Wednesday, August 8, 2007

Grand rounds

Today my morning began with Grand Rounds. Most of the time this meeting is neither grand nor do we make rounds. It is a get together, over coffee and donuts, to discuss the latest tribulations and triumphs of our medical community. This sharing of experiences among physicians is essential to the practice of good medicine.

Twice a month this conference consists of something called a CPC. Early in my medical career, while I was still spending hours every day listening to basic science lectures, I happened on my first CPC. That stands for Clinical Pathological Conference. As a lowly first year medical student, I found this to be an exciting meeting. If I can't attend one each week, I try to read the one in the New England Journal of Medicine. For someone intereted in medicine they read better than a well written mystery.

There is an interesting cast of characters. First there is the Presenter, usually a resident physician who has taken care of the patient. The Presenter outlines the case by reciting the medical history, reviewing the physical examination and initial laboratory testing but stops short of giving the diagnosis.

Next the Discussant steps up to the podium. Usually one of the senior residents or attending physicians, this person has the job of making the diagnosis. For those of you who are not physicians, coming up with a diagnosis is not as easy as the Internet would have you believe. Part of the problem is there are usually several diagnoses to which the signs, symptoms and test results point. This list of possibilities is called the "differential diagnosis." Listing the different diagnostic possibilities and why each is possibly the condition from which the patient suffers is the largest portion of the program. Not only is it an excellent learning tool for those present but it is also the Discussant's chance to show off.

Finally, the pathologist or radiologist appears. The most smug person in the room, this doctor has the answer. That is why certain people go into those specialities, they get the last word in the case. Drum roll please... Usually a slide appears on the screen with the final test, the results of which yield the diagnosis.

I realize that I am attracted to these conferences not just for the knowledge of medicine that I gain. I have also learned a great deal about what it takes to be a good physician. One has to be a good listener, thoughtful, diligent in looking at all the information, especially that information provided by the patient. More than just a little research in textbooks and medical journals is required. Some humility is also indispensable. No one can know everything, often other physicians have to be consulted. Occasionally after a brilliant presentation, the Discussant is found to be wrong.

Yes, unlike what other venues teach, you can be wrong and still be a good physician. That may not be what most get from these meetings but it is one of the aspects that I stress with the residents. Medicine is not an exact science. The good practitioners keep looking. Not just for the correct diagnosis but also for the most effective treatment for each individual patient.
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