The Art of Medicine

This past Thursday I spent the day in the Dermatology Clinic.  It was a special day for rounds that occurs once a month, in which dermatologists from the hospital bring outpatients that they have been following to be reviewed by the whole team.  The cases were undifferentiated and challenging and no formal diagnosis had been made yet.  As a group of medical students, residents, and attending physicians, we moved from one room to the next to see all of the patients.  In each room, we huddled around the patient, listened to the treating physician’s summary of the case and members of the Dermatology team asked any other relevant questions on history and examined the patient.

After seeing all of the patients, we sat around a table over lunch and discussed each case in detail, creating a differential diagnosis and an appropriate management plan for each.  The purpose was to pool everyone together and hear the input and opinions of several dermatologists.  At the end, a few of the final diagnoses were still somewhat uncertain but the goal of the discussion was to ensure that any worrisome and/or common diagnoses were being considered and that the possible avenues for therapeutic intervention had been trialled.

It was a unique learning opportunity for me to hear the thought processes of the team as they made decisions.  One of the cases was challenging given that most of the patient’s symptoms had resolved and it was difficult to make an assessment.  The patient had alopecia as per a few scalp biopsies, however the hair loss pattern did not neatly fit into one of our known alopecia diagnoses.  The discussion was centred around how to prevent this from happening again given the uncertainty of the cause.  Other patients had nail changes: one case was non-uniform nail hyperpigmentation NYD which was a nuisance for the patient, but there were no concerning features on examination and not likely to be any treatments for this.   Medicine is an art and making decisions with a team can often aid in determining the extent of a work-up, solidifying a diagnosis, knowing when to refer, and knowing when to treat.

Bedside rounding is particularly useful in a field like this where much of the learning and examination is done visually.  It creates an environment to learn from each other’s experiences and improve outcomes through combined decision-making and team consensus.   (Gonzalo et al., 2013) It has been shown that on internal medicine wards, patients receiving bedside rounds prefer this method.  (Gonzalo et al., 2010) During our Dermatology team rounds, one of the patients had nail findings similar to onychogryphosis but with some differing features.  She was encouraged that we were all at the bedside trying to help figure out why this had happened.  Team rounding at the bedside not only is an important educational tool as a trainee, but it also reinforces the importance of patient-centred care in medicine.

Stay tuned for more,

SH

Resources:

Gonzalo, J. D. et al. (2013). The Value of Bedside Rounds: A Multicenter Qualitative Study. Teaching and Learning in Medicine, 25(4): 326 – 333. doi: 10.1080/10401334.2013.830514.

Gonzalo, J. D. et al. (2010). The Return of Bedside Rounds: An Educational Intervention.  J Gen Intern Med, 25(8): 792 – 798.  doi:  10.1007/s11606-010-1344-7