Kevin R. Fontaine, PhD
Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, USA
|The Four Doctors, 1905
John Singer Sargent
Johns Hopkins University School of Medicine
Dr. Hunter Champion keys the code in and enters the Longcope Office holding two plastic bags and a cardboard box with Dunkin’ Donuts coffee. Senior resident Parker Ruhl, interns Ben McEnroy and Susan Quan, and third year medical student Justin Schaffe are tapping away at their keyboards as Champion lays out breakfast sandwiches and coffee for them. He then says, “Have something before we get started. Help yourself.”
The hungry young doctors devour the egg-filled English muffins and sip their coffee. Between bites they provide Champion with an overview of each of the patients under their charge. Champion writes notes on 5 x 7 note cards. He then nods to Ruhl. She lifts a thick, gray three-ring binder and says to her charges, “Okay, let’s go.” A little before 9 a.m. on this Saturday morning, the day of the Baltimore Marathon, they begin rounds.
In 1889 William Osler became the first Physician-in-Chief at the newly founded Johns Hopkins Hospital. He revolutionalized medical education by requiring that students be exposed to patients early in their training. As he was fond of saying, “Medicine is learned by the bedside and not in the classroom… Live in the ward.” So, medical students by their third year at Hopkins performed clinical examinations, took patient histories, and evaluated laboratory tests instead of merely sitting in lecture halls.
Each morning Osler, impeccably groomed and with a fresh flower in the buttonhole of his Prince Albert coat, conducted what came to be called “rounds”. Trailed by nurses and students, Osler would sit at the bedside, greet the patient, listen to a clinical summary, examine the patient, and facilitate a discussion, keen to ensure that each patient teaches something that could not be found in a textbook.
Largely due to Osler, rounding became and remains a cornerstone in the process of educating physicians. Rounding, along with the medical residency program, where the care of patients is delivered by a team that includes experienced physicians (the attending), newly minted physicians (residents and interns), and medical students, combine to provide a range of experiences to allow novices to develop and hone their medical skills.
In 1975, Hopkins changed its residency program by dividing its burgeoning staff and students into four units called firms. These firms, each named after four seminal chiefs of medicine at Hopkins, Lewellys F. Barker, Theodore C. Janeway, William S. Thayer, and Warfied T. Longcope, provide all medical care. Each firm is comprised of about thirty housestaff, one Assistant Chief of Service (ACS) and twenty faculty who share responsibility for teaching and supervision. Each firm cares for up to thirty inpatients and conducts several outpatient clinics each week.
On marathon Saturday, doctors from each firm scatter about the hospital. When the doctors from Longcope enter a ward, the speakers blare, “Longcope is rounding. Longcope is rounding.” A squat, older nurse in emerald green scrubs and white running shoes makes her way toward the gaggle of young physicians as they stand near the entrance to Mr. Harris’s room.
Mr. Harris is very sick. His list of chronic diseases includes kidney disease, HIV infection and sickle cell disease. Outside his room Ruhl lays her big binder on a portable wall-mounted fold-out table, a Wallaroo, and Justin Schaffe reads out Mr. Harris’s vital signs. Ruhl writes down the numbers, temperature 98.4, pulse 78, BP 145/78, oxygen 98% saturation on room air. Since Schaffe is a medical student, signified by a white lab coat that goes only to the waist, he reads out vitals, retrieves the files from the nurse’s station, listens and absorbs, but does not speak when the doctors discuss the patients.
As they discuss Mr. Harris, Quan goes to a computer (the walls of the wards have computers mounted on them about every forty feet). She logs onto Sunrise Clinic Manager, a software program that contains all the information on every patient in the hospital, and brings up Mr. Harris’s electronic file.
Ruhl turns to the nurse, “Do you have any questions?”
“No. He had a quiet night.”
The team enters his room. In his mid forties, Harris resembles a man from a famine plagued country. His arms, which lay atop the coarse white blanket, look not much thicker than garden hoses. His face is drawn and his cheek bones protrude making his eyes appear ghoulish. The whites of his eyes against his tar black skin illuminate his face in gray light. His chest and hips and legs, under the blanket, barely rise above the surface of the bed.
Ruhl leans in close and says, “Hi Mr. Harris. I’m Parker Ruhl. I’m the resident. How are you this morning?”
Harris, with no discernable facial expression, mumbles about pain. Ruhl leans in and says, “Oh, we can give you something for that.” She moves down and places her hand atop the blanket on the lower part of Harris’s emaciated left leg. She moves her hand back and forth, gently rubbing him. The other members of the team hover around his bed. Champion remains in the hallway fiddling with his iPhone. Ruhl, moving toward the door, says, “I hope you feel better Mr. Harris. Dr. Quan will be here all day. She will check on you later.”
The team exits. McEnroy, the Irish intern in the tight slacks and the eyeglasses that make him vaguely resemble a young Elvis Costello, goes to a wall computer and feeds in an order for morphine.
As rounds progress, the patients and their maladies blend together. The alcoholic with the scraggly grey beard and the hand tremors, the obese woman whose diabetes may cost her a foot, the 84 year-old man in the last stages of congestive heart failure, the emaciating women with expected inflammatory bowel disease, or worse. Some illnesses are imposed by social and economic consequence while others arise from an addictive or disease process previously residing dormant in the genes. There is, however, no judgment. The alcoholic is sick, a problem to be solved. His self-destructiveness is not read with a moral compass.
Like the marathon taking place a handful of blocks away, rounds are a test of endurance, intellectual endurance, and concentration. Ruhl and her acolytes plod away at each case. The ritual is identical. They assemble in front of the patient’s doorway, look at clinical and laboratory data, trade impressions, decide on a course of action, and go to the patient’s bed. Their self-assuredness is both encouraging and off-putting, as if modern medicine has conquered disease.
Champion always stays in the hallway. All that is required is his presence. An ACS’ job is to supervise, not to interfere with the teaching delivered by the senior resident.
In with the patients the Longcope doctors are respectful and professional. Although they do not seem pressed for time, they do not sit, they do not trade stories. Their words are generic.
After nearly four hours of walking to and from the various wards that contained their patients, they return to the Longcope Office. Longcope is a rectangular room on the hospital’s fourth floor that is quite coveted because it has two large windows that can be opened. There are six desktops, a laser printer, and an array of binders and medical books strewn about counter tops and on hanging shelves. There is a whiteboard on the wall closest to the door that contains a grid specifying which physician is assigned to which patient. It is color-coded to indicate the disposition of each patient. Patients to be discharged are circled in orange. Next to the board is a sheet of paper taped to the wall that holds the image and name of members of the social work department.
Though the finish line is in sight, rounds are not over, not until they set in motion all of the tests and procedures and therapies and discharge orders that were determined to be required when they saw the patients.
Champion, who is thanked again for supplying breakfast, leaves and Longcope launches into what appears to be the bulk of their patient care, tapping notes into the computer and coordinating X-rays and colonoscopies and MRI’s and whatever else is required to diagnose, treat, and discharge their patients.
Observing these young physicians at the desktops and on the phone leaves the impression that much of medicine these days involves harnessing evolving technologies. These young doctors may not realize that the practice of medicine has changed so dramatically. After all, they grew up with computers and cell phones and email and the internet. They also grew up with the ever-emerging wonders of modern medicine.
In Osler’s day, touch, attention and kindness were the staples of medicine. For there were no antibiotics, no precise imaging techniques, no advanced surgical techniques, no drugs to interrupt a disease process. Today, with the ever-growing advances in diagnostics, pharmacotherapy and intensive care, once the initial history and physical examination and diagnostic workup are completed, there seems less of a requirement to spend much face-to-face time with patients during rounds, other than to discuss treatment options, negotiate a course of action, and monitor progress toward discharge or death.
What would Osler think?
Dr. Fontaine is Professor and Chair in the Department of Health Behavior at UAB’s School of Public Health. He is also an Adjunct Faculty member in the Division of Rheumatology at the Johns Hopkins University School of Medicine and in the Department of Health, Behavior, and Society at the Johns Hopkins University Bloomberg School of Public Health. He received an M.A. in science and medical writing from Johns Hopkins University in 2010.