Personal View: Grand rounds
Authors: Colin Douglas
Journal: BMJ (2004)

It's the Friday lunchtime grand round, and I am presenting. The cardiologist stands up to introduce me: “Today we are going to tell you about a very interesting and unusual case, and I want you to shout out the diagnosis when you've got it. It's about a 46 year old man who first presented to us...” Someone shouts out from the floor: “Atrial myxoma.” Game over. Or was it?

Grand rounds have changed a lot in recent years. They used to be about patients with rare diseases who presented in an unusual way (a man with Whipple's disease who had a pyrexia of unknown origin). Progress brought us patients with rare diseases who had typical symptoms (a 30 year old woman with uncontrolled hypertension who had a phaeochromocytoma) and then patients with common diseases who presented in an unusual way (a 40 year old man with coeliac disease who had a myopathy).

And what's their future? Increasingly we will hear about patients with common diseases who have typical symptoms. Why shouldn't we? These are the patients we see every day in casualty departments. Good presenters will find out what the audience's learning needs are and will choose stories to fulfil those needs. For example, generalists are tired of hearing the same old lectures on cardiac failure. What they want to learn about is recent advances—such as the role of B-type natriuretic peptide in diagnosis, how to prescribe β blockers, and when to prescribe spironolactone. They will also want to know when to start concentrating on palliative care.


Know your audience and aim your presentation at them


Another way of finding out what the audience needs to learn about is to ask specialists what common errors in treatment are made by non-specialists. You can then choose stories to demonstrate these errors and, most importantly, how to avoid them. For example, a common error in the treatment of heart failure is to stop the angiotensin converting enzyme inhibitor the minute the patient starts coughing. But of course cough is a common symptom of pulmonary oedema or coexistent bronchitis, so you should also consider these causes.

The first rule of thumb for presentations is to know your audience and aim your presentation at them. But how do you engage an audience that is made up of medical students, junior doctors, and gastroenterologists (and chemical pathologists who always turn up and always sit at the front)? Everybody likes to hear about generic topics such as confidentiality or communication skills. You can promote good communication skills at grand rounds, but some of the audience will switch off. Mentioning the science of communication skills sometimes helps to engage them. Here is a good statistic to start off with: on average doctors will perform 200 000 consultations during their working life, so it is fairly important that they work on their skills.

And why don't we ask patients what they want their doctor to learn about? Cardiologists teaching about cardiac failure will talk about shortness of breath and peripheral oedema, but many patients will talk about fatigue, anxiety, and depression. These problems can affect their quality of life just as much as their shortness of breath, and you can treat these complications effectively—even if you are not a cardiologist.

In the first grand rounds specialists used to bring their patients along to the lecture theatre and demonstrate the symptoms and signs before everyone. With increasing use of video, grand rounds will return to their beginnings. It can be intimidating for a lay person to tell a large audience about their problems, but some patients and relatives don't mind telling their story face to face.

And how will we evaluate the effectiveness of these new, improved grand rounds? You could hand around evaluation forms, but many people are too polite to tell you what they really thought. It's better to hand around a mini-test at the start to establish everyone's baseline knowledge of the subject. In the test try to think of questions that will test the audience's application of knowledge and decision making ability rather than just their ability to remember dry facts. You can then ask them to fill it out again at the end to see what they have learnt. Hand it around again a few months later to see whether they have retained anything. And, most importantly, ask them whether they have put what they learnt into practice. The pre-test and post-test will, I hope, show that your presentation filled important gaps in their knowledge. The annual winner of the best presentation will then become the winner of the most effective presentation.

But the first thing we need to do is change the name. Grand rounds are only for those with delusions of grandeur. And for those people who will still only go to them because they like detective stories, here is the grand finale: without any trumpet blowing introductions I showed the histology result a few Friday lunchtimes later. The heckler with the mind reading powers was nearly right: it was an atrial tumour—but a haemangioma. How did he know that a cardiologist would present a cardiology rarity? I would have asked my sheepish boss, but he was busy.