Early last year, my boss Talmadge King and I were at an ABIM meeting (we’re both on the board), and the group was debating a controversial topic. Another participant at the meeting, like Talmadge the chair of a prominent department of medicine, said, “We polled 250 people at our grand rounds last week, and they said ‘X’.” The audience gasped – ‘X’ was a completely unexpected response. Talmadge and I looked at each other with equally stunned faces, but for another reason. Nearly simultaneously, we said, “How the hell did they get 250 people to come to Medical Grand Rounds?!”
Grand Rounds has a storied tradition in medicine, dating back to Osler’s case presentations at Johns Hopkins, where real patients were wheeled into the lecture hall to be interviewed and discussed by The Professor. And the iconic Surgical Grand Rounds, where audiences, seated in an amphitheater above the OR, actually watched a master surgeon demonstrate a new operation. (If you’re a Seinfeld addict like me, this reference immediately brings to mind the famous scene in which Kramer dropped a Junior Mint into a patient’s open abdomen.) This hands-on format is not entirely extinct: a few years ago, I attended grand rounds at a major Beijing hospital – a 14-year-old boy (seen here) with amyloid liver disease was wheeled in, and nearly one hundred doctors lined up to palpate the child’s protuberant belly.
But in this country, grand rounds changed over the past generation. Most Medical Grand Rounds (MGR) devolved into staid and formulaic weekly clinical or research updates – the very essence of passive learning. In a 2006 review, Mueller and colleagues observed,
The transition of MGR over time from an interactive teaching activity involving living patients to a passively received didactic lecture has led some to suggest that the term medical grand rounds… is no longer appropriate
When it comes to conferences, people can vote with their feet, and they progressively did. While I’ve been to some hospitals where grand rounds still generates large crowds and “a buzz,” this is not the norm. In most academic and community hospitals, grand rounds has lost its mojo.
(With one key exception: every hospital has its Octogenarian Row, retired docs who get both their CME and collegial Geritol from MGR. Since I’m closing in on their ranks with alarming rapidity, I’ve stopped making fun of the fact that the dimming of the auditorium lights sends many of their eyelids aflutter and their neurons into advanced stages of REM.)
The fall in grand rounds attendance has been a growing problem for a couple of decades, but, in teaching hospitals, housestaff duty hour limits have made things far worse. Today’s residents simply don’t have a minute to waste, and for many of them, grand rounds – particularly when it consists of a 50-minute talking-head lecture – has fallen off their To-Do list.
About 6 months ago, I noticed that our grand rounds attendance had, on some off-weeks, dwindled to 25 or 30 hardy souls (even counting the Tribal Elders). This showing was particularly mortifying when we had a visiting professor, but it was embarrassing when it was one of our faculty as well.
One day last spring, after a particularly pitiful showing, I pulled the plug, canceling MGR for the summer and organizing a group of key faculty and chief residents to determine the fate of the conference. The committee, highly engaged, quickly began to brainstorm about what we needed to do to spruce up the exercise: change the time, better food, new topics… But before we got too far, one committee member said simply: “Why do we need grand rounds? Perhaps we should just let it fade away.”
The committee froze in its tracks – this was obviously the key question. Here were my thoughts:
First, in a world in which we can increasingly segment our information (i.e., watch Glenn Beck or Rachel Maddow), making a habit of attending grand rounds is one of the few ways for physicians to be exposed to information and people outside their professional silos. We are all in danger of accruing new information about only those things we already know and like.
Second, grand rounds can help build, or promote, community. Think about it: increasingly, texting, email, and Facebook mean that we can get through our days without actual human contact. Grand rounds provides a venue for all the members of a social network (in this case, a department of medicine) to schmooze and bond.
Finally, grand rounds are an opportunity for faculty to connect with their peers, letting their colleagues and trainees know what they’re up to. These interactions create the mutual respect that fuels a great department, along with many serendipitous collaborations. But for this mixing to occur, I have to attend my colleague’s lecture, and she mine. Remember Yogi Berra’s famous observation: “If you don’t go to somebody’s funeral, they won’t come to yours.”
For these reasons, Talmadge, our chief residents, and I decided to try to re-boot grand rounds. We didn’t minimize the challenges: once social networks fray, it’s awfully hard to rebuild them – particularly when the youngins have punched out. Bowling Alone, Robert Putnam’s classic study of the withering of America’s social institutions, begins by recounting the demise of several organizations: The Glenn Valley (PA) Bridge Club, The Roanoke chapter of the NAACP, the Charity Club of Dallas. Writes Putnam,
It wasn’t so much that old members dropped out – at least not any more rapidly than age and the accidents of life had always meant. But community organizations were no longer revitalized… by freshets of new members…
So how could we breathe new life into our Medical Grand Rounds? To support our committee deliberations, we surveyed 12 major departments about their MGR. Most were, like ours, held at noon on a weekday (Tuesday and Thursday were the most popular days). Virtually all involved the classic 45-50 minute lecture, followed by a short Q&A. Three-quarters provided food. All offered a mix of content ranging from “bench-to-bedside” to health policy. 73% characterized attendance as “fair but disappointing, i.e., 50-100 people.” No one required faculty attendance (a few “expected” it, bolstered by sign-in sheets), while 60% required housestaff attendance. A few simulcast the conference to satellite locations, but none used audiovisual aids or the Internet in novel ways.
These results were extremely helpful, in that they told us: 1) Changing the conference’s timing probably wasn’t the answer; 2) most of our peer institutions are struggling with the same issues; 3) mandating attendance was not the way to go; 4) there were opportunities for innovation.
Here’s what we came up with, beginning with the format of the talks:
After I briefly introduce the speaker (I moderate the conference most weeks), he or she now must begin with a 3-5 minute discussion of something personally meaningful (without Powerpoint! For an academic physician, this is like Imelda Marcos without shoes). Since we relaunched two months ago, most faculty have spoken about what got them interested in their field, or recounted a meaningful patient encounter, or confessed to an error they made. These poignant and oftentimes funny stories have had the effect of humanizing the speaker and the session. They’re a terrific addition.
Second, we limit the talks themselves to a max of 35 minutes. The speaker must wrap up by 10 minutes to the hour, to provide adequate time for Q&A. And I prompt the audience members to state their name and affiliation when they ask a question (“Ken Sack, Rheumatology”) – a way of helping everybody in a big department get to know who’s who.
Third, we added the audience response system – the computerized gizmos Regis used to poll the audience on Who Wants to Be a Millionaire? – another way to promote active learning and audience engagement. Most speakers now fold 3-5 ARS questions into their talks.
Fourth, we bumped up the caliber of the speakers. Just in the past few weeks, we’ve had Steve Schroeder and Adams Dudley in a conversation about health reform, Andy Josephson on strokes, Bob Nussbaum on medical genetics, Janice Louie on H1N1 influenza, and more. (I did the inaugural talk, on patient safety.) Other than me, this is a lineup of some of UCSF’s best teachers.
There were lots of other things as well: we increased the food budget; we now send out email reminders every Monday before the Thursday conference, and again Thursday morning; we empowered our divisions to suggest speakers in their field and provided departmental matching funds for acceptable outside faculty; and we changed the housestaff’s Thursday morning schedule to free up some time.
The results have been impressive. Average attendance has tripled, now averaging 100-150. We’ve created some real buzz. I think attendees are learning and enjoying themselves, and so are the speakers.
A few months before we relaunched, I presented the plan to our division chiefs. One of the chiefs, a thoughtful guy in a very specialized and procedural field, said, “I go to so many conferences in my area of interest, why should I go to this one?” I answered, “For the same reason I read the New York Times every day.” My daily Times ritual is my chance to browse a diverse stream of content, developed and written by very smart people. Sure, I’m more likely to read pieces on topics I care about (national politics, golf, healthcare, blogging, kids in college), but periodically an article on the auto industry, or Brazil, or home repair, or, God help me, dancing catches my eye. And I have no doubt that reading such things makes me a better, more interesting person.
We need grand rounds and other venues that nurture our communities and expose us to content and concerns outside our sweet spots. It is too soon to know for sure, but our early experience with MGR 2.0 reassures me that – with some freshening up of the content and technology to promote active learning, a little marketing, and a commitment from departmental leadership – Grand Rounds need not go the way of the LP and the typewriter. But it does need a face lift, reflecting the fact that busy people will no longer make time for such things because they should, but only because they want to. It’s worth the trouble.
Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.
