Pulse
Grand Rounds’ Growing Pains
The venerable educational event is going back to its roots.
A senior physician stands next to an ailing patient on the wards, while a dozen junior physicians and residents gather around, offering their opinions on treatment and diagnosis, and listening eagerly as the seasoned physician offers his insights. Even three decades ago, the term for this interaction—“medical grand rounds”—was an apt descriptor. Today, it is a bit of a misnomer.
For one thing, the setting for grand rounds is likely to be a large auditorium, the patient is not likely to be present, and the presenter is likely delivering a lecture, rather than speaking to a handful of colleagues. “There’s no rounding about grand rounds anymore,” says Paul S. Mueller, M.D., chair of the division of general internal medicine at Mayo Clinic and director of medical grand rounds for Mayo from 1996 to 2001. Mueller did several studies on the status of grand rounds as an educational tool during the late 1990s. “It’s passive, it’s didactic, and there’s very little interactivity,” he says.
The shift in focus from patient to PowerPoint is one reason why grand rounds attendance at a number institutions has fallen off over the years. (Virginia Regional Medical Center in Virginia, Minnesota, went so far as to discontinue its entire CME program, including grand rounds, in 2007 because of poor participation and a lack of resources.) Those who plan and conduct grand rounds presentations are having to think anew about meeting the needs of their audience.
Competing Interests
Tom Elliott, M.D., chief of the Division of Education and Research at SMDC Health System in Duluth, says another reason for the waning interest in grand rounds is the fact that medicine itself has changed so much. “Over the last 20 years, the practice of medicine has become so intense, and productivity is so valued and measured, that there are very few loose hours in the day,” he says. Elliott explains that SMDC now holds two grand rounds each week—one at St. Mary’s Medical Center early in the morning that draws hospital-based physicians, family medicine residents, medical students, and retired physicians; and another at Duluth Clinic at noon on Fridays that focuses on outpatient cases and issues and draws a different crowd.
The Food Factor
In 2002, Paul S. Mueller, chair of the division of general internal medicine at Mayo Clinic, wanted to test an idea for drawing more people to grand rounds: making free food available.
Mueller and colleagues monitored grand rounds attendance at Mayo for 29 weeks from September 2002 to May 2003, when no food was offered, and then for another 29-week period from September 2003 to June 2004, during which they provided complimentary food. He found overall attendance increased 38 percent after food was introduced, and 70 percent of attendees indicated that they were more apt to attend grand rounds if food were provided. The findings were published in BMC Medical Education in 2007.
That same year, Mayo stopped offering food as a cost-saving measure. Mueller says attendance dipped. (He is quick to add that he cannot prove whether that decline is solely because of the absence of food.)
Now, he says, free food has come back and so have physicians.
Dimitri Drekonja, M.D., an infectious disease physician at the VA Medical Center in Minneapolis, remembers when the VA eliminated food at grand rounds about five years ago. “It was a big deal because attendance dropped,” he recalls.—J.M.
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“We’ve had a lot of technology and specialization over the last several years, and it’s tough to find a topic that embraces all physicians,” he says. “And so what’s happened is we’ve developed more specialty-focused conferences. A cardiologist may never go to grand rounds but may go to the cardiology conference every week within their department.”
Dimitri Drekonja, M.D., an infectious disease physician at the VA Medical Center in Minneapolis, who attends grand rounds weekly and once each year is in charge of presenting or finding a speaker to do one of the presentations, notes that grand rounds is but one of many things that compete for physicians’ attention. “It used to be that once you got the attendees in the door, you just had to keep them awake; the alternative to listening to you was either nodding off or staring at the wall,” he says, explaining that attendance ebbs and flows depending on the topic. “Now, you have to be interesting enough to outmatch the email or other apps on their iPhones.”
Case in Point
Interestingly, a number of institutions are finding that the thing that may breathe new life into their grand rounds programs is returning to what grand rounds once was—an exploration of an actual case. At SMDC, for instance, half of all grand rounds activities are case-based presentations, in which physicians present the patient’s story, the physical examination data, and the X-rays and lab values, and then ask the audience what they think the diagnosis and treatment plan should be. “The more the learner has to work, the more learning is going to take place,” Elliott says. “Case presentations are a great way to make the education interactive and learner-based.”
The case presentation is also the focus of the Schwartz Center Rounds, which were introduced earlier this year at Park Nicollet Health Services. But instead of talking about the patient’s lab results and treatments, presenters focus on the psychosocial and emotional aspects of the ill and those who care for them. It’s an approach conceived in the late 1990s by Kenneth Schwartz, a health care attorney, after he was diagnosed with late-stage lung cancer. Sessions thus far have explored the needs of a family with an elderly parent who has progressive dementia and the emotional journey of a previously healthy 41-year-old woman with advanced lung cancer. Attendance at the monthly sessions, which alternate between Methodist Hospital and Park Nicollet’s ambulatory clinic in St. Louis Park, has averaged between 75 and 100 people. Schwartz Rounds are open to physicians, nurses, social workers, patients, even security guards, housekeepers, administrators, and unit secretaries.
“The point is not to solve a problem but to share our stories and humanity and learn how to take care of ourselves as healers, decrease isolation, have courageous conversations, and better understand the patient experience,” says Judson Reaney, M.D., physician lead for professional renewal at Park Nicollet Health Services. “We feel strongly that it is important to care for one another, to support teams, to create a place where people can talk about difficult things, and where we can emphasize humanism and compassionate care in medicine.”
At Hennepin County Medical Center (HCMC) in Minneapolis, a number of the weekly grand rounds are focused on actual cases that have occurred during the previous week, and presenters get the audience involved right away. Attendees are given a hand-held audience response device to use to indicate their choice of diagnosis and treatment before the presenter discusses what he or she ultimately identified and implemented. “The audience response tool, combined with the case-based approach, has made grand rounds a great learning experience,” says Robin Hoppenrath, administrative manager in HCMC’s Office of the Medical Director. She says between 50 and 100 physicians attend the sessions, depending on the topic, and that they use the audience participation system whenever possible. “It allows them to remain engaged in the presentation, which enhances the attendees’ learning,” she says.
In addition to working to make its grand rounds engaging, HCMC is also studying whether they’re effective. A committee is exploring how to assess whether grand rounds and other CME programs change physicians’ practice. That is something that CME programs have only recently been asked to document and that is likely to affect the content of grand rounds in the future.
Says Mayo Clinic’s Mueller: “If you really want to know if grand rounds is effective, you want to be able to answer the questions, Did this presentation change the knowledge base of attendees? Did it change their practice? Did it change patient outcomes? That’s what I believe the future should be—outcomes data related to grand rounds learning. And that’s a future that’s not without its own set of challenges.”—Jeanne Mettner