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With the sad news of the death of neurologist Gerald Stern, it is a fitting time to recall his treatise in praise of Grand Rounds.1 This traditional style of learning has long been cherished by neurologists as the optimal way to teach both the clinical method and deductive reasoning.2 Medical education has significantly evolved, with the recognition of varying learning styles, availability of simulations and remote e-learning. Case presentations and the clinicopathological conference are among the most popular sessions in feedback from the Association of British Neurologists’ annual meeting, but the tradition of regional hospital-based Grand Rounds is no longer widespread. Attendance struggles with increasingly squeezed job plans, and the educational environment itself has been open to criticism.
Grand Rounds evolved as a concept around the turn of the 20th century from the bedside teaching pioneered by Sir William Osler, but with exemplars such as Jean-Martin Charcot’s ‘Leçons du Mardi’ at the Salpêtrière Hospital, and Sir William Gowers’ now eponymous gathering at the National Hospital for Neurology and Neurosurgery, Queen Square. The term ‘rounds’ is linked to Osler’s tour of patients at Johns Hopkins Hospital, Baltimore, though the satellite wards were octagonal in shape rather than the circular ones proposed by British anatomist and surgeon John Marshall in 1878 (reviewed in Taylor3).
The classic Grand Rounds structure comprises the case description, originally with the patient present. Discussion is intended to be educational, with audience participation encouraged. It has evolved as both an educational event for trainees and a unique forum for consultant colleagues to debate the clinical history and signs, mechanistic theories and management. Although patient attendance still occurs routinely in some, for example, Gowers’ Round at Queen Square, it has more often than not been replaced by projected text, ideally including a video examination.
Insular working has been linked to stress. With rising concern about burnout, neurologists may derive important psychological health benefits from regular face-to-face meetings, in turn improving patient welfare. The Hippocratic Oath enshrines the principle of doctors sharing knowledge with each other for the improvement of patient care. Grand Rounds, as well as a rare forum for consultant interaction, is an opportunity for more experienced physicians to guide students, junior doctors and specialist trainees through the Bayesian logic that underpins medicine. It is an opportunity to see this done in different formats and styles, allowing trainees to establish their own techniques for formulating differential diagnoses and management plans. The preservation of a hierarchy is not incompatible with an environment where ideas are welcomed, and debate encouraged.
Grand Rounds provide a forum for case discussion in greater depth. The act of preparing the history and investigations may be the first time the entire set of clinical information has been distilled, bringing new insights. Faced with a diagnostically challenging case, perhaps compounded by pressure from anxious family members, the opportunity to present the problem to a room of specialists has obvious value. Judicious acceptance of the presence of the patient or select relatives may provide important objective evidence that the problem is both difficult and being given serious collective thought.4 Colleagues may also reveal a previously untapped breadth of experience that proves valuable in improving outcomes.
The slick showpiece with an obscure or pun-based title, where ‘a diagnostic test’ precedes the denouement, has its place, but ‘grey’ cases generally provide the best discussion. ‘Cold’ cases from the clinic are equally valuable in demonstrating real-world dilemmas such as genetic counselling or complications of therapy.
All doctors need to understand that managing uncertainty and consensus-based medicine is part of routine and optimal practice. Synthesising information and presenting it in a logical manner, providing a differential diagnosis and management suggestions to colleagues, are essential skills for the effective physician. As Stern says, a chairperson is needed to ‘encourage the diffident while firmly suppressing the garrulous’ and to ensure all attendees may benefit. There is of course no value in humiliation or belittling individuals. Where gentle encouragement becomes enforced, participation is inevitably subject to individual and variable interpretation. Warlow makes the point that ‘the abilities of the trainees and the consultants are much the same, but their knowledge and experience are different, and this should be allowed for by a good chair …’ Where case presentations and discussions are chaired efficiently, Grand Rounds may be among the most time cost-effective forms of continuing medical education.
The principle and need for lifelong learning is self-evident to most doctors looking back on the changes in practice since medical school. Yet, this is threatened by increasing service demands and associated administrative tasks. A consistent move towards shift working would make regular attendance at Grand Rounds challenging. Poor consultant attendance is likely to disincentivise trainees, as they gain less and perceive that it is not valued by their seniors. During the COVID-19 pandemic, there was a rapid increase in the use of web-based conferencing platforms (figure 1). The format can be applied successfully, although the loss of physical presence undoubtedly reduces audience interaction. It should not be seen as a permanent substitute, but streaming of live sessions may increase access for colleagues who cannot always attend in person.
As Osler observed, doctors hone their practice only through seeing patients as well as reading books. Contemporary neurologists see only a small fraction of the number of patients that their predecessors of the last century did. Neurology has one of the most rapidly developing therapeutic landscapes, coupled to the demands of an ageing population and the complications of complex immunotherapies. It will no longer be possible to be expert across the full range of neurological disease so that the routine sharing of knowledge and experience between sub-specialties will be even more essential for optimal patient care.
Some suggested reflections
Where do I get more useful continuing medical education than a gathering of my peers?
Does my hospital have Grand Rounds (if not dedicated to neurology cases then at least a meeting that includes such cases)? If not, why not?
Why is attending Grand Rounds not a higher priority in my ideal job plan?
How do I know that my neurological practice is in line with my peers?
We thank Dr Johannes Jungilligens, Ruhr-University Bochum, Germany, for generously sharing his adapted image as our figure.
Contributors MRT suggested the article. The manuscript was drafted by ALRR, with input and review by all authors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned. Externally peer reviewed by Andrew Chancellor, Tauranga, New Zealand.
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