High Point of the Week
For nearly 50 years, on Saturday mornings in Hurd Hall, Grand Rounds was the place to be.
Janet Farrar Worthington
Date: October 1, 2010
It was a drama not to be missed. For a half century starting in 1932, Grand Rounds—the premier case presentation that teaching hospitals around the country use to train physicians in the art of diagnosis—took place every Saturday morning from 10 to 12 in the old-fashioned, steeply sloped amphitheater known as Hurd Hall. There, under the tutelage of some of the world’s most famous diagnosticians, Grand Rounds at Johns Hopkins played to a standing-room-only crowd.
Filling the first two rows in the center would be the senior faculty. To their right—a noticeable phalanx of white coats amid a sea of dark suits—sat the house staff. (“The only excuse for a house officer to miss rounds was to have a patient in cardiac arrest,” remembered two former residents, John Stobo and Patrick Murphy, in a 1989 JAMA article commemorating Hopkins’ 100th anniversary.) Packed into the rest of the auditorium, often overflowing into the balconies and the hall at the back, were part-time faculty and visiting physicians from other hospitals.
Patients under discussion in those days appeared front and center in the auditorium as their conditions were deciphered. Wheeled in and out in an iron bed by two assistant residents, they were attended by the Osler nursing supervisor herself, crisp in her starched white uniform and cap. Starting just after World War II, the patients in question would be determined each Thursday when the chief resident would tell the legendary head of Medicine, A. McGehee “Mac” Harvey, about six to eight cases that might be of interest. Of these, Harvey would pick four, and the doctors who would be doing the talking—a house officer and faculty member for each patient—would get busy preparing for the spotlight.
“It was traditional that the assistant resident would present the patient without any notes—have the whole thing memorized—and then show the lab results on a slide,” recalls Richard Johns ’48, Hopkins’ first chairman of Biomedical Engineering, who went through his medical residency here in the years just after the war. Decades before PowerPoint, “you would type your own slide on a typewriter that had carbon paper, on a piece of cellophane, and stick it between two pieces of glass.” In many cases, the pathologist would analyze tissue slides, as well. Finally, the attending physician would discuss the case—the symptoms, the lab data, and the diagnostic challenges. The time limit for the entire presentation was 20 minutes, strictly enforced by Harvey, who at 18 minutes would ostentatiously begin to consult his watch.
Johns remembers well his first on-stage appearance in Hurd Hall: “I made my presentation, and that went fine, and then I said, ‘The lab data is on the next slide,’ and I went through all that. When I was all done, the first comment was from the chief of service at Sinai Hospital [then located right across the street from the hospital, where the Turner Auditorium is now]. “He said, ‘Dr. Johns, the word data is plural. You should say, “‘The lab data are on the next slide.’”
On another Saturday, Johns remembers, an assistant resident presented a man from California with diabetes insipidus, a disorder characterized by frequent urination and extreme thirst. “You always started off by telling the audience what the patient’s chief complaint was. In this case, it was that he had walked across the United States to come to Hopkins. This was because the patient’s railroad coach had the drinking fountain at one end and the men’s room at the other end, and he had spent his entire journey walking back and forth between the two.”
Many doctors smoked in those days, but they weren’t allowed to light up until the last patient was wheeled out the door. Richard S. Ross, dean emeritus of the School of Medicine, an assistant resident then, recalled that like clockwork during the discussion of the last case, you could see the addicts take out their cigarettes to get them ready. “As soon as the last patient was wheeled to the door, there would be a clicking of cigarette lighters and flashes of fire from lighters and matches.” A few minutes later when the room went dark, you could see plumes of smoke and little red spots everywhere.
Peter Dans, an Osler house officer from 1961 to 1963, remembers feeling part of a long Hopkins tradition as he sat in Hurd Hall, with its stadium seating. “It was just such a great learning experience,” he says, reeling off names of some of the great clinicians of the day: Katie Borkovich, Warde Allan, C. Lockhard Conley, Leigh Cluff. “A lot more of the people who taught on the wards were part-time clinicians from the community who were outstanding, who took that as a very serious obligation, and really contributed to the discussions.”
By the time Dans returned to Hopkins in 1978 as a health policy expert, Grand Rounds had moved to Turner Auditorium. The difference, he says, was striking. “In Hurd Hall, Grand Rounds had often featured patients who had fairly common problems that could present unusually—“things like TB or syphilis that you had to keep in mind, because they could be manifested in many different ways.”
In Turner, the program had become more instructional, with a brief discussion of an illustrative case and then a specialist in the field giving a lecture on the condition, or therapy, or diagnostic procedure. The patient’s case was a springboard for discussion of new science or a new treatment of the condition itself. And increasingly, cases were presented without the patient being there. One reason for this, of course, was that the average hospital patient stay had shortened, and the patient under discussion might well have gone home.
Then, in the 1990s, about the time that residents and their families stopped living on campus in the housing unit known as The Compound (where the Outpatient Center stands today), Grand Rounds moved from Saturday to Friday. The new time slot gave house staff more weekend time at home with their families, but for the community physicians who had faithfully attended Grand Rounds it signaled the end of an era. With rounds now scheduled during the week they could no longer attend.
Today, Grand Rounds remains an important component of the educational mission, according to Charlie Wiener, director of the Osler residency training program, “a great way to keep abreast of medicine, to hear from colleagues and keep up with what they are doing.” Still, as medicine has grown more specialized and pressed economically, the tradition has become less of a grand affair. Fewer faculty attend now due to conflicting commitments, and new work-hour restrictions have hurt house staff attendance.
But perhaps a single sentence from Johns sums up the real difference. Thinking back to the Saturday morning Grand Rounds of his youth, he says, “They were really the high point of the week.”