildings are the temples and churches in which people worship, and for us, our grand rounds is sort of our church service."

Many credit its genesis to Sir William Osler, the legendary first physician-in-chief, who believed that the patient was the source of medical knowledge. In Hopkins' original hospital, there was an octagonal ward, and when a team of physicians toured patients' bedsides, it was called "rounds." On days when Dr. Osler -- known for his encyclopedic knowledge and tough questioning of residents -- arrived unannounced, the sessions were dubbed "grand rounds."

Years later, the setting is less intimate but Dr. Osler's legacy persists. Row after row of the physicians are wearing navy ties or scarves designed to honor him with their pattern of white shields bearing the Latin word for equanimity. And the pressure to perform, as superiors and colleagues look on, is just as intense.

Yesterday morning, down in front, Dr. William Bell whispers to his patient, coaching her: "You just say, 'All these bruises were coming up.' You know all the answers. It won't be hard."

He quickly reviews details of her case with her. Harriet Boston, 68, glances back over her shoulder to see a packed hall. She had expected maybe 10 or 12 physicians.

After two presentations without patients, Dr. Bell takes the podium to make a few introductory remarks. Then he gently escorts Mrs. Boston, leaning on a cane, to center stage.

"There's absolutely no substitute for hearing this directly from the person who experienced the problems," Dr. Bell declares.

Sitting next to one another, they begin a dialogue about her case. She describes the morning she woke up with blood coming from her nose and mouth, how doctors had told her that her count of platelets -- the blood's clotting element -- had dropped.

A question comes from the audience. "Did you have a transfusion?"

"I donated my own blood," Mrs. Boston responds confidently.

Watching approvingly from the front row, her daughter, Phyllis Boston, beams.

"You feel like a parent, that all these people are really interested in what happened and what was the end result," the daughter says. "I'm just tickled."

Dr. Bell goes on to explain that another hospital had mistakenly removed Mrs. Boston's spleen, thinking that would control the ,, platelet problem. But later, Dr. Bell, a hematologist, discovered a severe infection was to blame. An abscess had eaten away a vertebra in her spine. After reconstructive surgery, and several months in the hospital, Mrs. Boston is doing better.

The case history leads into a discussion of lab results and possible causes of her condition. One of Dr. Bell's concluding comments: a doctor should not perform any irreversible procedures until making sure what is wrong.

Afterward, Dr. Hellmann shakes Mrs. Boston's hand and

exclaims, "You were terrific!"

Rounds are still routinely done in the hospital wards with small teams of young doctors, but the Department of Medicine's grand rounds, with two instructive cases each week, have been taking place for years in 63-year-old Hurd Hall, so more physicians may attend.

While most other hospitals have gradually turned the session into a lecture, Hopkins has hung on to its distinct spirit: bring in the patients and let them speak.

For the patients, it is a moment to revel in the attention, to marvel at the intricacies of their cases, and to hear the doctors' opinions.

Said Gerald Kirkendall, 41, an Essex man who appeared a week ago Friday: "It really didn't bother me a whole lot being up there, but Dr. Hellmann seemed to be real nervous."

Even though many presenters have worked at Hopkins for years, some confess their anxieties have subsided only slightly. For them, the grand rounds is more than a class. The session is a way to commune with colleagues, a 90-minute reprieve to contemplate the essence of medicine, even though pagers beep throughout. It is also a rite of passage. Every doctor wants to do an impeccable job.

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