Why Grand Rounds?

By Henry Buchwald, MD, PhD

Once upon a time in surgery, grand rounds were truly grand. In many institutions they still are. In many others, they are not. The question I propose for thoughtful consideration is this: Does this surgical tradition still have an important role to play?

We are indebted to Johns Hopkins Hospital, in Baltimore, at the close of the 19th century for the origins of many of our surgical traditions and disciplines, including the first formal surgical residency program in the United States, established by William Halsted, MD, the chief of surgery, and the first grand rounds, initiated by Sir William Osler, 1st Baronet, FRS, FRCP, the chief of medicine.

Grand rounds through the 20th century became an East Coast tradition. Surgical grand rounds usually consisted of a resident talking over a patient, wheeled in on a gurney for the occasion, with the opportunity for the attending surgeons to question and examine the patient, followed by a formal prepared talk by one of the faculties on the nature of the patient’s problem. This tradition metamorphosed at the University of Minnesota, in Minneapolis, under the aegis of Owen H. Wangensteen, MD, Ph.D., FACS.

When I first attended grand rounds at Minnesota in September 1960, after medical school and internship in the East, I was amazed; indeed, I was shocked. There was no patient on a gurney. There was no staid professorial summary. Instead, there was freewheeling and spontaneous commentary about one case presentation after another, evoking professional and at times personal attacks between members of the faculty. It was riveting; it was unpredictable; it was educational.
Everyone came to grand rounds. Attendance at surgery grand rounds was not only required but eagerly anticipated. By the start of the session, the amphitheater in which grand rounds were held often had no empty seats. Indeed, attendees at times were forced to stand in the back. Grand rounds took place at a dedicated time, held on Saturday mornings from 9 a.m. to noon; they were considered the highlight of the surgical week.

The department chair led the conference. Every faculty member who was in town attended; indeed, all had their self-assigned specific seats. On the wall of the Department of Surgery offices at the University of Minnesota, a cartoon shows the faculty at the time of Dr. Wangensteen all in their seats in the amphitheater except for the presenter in the amphitheater pit.

The house staff, unless in the operating room for an emergency case that could not wait, was present. The students on their surgery rotation, by their choice, filled the back rows. Radiologists and pathologists routinely participated. Internists, pediatricians, and another faculty, as well as community surgeons, would often be present to discuss a case, hear a speaker or attend an educational event—even before the era of CME credits—for the joy of learning.

When I was a junior resident, I once elected not to attend grand rounds for a reason I have long forgotten. The aftermath, however, remains clearly in my memory. Two days later, Dr. Wangensteen asked me during morning rounds whether I had recovered from the illness that must surely have prevented my attendance at grand rounds. I was at first perplexed by his question; I then comprehended its implication; I stuttered some response. I never missed grand rounds again.

All the disciplines of surgery participated. Sometimes world-famous surgeons were the invited speakers, and sometimes local clinicians and scientists. Often community physicians attended and took part. Case presentations, one by each service, lasted up to two hours. Cases were selected for discussion of the disease or problem, the difficulty of diagnosis, the outcomes and, for the most part, therapy—to operate or not, to consider which procedure was the right one, and to discuss how it should be performed. The audience listened as the case presenter talked, without slides and without the current obligatory reassurance by the speaker that he/she had no conflict of interest with the unfortunate patient or his/her problem. The radiologist read x-rays on a view box in the amphitheater pit, and those of us who desired to do so would walk down to have a closer view. Only the officiating pathologist routinely used slides. Most importantly, the radiologist and the pathologist, and, if present, the internist, pediatrician or other clinician were there, not represented by a surgical resident telling the audience what he/she had been told by others.

The speaker was allowed one hour for presentation and for subsequent commentary and questions. The speaker could be a member of the department or of the general faculty, but, more often, was a prominent outside surgeon or other medical person invited for the occasion. They talked of their clinical life’s work or their basic research. Speakers from other countries offered a world perspective, representing the practices of their nations.

The discussions following the case presentations and the speakers’ lectures were the anticipated highlights of grand rounds. The open discussions would at times rise to a debate of orators or become a battle of wits. In addition to being a learning experience, grand rounds were a spectacle, a form of entertainment.

This was teaching at its best, and it was spontaneous, not didactic. Two of our senior staff surgeons routinely opposed each other’s perspective and would resort to vituperation. The older of the two had more wisdom; the younger one had the formidable ability to make the audience laugh, a most powerful tool for debate. One day, however, the older one responded to the laughter that had come at his expense with the words, “every court needs a jester,” successfully reversing the tide of mirth. And how did Dr. Wangensteen, our chair, respond to such sharp banter? He smiled benevolently, proud of the intellectual prowess of his progeny and not at all disconcerted by their combativeness.

At heart, we were still general surgeons, not specialists in a discipline or super specialists in a limited aspect of a discipline, and, therefore, all involved in gaining new insights into our field. I should add that in times past, we were not subjected to talks on how to make residents or practicing surgeons happier in their chosen profession, how to cope with mandatory administrative precepts, or how to earn a living by filling out the proper forms with the appropriate codes. The speakers at grand rounds represented academic interests, intellectual interests. To be asked to be a grand rounds speaker was a great privilege, listed in the curriculum vitae of those so honored.

There has been a decline in some departments in what was once a cornerstone of the practice of surgical education. In speaking with surgeons at centers where grand rounds have deteriorated, I learned that at these institutions the event is no longer an obligation or an anticipated event. Attendance is routinely poor, and therefore amphitheaters have been abandoned for smaller conference rooms. Members of a discipline attend only when their discipline is featured. Case presentations are slideshows; brilliant speakers are fewer in number; the content of speaker topics is often administrative rather than relevant to surgery or research, and the discussions are not only subject to time restraints but are rarely freewheeling or truly educational.

Specialization and super specialization in surgery have, for all practical purposes, done away with general surgery. Today’s surgeons have difficulty keeping up with the pace and expansion of their own particular discipline in the age of the internet and the massive amount of available online data. Further, having no obligations in a particular area, they may have lost interest in other aspects of surgery or medicine in general.

Many of today’s practicing surgeons work for a healthcare conglomerate, and some, therefore, has taken on a job mentality of performing limited tasks. Academic surgeons are encouraged to spend more time operating to make money for administration and for other faculties. Less money is available in departmental coffers for obtaining guest speakers. Certainly, the up to 50% of surgeons’ time spent daily in today’s required computer work is a factor that promotes time restraints. Additionally, house staff often have families and look for any time not directly involved with their work to spend with those families, rather than at events that might seem like simply another way to compel them to listen to administrative injunctions.

The decline in grand rounds as a unifying tradition undoubtedly reflects a combination of these issues, but that decline seems to me to be a loss for the department, the medical school, for our patients and for our profession of surgery.

Is the tradition of grand rounds worth rejuvenating as a powerful educational and professional experience for all involved, a weekly environment that provides intellectual ferment, aspiration and inspiration for medical students, house staff, faculty and community surgeons? In the past, grand rounds were an occasion for intellectual questioning, intense surgical discussion, and reflection, a Sabbath of sorts. In fact, grand rounds might have been called the soul of a department of surgery.

உடல் பருமன் குறைக்கும் அறுவை சிகிச்சை உயிரைக் குடிக்குமா?

உடல் பருமனாக இருப்பவர்களை வேடிக்கையாகப் பார்த்து வியந்த காலம் மாறி, இன்று பெரும்பாலானோருக்கு அது பொதுப் பிரச்னையாகிவிட்டது. வாழ்க்கை முறை மாற்றம், உணவுப்பழக்கம், வளரும் சூழல் என உடல் பருமனுக்கான காரணங்கள் நம் வாழ்க்கையோடு பின்னிப் பிணைந்திருக்கின்றன. அதனால் இன்று உலகை ஆட்டுவிக்கும் பெரும் பிரச்னையாக உடல் பருமன் உருவெடுத்து நிற்கிறது.

உடல் பருமன்

சாதாரணமாக உடல் எடையை குறைக்க மாத்திரை,  டயட் என பல வழிமுறைகள் உண்டு. ஆனால், குறிப்பிட்ட உடல் எடையை தாண்டியவர்களுக்கு அறுவை சிகிச்சை ஒன்றே தீர்வாக இருக்கிறது என்கிறார்கள் மருத்துவர்கள்.

ஆனால், உடல் எடை குறைக்கும் அறுவை சிகிச்சையில் பல அபாயங்கள் இருக்கின்றன. மேலும் எல்லோருக்கும் இது பொருந்திப் போவதும் இல்லை.  சில மருத்துவமனைகள் அந்த அபாயங்களை மறைத்து வருவோர் அனைவருக்கும் அறுவை சிகிச்சை செய்து காசு பார்ப்பதும் நடக்கிறது.

அண்மையில்,  சென்னையில் உள்ள ஒரு மருத்துவமனையில் எடை குறைக்கும் அறுவை சிகிச்சைக்காக அனுமதிக்கப்பட்ட வளர்மதி என்ற பெண், உயிரிழந்தார். இது பெரும் அதிர்ச்சியை ஏற்படுத்தியுள்ளது.

உடல் எடையைக் குறைக்க அறுவை சிகிச்சை செய்துகொள்ளுங்கள் என்று ஏராளமான விளம்பரங்கள் வெளியிடப்படுகின்றன. உடற்பயிற்சி, டயட் போன்றவற்றை செய்து உடல் எடையைக் குறைக்க சோம்பல் படும் இளம் தலைமுறையை, இந்த அறுவை சிகிச்சை ஈர்க்கிறது. இச்சூழலில் அண்மைக்காலமாக இந்த அறுவை சிகிச்சை பற்றி பரவும் செய்திகளும், தற்போது ஏற்பட்டுள்ள உயிரிழப்பும் பெரும் அச்சத்தை உருவாக்கியிருக்கிறது.

உடற்பருமன்

“அறுவை சிகிச்சை மூலம் எடை குறைப்பது  சாத்தியமா? யாருக்கெல்லாம் இந்த சிகிச்சைகளை பரிந்துரைக்கலாம்..?”

குடல் மற்றும் இரைப்பை அறுவை சிகிச்சை நிபுணர், பட்டா ராதாகிருஷ்ணன் கேட்டோம்.

டாக்டர் ராதாகிருஷ்ணன்

“நிச்சயமாக, அறுவை சிகிச்சை மூலம் உடல் எடையைக் குறைக்க முடியும். அதில் எந்த சந்தேகமும் இல்லை.  உடல் எடை குறைக்க, உதவும் பேரியாட்ரிக் (Bariatric Surgery)   அறுவை சிகிச்சைகளில், ஸ்லீவ் கேஸ்ட்ரோக்டமி  (Sleeve Gastrectomy), கேஸ்ட்ரிக் பைபாஸ் அறுவை சிகிச்சை  (gastric bypass surgery) ஆகியவை முக்கியமானவை.

ஸ்லீவ் கேஸ்ட்ரோக்டமி  அறுவை சிகிச்சையில் இரைப்பையின் ஒரு பகுதி லேப்ராஸ்கோபி (Laparoscopically) மூலம் அகற்றப்படும். இந்த அறுவை சிகிச்சை செய்துகொண்ட 2 நாள்களுக்குப் பிறகு வீடு திரும்பலாம்.  இதனால் இரைப்பையின் அளவு குறைந்து விடுவதால், சாப்பிடும் உணவின் அளவு குறையும். இந்த அறுவை சிகிச்சையின்போது வயிற்றில் உள்ள பசியைத் தூண்டும்  ‘க்ரெலின்’ (Ghrelin) என்கிற ஹார்மோனை சுரப்புப்பகுதி அகற்றப்படும். இதன் விளைவாக, பசி மட்டுப்படும். சாப்பிடத் தோன்றாது. அதனால் இயல்பாகவே எடை குறையும்.  அறுவை சிகிச்சைக்குப்பின், உணவின் அளவு குறைவதால், உடலுக்குத் தேவையான ஊட்டச்சத்துக்களும் குறையும். இதை ஈடுசெய்ய ஊட்டச்சத்து நிபுணர், கொழுப்பற்ற ஊட்டச்சத்து உணவுகளைப் பரிந்துரைப்பார். சிகிச்சை மேற்கொண்ட பிறகு உரிய உணவுப் பழக்கத்தை (டயட்) மேற்கொள்ளாவிட்டால் 3 வருடங்களுக்குப் பிறகு மேலும் இரைப்பை பெரிதாகி உடல் எடை அதிகரிக்கும் வாய்ப்புகள் உள்ளன.

கேஸ்ட்ரிக் பைபாஸ் அறுவை சிகிச்சையிலும் இரைப்பையின் அளவில் ஒரு பகுதி நீக்கப்பட்டு விடும்.  நாம் உண்ணும் உணவு சிறுகுடல்களில் தான் சத்துகளை உட்கிரக்கும். சிறுகுடலின் ஒரு பகுதியை அறுவை சிகிச்சை மூலம் நீக்குவதால், உணவின் மூலம் கிடைக்கக் கூடிய சத்துகள் குறைக்கப்படுகிறது. அதனால் எடை கட்டுக்குள் வரும்.

பேரியாட்ரிக் அறுவை சிகிச்சைகள்

உடலில் குறிப்பிட்ட பகுதியில் மட்டும் தேங்கியிருக்கும் கொழுப்பை நீக்க லைப்போசக்‌ஷன்(Liposuction) அறுவை சிகிச்சை செய்யப்படுகிறது.

லைப்போசக்‌ஷன் சிகிச்சையின் மூலம் கை, வயிறு, இடுப்பு, தொடை, மார்புப் பகுதியில் உள்ள அதிகப்படியான கொழுப்பு அகற்றப்படும். அல்ட்ரா சவுண்ட் துணையுடனும், சாதாரண  ஊசி மூலமாகவும் உடலில் உள்ள கொழுப்பு உறிஞ்சி எடுக்கப்படும். இந்த சிகிச்சையில்  ரத்த இழப்பு பெருமளவு குறைக்கப்படும். ஆனால், அதிகளவு உடல் எடையைக் குறைக்க இந்த முறை, உதவாது.

சிகிச்சையின்போது உயிரிழப்பு ஏன் ஏற்படுகிறது?

பொதுவாக,  உடல் பருமன் சிகிச்சைக்காக வருபவர்களுக்கு ஏற்கெனவே தைராய்டு, சர்க்கரைநோய், இதயம் தொடர்பான நோய்கள் இருக்கலாம். எனவே, அறுவை சிகிச்சைக்கு முன்பாக, அவரது உடல்நிலை தொடர்பான முழுமையான விவரங்களைக் கேட்டு, பரிசோதித்து அறிந்துகொள்ள வேண்டும். இதற்கு நோயாளியும்  ஒத்துழைக்கவேண்டும்.

அறுவை சிகிச்சைக்கு 10 நாள்களுக்கு முன்பிருந்தே,  திரவ டயட் முறையைப் பின்பற்ற வேண்டும். இந்த சிகிச்சையில் உணவியல் நிபுணர்களும் அங்கமாக இருக்க வேண்டும். அதுமட்டுமின்றி, சுரப்பியல் நிபுணர், இதய நோய் மருத்துவர், சுவாச மருத்துவர் எனப் பல கட்ட பரிசோதனைக்குப் பிறகே அறுவை சிகிச்சையைத் தொடங்க வேண்டும்.

நோயாளிகளின் அவசரத்துக்காக நேரடியாக அறுவை சிகிச்சையைத் தொடங்கக் கூடாது. அதேபோல  மற்ற துறை வல்லுநர்கள், போதுமான மருத்துவ வசதி இல்லாத இடங்களில் இதுபோன்ற அறுவை சிகிச்சையைச் செய்தால் உயிரழப்பு ஏற்படவே செய்யும் . மற்றபடி, தகுந்த வாய்ப்புள்ள, வசதியுள்ள, தகுதி வாய்ந்த மருத்துவர்களைக் கொண்ட இடங்களில் அறுவை சிகிசை செய்துகொண்டால் உயிருக்குப் ஆபத்து ஏற்பட வாய்ப்பில்லை.

இந்த அறுவை சிகிச்சையை யாரெல்லாம் செய்துகொள்ளலாம்?

நாள்பட்ட டைப் 2 சர்க்கரைநோய், உயர் ரத்த அழுத்தம், இதயநோய், அதிகக்கொழுப்பு, தூக்கத்தில் மூச்சுத்திணறல், நீண்டநாள் செரிமானக் கோளாறுகள் மற்றும் உடல்பருமனால் வரும் புற்றுநோய் போன்ற பிரச்னைகளுக்கு அறுவை சிகிச்சை மூலம் உடல் எடையை குறைப்பதே ஒரே வழி.

உடல் எடை குறைக்கும் பயிற்சி

பேரியாட்ரிக் அறுவை சிகிச்சை செய்துகொள்பவர்களது, குறைந்தபட்ச பி.எம்.ஐ. அளவு 40-க்கு மேலும், சர்க்கரை நோய் போன்ற மருத்துவப் பிரச்னை உள்ளவர்களுக்கு பி.எம்.ஐ. அளவு 35-க்கு மேலும் இருந்தால் இந்த அறுவை சிகிச்சை செய்துகொள்ளலாம்.  ஆனால், இந்த பி.எம்.ஐ அளவு குறைவாக இருக்கும் நிலையில், அழகுக்காக சிலர் இந்த அறுவை சிகிச்சை செய்துகொள்ள வருகிறார்கள். அது தேவையற்றது. விபரீதத்திலும் முடியலாம்.

உடல் எடையைக் குறைக்க, உடற்பயிற்சிக் கூடங்கள், உணவுக் கட்டுப்பாடுகள், நடைபயிற்சி, சைக்ளிங் போன்ற சில வழிகள் இருக்கின்றன. அவற்றை மேற்கொண்டு ஆரோக்கியமான முறையில் உடல் எடையை கட்டுக்குள் வைக்கலாம்…” என்கிறார் அவர்.

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FREQUENTLY ASKED QUESTIONS

What is Gastroenterology?

Gastroenterology is a medical specialty involved with the diagnosis and treatment of disorders and diseases of the digestive system; this includes the esophagus, stomach, small intestine, colon and rectum, pancreas, liver, gallbladder and biliary system.

 

Upper Endoscopy (EGD)

What is upper endoscopy?

Upper endoscopy allows your doctor to examine the lining of the upper part of your gastrointestinal tract, which includes the esophagus, stomach and duodenum (first portion of the small intestine). An EGD is used for stretching a narrowed esophagus if you are experiencing difficulty swallowing, the removal of polyps or swallowed foreign objects. For more information, visit http://chennaigastrosurgeon.com/index.html

Why is upper endoscopy done?

Upper endoscopy helps your doctor evaluate symptoms of persistent upper abdominal pain, nausea, vomiting, difficulty swallowing or the cause of bleeding from the upper gastrointestinal tract.

How do I prepare for the upper endoscopy?

Your stomach must be empty. Do not eat or drink anything, including water, for approximately six hours before the procedure. Our schedulers will tell you when to start fasting.

What can I expect during upper endoscopy?

Sedation will be given before and during the procedure to help you relax and make you sleepy. You will lie comfortably on your left side. The doctor will pass the endoscope through your mouth and into the esophagus, stomach and duodenum. The endoscope does not interfere with your breathing. The scope blows air into the stomach to expand the folds of tissue making it easier for the physician to examine your stomach. You should experience little to no discomfort with this procedure.

What happens following my upper endoscopy?

Your throat may be slightly sore, and you might feel bloated because of the air introduced into your stomach.

Why is a biopsy done?

A suspicious area may be found and a biopsy is needed to distinguish between benign and cancerous tissues. This is done with small forceps passed through the scope with no discomfort to the patient. Biopsies are done even if cancer is not suspected. Your doctor may do a biopsy to test for Helicobacter pylori, bacteria that cause ulcers.

Colonoscopy

What is colonoscopy?

Colonoscopy enables your doctor to examine the lining of your colon (large intestine) and rectum. It is the most effective way to evaluate your entire colon for the presence of colorectal cancer or polyps. Early detection can prevent surgery and save lives.

For more information, visit http://chennaigastrosurgeon.com/index.html

How do I prepare for the colonoscopy?

A colonoscopy requires a cleansing preparation of the colon the day before the procedure so that the colon can be fully visualized. This is usually accomplished by drinking a liquid that causes complete emptying of the colon. Our schedulers will tell you what dietary restrictions to follow and what cleansing routine to use as prescribed by your doctor. It is important to follow your directions carefully.

What can I expect during the colon exam?

Sedation will be given before and during your procedure to help you relax and make you sleepy. You will lie on your left side as a flexible tube is inserted into your anus and slowly advanced into the rectum and colon. The procedure will cause you little to no discomfort.

What if a polyp is found?

A polyp is an abnormal growth found in the colon lining. They vary in size and shape, and while most are benign (non-cancerous), some may turn into cancer. It is important to remove pre-cancerous polyps as a preventative measure for colorectal cancer. Very small polyps may be totally destroyed by fulguration (burning). Larger polyps are removed by a technique called snare polypectomy. A wire loop (snare) is passed through the scope and removes the polyp from the intestinal wall. This technique causes no pain to the patient.

What can you expect after your colonoscopy?

You may experience some bloating or mild cramping because of the air introduced into your colon. These symptoms should disappear when you pass gas.

Do I have to drink all the solution to cleanse my colon?

Please follow all instructions and make every effort to drink all of the purging solution. The height and weight of a patient does not determine the amount of solution needed to purge your colon. Remember, we are trying to clean out your entire digestive tract. If your colon is not clean, the physician cannot do a thorough exam. We may have to reschedule your test for another day.

What if I start vomiting while drinking the solution?

If you develop symptoms of nausea or vomiting, stop the prep for an hour then resume the process. If you were not able to complete the prep, call our office at (816) 561-2000 and the physician on call will assist you. It may be necessary to reschedule your procedure and try an alternative prep.

What are clear liquids?

Clear liquids include black coffee, tea, soda pop (Coke, Pepsi, 7-Up or Sprite), apple juice, Gatorade, Popsicles, Jell-O, broth, and bouillon. Do not consume any milk products or anything that is red or purple.

Do I need to bring medical records (previous procedure reports) with me?

Yes. If your procedure was done by another physician, reports are needed because follow-ups vary with previous findings. If you had previous colon polyps, the physician will know from the report the location and size of the polyps.

Procedure Related Questions

Why do I need to bring someone to drive me home after my procedure?

Because of the sedation given during your procedure, you will need a friend or family member to come with you and drive you home. These medications make the test easier for the patient, but do not wear off immediately. For your safety, you should not operate machinery or drive following your procedure. During your recovery time, your family will be allowed to sit with you until you are discharged. You may not use public transportation unless accompanied by family or a friend.

How long will my procedure take?

The actual procedure will take 15-20 minutes. Registration, pre-operative and post-operative care will keep you in our facility approximately 1½ to 2 hours.

How long will I have to wait for the results of my procedure?

The physician will speak with you about the visual findings on your procedure before you go home. If biopsies were taken or polyps removed, you should call the office for results a week from your procedure date.

How soon may I eat after my procedure?

Unless your physician gives you dietary restrictions, you are free to eat a normal breakfast or lunch after leaving our endoscopy center.

How soon may I return to work?

Most patients are able to return to work the following day.

What about follow-up care?

Follow-up care is an important part of your treatment plan. We have a recall system that notifies the patient by mail when you are due for follow up care such as an office visit, labs or procedure. Once you receive your recall letter, please contact our scheduling department to schedule your next appointment.

Will the results of my visit be sent to my primary care physician?

Our findings and recommendations will be discussed with you and a letter and/or copy of your procedure note will be forwarded to your primary care physician for their records.

What is virtual colonoscopy and can I have that instead?

Virtual colonoscopy is a technique designed to reconstruct three-dimensional images of the colon using a CAT scan. Studies have suggested that this technique might miss a significant percentage of smaller polyps that can be found with colonoscopy. Virtual colonoscopy requires you to be cleansed just as if you were having a traditional colonoscopy. Furthermore, if polyps were detected by virtual colonoscopy, you would still need a traditional colonoscopy to remove these polyps, thus resulting in two procedures. We do not recommend virtual colonoscopy as an adequate screening test.