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Saturday, September 8, 2007

Grand Rounds Foolishness

Dr Shock still makes mistakes. But he'll never be as naif and stupid as he was during one of his internships. It was after a grand round on a neurolgy ward in an Academic Hopsital. Even in those days we didn't discuss diagnosis and treatment over the heads of the patients while they were surrounded on their beds by numerous white coats. The discussion was done afterwards with the professor and several senior and junior staff members as well as residents. Interns could listen to the discussion on the back benches of the room.

During a discusion after such a ground round one of the senior staff members ended the discussion with the statement that patients X was clearly suffering from disease Y as derived from his symptomps and recently published in the Lancet by Prof Z. Soon the discussion ended, and everybody got back to work, leaving us interns flabbergasted.

Young Dr Shock was so impressed that he decided to search for the literature mentioned, but no matter how long he searched for Porf Z in The Lancet about disease Y he couldn't find it nor any other recent publication on the topic of discussion. Well that's just being naif probably corresponding with has age then, a long time ago. More stupid was that on the next discussion after a grand round he decided to inform the attendees about his bad luck on his search. Obviously the senior staff member was not amused, after a short and brisk remark the meeting was over quickly.

Bold Statements during Grand Rounds
Bold statements mostly done by senior staff members during grand rounds about material that is less well known occurs frequently. Such bold statements are frequently articulated with great conviction and are usually accepted and assimilated by junior staff and the likes of them. Until recently it was unclear whether these exotic statements were substantiated with scientific evidence.

Researching Grand Rounds
In Medical Education, one of Dr Shock's favorite journals, a study about this phenomenon was published. The study aimed to evaluate the degree of scientific proof behind the bold statements made during grand rounds.

What they did was evaluate the level of scientific evidence for all bold statements during grand rounds for a period of 4 months. The study was performed on the Departement of Internal Medicine in a large teaching hospital in Amsterdam, The Netherlands. The evidence was searched on PubMed and discussed in short plenary discussion by the internal medicine residents. Outcome was categorical: supported by evidence based medical knowledge or unfounded exotic statement. Result were statistically analyzed.

The Truth on Grand Rounds
In total 25 cases of bold statements were indentified during these 4 months, of which 22 were made by senior staff and 3 by residents. An exaple of such a statement: "Legionella pneumonia never causes pleuritic pain". Only 8 (32%) statements were found to be supported by scientific evidence. In 17 (68%) statements the available literature contradicted (n=13) the statement, or no literature was avalable (n=4). The difference between confirmed and false or not confirmed statements was significant. Every intern and resident should read this article before they are send into clinical practice.

Article Discussed:
Gabor E Linthorst, Johannes M A Daniels, David J van Westerloo (2007)
The majority of bold statements expressed during grand rounds lack scientific merit
Medical Education 41 (10), 965–967.


Anonymous said...

Oh, my, that also happens in GRs here in my country. When the senior consultant speaks, it's as if it's already final and nobody would dare question it further. Now it comes to mind whether everything that the senior consultants said were really based on evidence or merely their way of ending the discussion.

Dr. Shock said...

I think the latter, but take care, regards Dr Shock