The Neurological Grand Round is wreathed in rite and ritual, often in a format little changed over countless years; as such, it risks a falling attendance and waning interest. Recent discussion in Practical Neurology1 has questioned, ‘For whom is the Grand Round for?’, asking whether it is to benefit consultants, trainees, patients or even students.2 In truth, it is all of these. For those passing through, such as students and junior colleagues, it is a baptism into the neurologist's approach: to spark interest, to explain, to inspire and to offer an exposition of the way neurologists think about difficult problems. For those starting the neurological path, it is a way to prepare, test and improve themselves. For those confirmed in neurology, it is interesting and provides an informed sounding board for difficult cases. To my mind, there is little doubting the Grand Round's strength as a concept; it may just need tweaking to remind participants of its value and make it fit for 21st century purposes.

In our institution, the Grand Round format is two junior doctor case presentations followed by an outside speaker talk, an additional draw to tempt attendance. Patients are brought to the meeting less frequently than before but increased use of computer technology, videos and pictures of examinations help to maintain some of the bygone theatre. A few years ago, the meeting was in decline but some simple changes helped. First, the seating hierarchy was inverted, the registrars now in the front row, directly in sight of the Chair, with the remaining junior team and students behind, followed by the consultant body. This change improved engagement at all levels, the registrars not having to look at rows of cricked and disapproving necks when struggling to describe thalamic blood supply, and consultants no longer haunted by sniggers and whispers behind when trying to distil their wisdom. Second, we encourage student attendance and active involvement, the Chair facilitating them to discuss the simplicities and essentials of the case, such as possible mechanisms and localisation. Involving students both beefs up attendance and ensures each case discussion starts from first principles, to the benefit not only of students. This re-appraisal of the format has been beneficial and I would encourage those who doubt the value of similar meetings in their own institution to think again. The Grand Round remains solid: what is needed is not root and branch reform but merely a pruning back, to let new leaves grow.