Bringing new respect to an old teaching method
On a recent Thursday morning, Dr. Allan H. Ropper walked into a conference room jammed with medical students, residents, and doctors, welcomed that day's patient, and began his examination.
Carol Silvia, a white-haired 63-year-old, had seen doctor after doctor since a seizure a month earlier. Her symptoms -- including bouts of dementia and an inability to walk -- were not typical of a woman her age.
Ropper, the chief neurologist at Caritas St. Elizabeth's Medical Center in Brighton, is a firm believer in, and one of the area's only practitioners of, grand rounds -- a time-honored practice in which senior doctors publicly examine and quiz patients, as a learning experience for other doctors and students in the room.
Grand rounds were once a standard by which many doctors were taught. But over time, patient privacy concerns combined with a more scientific, test-based medical education has led to the near extinction of this style of teaching.
"Medicine became more academic, less craft," said Ropper, also chairman of the neurology department at Tufts University School of Medicine. "Grand rounds recognize that medicine is a craft. . . . I view it as a way back to the future."
Though it may seem impersonal to interview a patient in front of a crowd, Ropper said it's the best way for students to learn the importance of really listening to the patient's problems and figuring out how to help.
"In neurology you have to have hands-on face time," he said.
During Ropper's residence at Massachusetts General Hospital, he attended grand rounds under doctors he calls, "the three horsemen of neurology." One of them, Ray Adams, taught him bedside manner, patient interaction, and the basics of empathy. A graying photo of Adams still hangs amid scholarly awards on Ropper's office wall. Each Friday, Ropper visits Adams at his Chestnut Hill home.
Ropper now plays that mentoring role for a new generation of neurologists, including Alec Glass, 29, of Houston, a fourth-year senior resident.
"This style teaches you how to draw out information from patients and solve their unique case. You can't learn that from a textbook," said Glass, who cited Ropper as the reason he chose St. Elizabeth's for his residency.
When Ropper's not teaching, he treats patients from Hollywood actor Michael J. Fox and rock singer Ozzy Osbourne to everyday suburbanites. Ropper said he cares more about the interest and difficulty of the case, rather than the prestige of the patient.
Sitting in his office, holding the textbook he wrote, Ropper repeatedly returns to the importance of the patient experience. "The treatment of a patient must be completely personal," he said, quoting Harvard physician and humanitarian Dr. Francis Weld Peabody.
Ropper asked Silvia, that morning's patient, to explain what was bothering her. As she responded, he translated her layman's terms into the medical lingo the doctors could better understand. "It's just shop talk," he explained to her. The conference attendees took notes, sipped coffee, and furrowed their brows.
Ropper took Silvia through a battery of tests for about half an hour and then thanked her for her time and cooperation.
Once she left, Ropper began calling on attendees, asking for input and diagnoses. The older physicians and clinicians wearily eyed the younger medical students and the younger set crinkled their noses or raised their brows at the conclusions of the long-tenured staff.
Two televisions and video cameras linked the session to a dozen students, residents, and staff members at the New England Medical Center and Carney Hospital and allowed them to also offer ideas.
After hearing from most of the table and some via teleconference, all eyes turned to Ropper. "I recall a similar case in 1993. . . . I believe it is Rasmussen's encephalitis, a rare auto-immune disease."
Medical associates nodded their approval. His diagnosis, though unusual for a woman her age, perfectly fit the symptoms. And Silvia, who reacted well to the anti-seizure medication Ropper prescribed, will undergo blood testing to confirm the analysis.
"Illnesses are complicated," Ropper said. "People are complicated. You can do all the laboratory tests, but you need to solve the problem in the human condition."
