Grand Rounds: Volume 3, Issue 26

Welcome to Grand Rounds

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William Osler conducting Grand Rounds
(courtesy of the medical archives at Johns Hopkins University)

Introduction

It is a privilege to host the current issue of the medical blog Grand Rounds. As an afficionado of medical history, it is remarkable to see this latest incarnation of process that has “evolved from centuries-old practices that trained physicians by means of apprenticeships.” (Mueller et al., Mayo Clin Proc 2003 ). Medical grand rounds have morphed from ward-based teaching or using an illustrative case presented in an auditorium (as illustrated above) to a lecture format. In William Osler’s day, grand rounds took place at the bedside and were lead by master clinicians. It is now uncommon for patients to have anything to do with medical grand rounds. Most of the grand rounds that I have attended have been didactic talks delivered by the more senior members of the faculty or occasionally by a guest speaker. More and more, grand rounds appears to be no more than a weekly lecture series. Grand rounds have been poked at in the medical literature, have been critically analyzed with regard to their utility and cost, and have been entirely revamped at one of the oldest hospitals in the country. More recently, some have recommended looking at grand rounds from a “consumers’ perspective“. Clearly, grand rounds will continue to have an important education and social value, but it appears model will continue to evolve over time.

I recommend Dr. Lawrence Altman’s terrific piece on the changes in grand rounds from the 12.12.06 issue of the New York Times. Interestingly, Altman ends his piece with a anecdote about how humor can occasionally crop up in grand rounds. As an in silico experiment I Googled the phrase “grand rounds humor” and was thrilled to see that nearly every one of the first 30 entries linked to an edition of the medical blog grand rounds. I conclude that we are on the forefront of a revolution on grand roundsmanship, one that blends medicine with humor, thoughtfulness, open-mindedness and inclusiveness.With this as an introduction, I present to you the best of the week’s medical blog entries.

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Students

It is unusual to have students present cases at traditional hospital grand rounds, which is exactly why I feel compelled to lead off with the medical student entries this week. Of course, the first entry that I will share with you came to me a good 7-1/2 hours after the deadline. Jeffrey, a medical student at Monash University in Australia, being properly interested in the basics of physiology and neuroscience, contributes an interesting review of a phenomena that I’ve experienced, and I am certain that others have as well: music can motivate you during physical exercise and more importantly, help you build positive associations that will increase your desire to continue exercising in the future. Clearly Apple and Nike have capitalized on electronic positive feedback during exercise.

Jeffrey gets an inadvertant bonus point: while looking for something with which to back a pithy comment about his tardiness, I came across a fascinating and personally relevant study done by Dan Ariely at the Massachusetts Institute of Technology entitled, “Procrastination, Deadlines, and Performance: Self-Control by Precommittment” (click here for .pdf). In this study, the authors, after recognizing that procrastination is a familiar trait and that people sometimes attempt to control their procrastination by setting deadlines for themselves, pose three questions:

(1) Are people willing to self-impose meaningful (i.e., costly) deadlines to overcome procrastination? (2) Are self-imposed deadlines effective in improving task performance? (3) When self-imposing deadlines, do people set them optimally, for maximum performance enhancement? A set of studies examined these issues experimentally, showing that the answer is “yes” to the first two questions, and “no” to the third. People have self-control problems, they recognize them, and they try to control them by self-imposing costly deadlines. These deadlines help people control procrastination, but they are not as effective as some externally imposed deadlines in improving task performance.

Also earning bonus points this week is the remarkable Bertalan Mesko, a medical student at the University of Debrecen, Hungary. I am certain that those of you who read last week’s Grand Rounds, or who regularly read his blog, ScienceRoll, are as impressed as I am with the quality of his writing, the depth of his interest, and his sheer productivity. Clearly, Bertalan has a unique degree of intellectual curiosity and an impressive dedication to genetics. As a result of one of his blog entries on newborn genetic screening, he had the chance to make contact with the mother of a child with medium chain acyl CoA dehydrogenase defect. He shares what he learned of the newborn screening system in the United States.

We received another international medical student entry courtesy of Mexico Medical Student, who studies in one of my favorite places in Mexico, Guadalajara. Enrico is a 2nd year student who has been blogging on-and-off since 2000 and has submitted the fascinating “5/4“. I’ve encountered a couple of physicians in my life who enjoy integrating mathematics into medicine (pun well intended). Enrico’s blending of music, math and medicine deserves recognition for creativity and insight.

Patients and Families

The inclusion of families at grand rounds is probably less common than that of medical students or patients. A Medline search for the phrase “parents AND grand rounds” turned up only three papers, including this fascinating speech given by parents of a NICU child to an audience of physicians at teaching hospital.

This week I was fortunate to receive a number of entries from both patients and families, including one from Moreena, the mother of a child awaiting a 3rd liver transplant. At her blog, The Wait and the Wonder, she writes about the public nature of illness, in particular the isolation in plain sight that occurs when a clearly ill child is out in a public place. She also has written a thoughtful piece in response to some of this blog’s musings about privacy issues in medicine in the age of Google and webcams. Moreena brings up the boundary issues in medicine, but not as the idiom used by physicians and nurses refer to professional boundaries. Instead, Moreena thoughtfully discusses the public/private boundaries with regard to illness:

Trying to figure out how much to reveal, and where to draw the line between the personal and the private in the medical world, is still a delicate subject. I’m guessing that many doctors and nurses have a stronger sense of that boundary, since the nature of their jobs thrusts them into the private world of so many people, and with so little ado. (”Hello. My name is Dr. X. And now it is time to feel up your liver!”) Certainly, I would agree that videotaping the comings and goings of hospital personnel without their permission shouldn’t be allowed, especially since so much that was previously private is now broadcast with little thought.But, in trying to protect privacy and the legal interests of the hospital, I hope that doctors and nurses will remember that the medical life, the details that may seem so squicky and intimate to them, are also just part of everyday life for their patients.

Speaking of “squicky and intimate” details, I received an eyebrow-raising entry from Amy Tenderich who writes Diabetes Mine. Her entry entitled, “Too Sexy for My … Pod?” reminds us that patients who live with internal and external devices still need to get undressed in front of their spouses as part of “every day life”. I’ve been fortunate to not really have to consider whether or not my patients consider their port-a-caths to be “not sexy”. Very fortunate. But clearly for a woman with a wireless, continuous glucose monitor attached to her lower abdomen, this may be an issue.

For more on new technologies in diabetes care, I refer you to Dr. Rima Bishara’s entry on insulin pumps. Dr. Bishara is a relatively new blogger with 15 years under her belt as an internest, and we should welcome her into the fold.

Nurses, Dieticians and Pharmacists

It is much more common, in today’s large medical centers, to see specialized versions of grand rounds, including Nursing Grand Rounds (from my residency alma mater), Palliative Care Grand Rounds, and Pharmacy Grand Rounds, among others. Rather than have all of these exist as separate forum, I’m pleased to use thus edition of the medical blog Grand Rounds as a means to include other health care providers.

In doing so, I want to start with an entry from n=1’s Universal Health blog, which is entitled, “Docs On Nurses: CME is a Must. As the husband of a nurse, I found his/her perspective to be both refreshing and enlightening as well as important and extremely well expressed. N=1 makes an important observation that I have, of course, witnessed and been guilty of but had not, until now,appreciated in this manner:

At any given time, in any given healthcare patient setting, nurses are routinely interrupted more than once per minute. This includes while they are administering medications, while they are validating orders, while they are planning care, while they are teaching, while they are comforting a grieving family, while they are discharge planning, while they are in the middle of a sterile procedure – any time, anywhere. This multitasking capability is difficult and complex to learn and to use on a continual basis.Physicians wouldn’t tolerate that routine interruption to that degree and on that basis. But nurses do, and that’s considered the norm of clinical practice.

N=1 reminds physicians (and everyone else) that nurses are not in pace to be “bacon savers” – an attribute that I’ve ascribed to many a nurse who has kept me from making a mistake – but are equals in the healthcare team. This view is probably more common to my generation of physician than, say, my father’s generation, but is still not universally accepted. I want to highlight this post for both the importance topic and the excellence of the writing. My stethoscope is off to you, N=1.

Nurse Ratched, among others, has been set upon both by JCAHO and by her hospital’s attempt to create new revenue streams. Her post entitled “Bottom Line Therapy” sheds light onto the seemingly endless upward spiral of new programs, metrics, and technologies implemented as the health care system evolves away from simply caring for patients.

In honor of March being National Nutrition Month, Andrea Giancoli who writes The Family Fork, brings us some useful tips for helping patients to evaluate claims made by many of the fad diets that have been popular for the past 30 or 40 years.

On the pharmacy front, the prolific and thought-provoking David E. Williams takes on last week’s Wall Street Journal piece on disparities in the pricing of generic medicines.

Physicians

Finally, we come to the physicians who have, as usual, provided a wealth of thought provoking entries. Dr. Elmer at Parallel Universes provides what will undoubtedly be one of the first in a slew of posts stimulated by Dr. Jerome Groopman’s latest book, How Doctors Think. Dr. Elmer’s recounting of his colleague’s ‘thinking error’ leads him to opine that we should focus more of our medical education efforts on teaching students how to think as well as what to think about. For those interested in one view of the ‘thinking’ behind medical decision making, I strongly recommend Edmond A. Murphy’s The Logic of Medicine.

RayGunGirl, an intern headed for a career in radiation oncology, shares an extraordinarily personal story that links nicely to Jerome Groopman’s work. One of the problems that Groopman believes leads physicians down the wrong path in their thinking are their biases against certain patients or types of patient. In her entry entitled “Toys in the Attic” she realizes what many seasoned physicians have learned: we all have a lot more in common with our patients that we realize – we just need to be willing to find, admit, or recognize it. Making these types of connections facilitates the empathy that makes for the best physician-patient (or nurse-, pharmacist-, etc.) relationships.

Speaking of interns, surely all of you know that last Thursday was Match Day for nearly 22,000 medical students. For most, it was a fine day, including the author of pumpkin doodle – a fourth year student who matched to her first choice last week, and who I file under “doctors” today on the occasion of her impending graduation and the fact that this is her very first Grand Rounds post. Despite pumpkin doodle’s joy, it should be recognized that there were nearly 28,000 applicants for only 22,000 positions, making for 6,000 unhappy individuals. Dr. Bard Parker at A Chance to Cut is a Chance to Cure reviews the match statistics for the 2007. He finds that family medicine continues to be in decline from the standpoint of filling residency slots with US medical graduates, while radiology and surgery did well. To my surprise, given the stress on the nation’s emergency medicine system, Bard reports Emergency Medicine was this year’s “big winner” according to this one metric.

While the match numbers for internal medicine may be flat, Dr. Val Jones, who writes Dr. Val & The Voice of Reason, has seen interns with the compassion, drive, and determination needed to be tireless advocates for their patients. She describes one such intern in her entry entitled, “Do The Right Thing“:

The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”

Dr. Kenneth Trofatte writes the amusingly titled Fruit of the Womb. His two posts this week on early pregnancy loss (part one and part two) shed light on the far less amusing side of obstetrics and gynecology. It wasn’t until I read Dr. Trofatter’s post that I realized that he has given, and will continue to give, far more bad news about the loss of a child that either I or most pediatric oncologists will. I particuarly appreciated this quote:

The MD after my name means that I am the one responsible for the Morbid Discussion that has to take place to inform a couple that they have a pregnancy that didn’t make it through the first trimester.

We have a couple of other great perspectives on discussions with patients. Representing frustrated this week is Artemis who writes (naturally) The Thoughts of Artemis where she vents her frustration with getting her patients to answer questions:

Why is it so difficult to put together a history? It’s not just patients with memory issues who have a hard time compiling a list — so-called “normal” folks have as much difficulty as well. [I]t’s frustrating to have to spend so much time trying to put together the ‘back story’ when it should be as readily supplied as the list of medications that (some) patients put together.

Representing wistful is the always eloquent Signout, who expresses her regret at missing the opportunity to answer a question for her patient:

“I’m a sick, sad old man,” he said, and was quiet for a while. Through the stethoscope, his silence sounded like the inside of a seashell. Then, foggily, as if from inside the earth, he said, “Is this worth it?”I didn’t know how to answer his question. Looking back, I cheerily ignored it.

Keagirl (who I guess chose her name as a play on Kegel), our friendly urologist who writes Urostream, sounded neither frustrated nor wistful following her encounter with a surly and inappropriate Emergency Department physician. I hope that Dr. Bard (above) is correct because it sounds like Emergency Medicine could use the extra help in order to keep their physicians from acting this poorly to the consulting specialists.

We actually heard from two urologists this week, one of whom works on the cutting edge of surgical technology. In his blog, Thoughts from a Robotic Surgeon, Dr. Domenico Savatta shares some of his practice data with regard to robotic prostatectomies and, in my opinion, correctly implores his fellow surgeons to collect and report accurate data to their patients in order to avoid “guesstimating” and in order to help patients make their own informed decisions.

A number of the physician bloggers took on items in the news this week. Of note is an entry from Dr. Philip Gordon’s Tales from the Womb on the use of recombinant human erythropoietin in cancer patients. Once again we find ourselves in a situation where the marketing, and in this case the strong direct-to-consumer (DTC) marketing, has gotten far ahead of the efficacy data for a drug. As one who has used erythropoietin in some non-malignant hematologic disorders as well as in post-stem cell transplant patients, it is interesting and concerning to read his description of the increasing use of rhEpo in neonatology in the absence of clinical trial data in this population. I also agree with his harsh criticism of DTC ads for these remarkably expensive and specialized drugs. It’s one thing to consider the general populations ability to critically assess their need for a drug like sildenafil. It’s another to expect them to be able to critically assess the utility of recombinant hematopoietic growth factors such as erythropoietin or PEG-filgrastim (Neulasta).

In a similar vein, Grunt Doc addresses the recent FDA warnings regarding the reports of bizarre behavioral effects of the prescription sleep medications and shares a case he observed. I strongly recommend reading through the comments to this post, which are nearly as fascinating and entertaining.

Dr. Anonymous, apparently more concerned with staying awake than going to sleep, reports on the news that the “pick me up” people feel when drinking that first cup of coffee in the morning may have more to do with stopping withdrawal symptoms than with the stimulant effects of caffeine.

Over at the superbly produced and extremely well-written Aetiology we have Dr. Tara Smith’s entry on antibiotic resistant bacteria in the non-human members of the primate order. Her entry was inspired by the recent news, and subsequent blog entries, regarding the use of the 4th-generation cephalosporin cefquinome in cattle. We often think about antibiotic resistance from the point-of-view of humans or domestic animals intended for human consumption. Dr. Smith opens our eyes to the potential for spread of resistant organisms to the farthest corners of the planet. Slipping into the juvenile, I must take a minute to say that her line, “I told you you could learn a lot from studying an animal’s ass!” is will surely share with my gastroenterology colleagues in the future.

The international use of antibiotics was also discussed by Dr. Paul Auerbach, who a surgeon with an appointment in Emergency Medicine at Stanford, who specializes in Wilderness Medicine. I envy Dr. Auerbach’s travels to Everest Base Camp in Nepal. He returns with some good advice on the antibiotics that he would recommend taking with for international travel.

While I prefer to share essays in Grand Rounds, I feel compelled to add Dr. Jon Inarritu’s contribution from his blog, Unbounded Medicine. Dr. Inarritu sends us this video of a public service annoucment regarding anorexia, bulimia, and body dysmorphic disorder.

I want to close with two entries from a source that I would not have discovered had it not been for my hosting this issue of Grand Rounds. Reading these reinforces my believe that we are truly privileged, not just to have our remarkable medical blogging community to share our thoughts with, but that we are also very lucky to be able to do what we do in the field of medicine. Susan Palwick is a volunteer emergency room chaplain who has been constructing a series of sonnets based on her experiences. She sends us The Ed Sonnets: Room 6.2 which is beautiful in both its construction and message. To have this alone would have been enough. But read ing through her blog, Rickety Contrivances of Doing Good, I came across this remarkable entry entitled ‘Chaplain Stress’ in which she provides yet another unique perspective and set of observations on circumstances that I have missed due to the desensitization that accompanies frequent exposure. I can’t pull out any one quote because the entire post should be read. I strongly encourage you to visit this and share in the rich subtext that physicians and nurses can sometimes overlook in the stuggle to handle our busy workloads.

Conclusion

That’s all for this issue of medical blog Grand Rounds. It was a treat to assemble Grand Rounds and I hope that you take away as much from reading it as I did from writing it. My thanks to the bloggers whose entries have been used, and to the bloggers who entries there was enough room for. The next issue will be hosted at Medviews on Tueday, March 27th. My thanks also go out to the talented Dr. Nick Genes for keeping this remarkable tradition alive.