The 7th Time’s a Charm

If you were asked what common theme you might expect at a bedside medicine symposium, Sherlock Holmes might not be the first thing you’d list.  But at the 7^th Annual Stanford 25 Skills Symposium, Mr. Holmes became a surprising through-line in many presentations.

Why would a fictional character fit in at this highly informational clinical teaching symposium?  Well for one thing, Mr. Holmes, while fictional, is a character created by a physician and also based on a historical physician (a Dr. Joseph Bell, whom Arthur Conan Doyle studied under).  And for another, he’s a perfect tool to describe the power and the joys of bedside medicine, which are, of course, the goals of the Stanford 25 symposium.

The symposium kicked off on Friday morning with a rousing introduction from John Kugler, MD, clinical associate professor of medicine, to an audience of around 120 from all around the country (and the world).  Kugler naturally acknowledged the difficulties of teaching bedside medicine during a worldwide pandemic, saying, “We managed to teach the entire physical exam over Zoom,” but he urged his audience to leave the symposium with a renewed sense of purpose as well as practical tips to share.  “It all starts with your enthusiasm for seeing patients and taking students to the bedside,” he said, asking attendees to concentrate on at least one thing from the symposium that they were excited about taking back to their learners.

In her talk entitled “The Post-Pandemic Bedside Exam,” Subha Ramani, PhD, MBBS, associate professor of medicine at Harvard Medical School, also emphasized the importance of enthusiasm and diligence.  She was the first to cite Sherlock Holmes, saying that “When I go to the bedside, I become the person who lived on Baker Street.” 

She urged her listeners to bring their human side to every bedside encounter, and to pivot from a “solar teaching model,” where the teacher is the sun and the patients and students revolve around him or her, to a “lunar teaching model,” where the teachers are the moon and revolve around the students.  She also emphasized that patients should be crucial to the teaching process, quoting Laurence Savett who stated, “The interaction between physician and patient is the interaction between a generalist and a specialist: the doctor is the generalist, and the patient the specialist.”

Poonam Hosamani, MD, clinical associate professor of medicine, and Errol Ozdalga, MD, clinical professor of medicine, echoed this emphasis on the patient in their dueling presentation on bedside rounds.  Hosamani pointed out that patients appreciate rounds with residents because it gives them a chance to see how many doctors are focused on their care.  Ozdalga acknowledged that we have to accept the difficulties that integrating technology into rounding can bring, and instead focus on improving the little things that help residents learn: efficient, relevant details that can’t be looked up easily later, minimizing administrative work, and, of course, free food.

Linda Geng, MD, PhD, clinical assistant professor of primary care and population health, spoke about the challenges of long COVID and facing patients when you don’t know all the answers.  She focused on validating patients’ suffering as well as keeping an open mind.  She closed with a simple but powerful sentiment: “We can be guided by our compassion and our humanity and the Hippocratic oath: first, do no harm.”

Andrew Elder, MD, FRCPE, geriatrician and President of the Royal College of Physicians in Edinburgh, focused on the power of individual patient stories at the bedside with his talk, appropriately titled “The Power of One.”  He explained that his work in geriatric medicine often starts with looking in a patient’s eyes, which can mean either squatting by a hospital bed or adjusting your own perspective to match the patient’s eye level.  He told a story which combined a case study, a brief history of the fates in Greek mythology, and a study of pupil size and attractiveness.

The story was of an elderly COVID patient at his hospital who seemed to be responding to COVID treatment but then developed hallucinations, and no one could figure out why.  By examining her pupils, which were unusually large, he was able to figure out that her medications were actually poisoning her.  His take on Sherlock was that it’s not just his analysis that makes him remarkable: it’s his “genius of meticulous collection of information.”

Elder went on to quote Goya’s “aun aprendo,”  (“I’m still learning,”) and assert that it’s okay to tell people, even as a clinician, when you don’t know something.  “If I stop learning,” he concluded, “I shouldn’t be doing my job anymore.”

Clinical approaches and tips (often called “pearls”) were also a common theme of the symposium.  Jeffrey Dunn, MD, clinical professor of neurology, shared his pearls of the neurological exam, and Bernice Kwong, MD, clinical professor of dermatology, shared her pearls from dermatology.  Both speakers wowed the audience with their level of expertise and detailed scenarios. Dunn demonstrated neurological tests that you can do with a broken-off piece of a Q-tip, reminding his listeners that there’s “always a bit of art, always a bit of theater involved in the bedside manner,” and Kwong told two stories that sounded like something straight out of a mystery novel: “The Red Face” and “The Itchy Patient With No Rash.”

Richard Hoppman, MD, clinical professor of internal medicine at Columbia University, extolled the virtues of the ultrasound and its use in bedside medicine.  He pointed out that it poses no radiation risk to patients and can be integrated into many different areas of care. Then he brought it all home, saying, “The greatest advantage of getting ultrasound in curriculum is getting students back to the bedside.”

Another Sherlock Holmes-like tip cropped up in Maja Artandi’s discussion of the musculoskeletal (MSK) exam.  Artandi, MD, clinical professor of primary care and population health, suggested that particularly for foot injuries, doctors should examine the soles of the patient’s shoes, which can tell them a great deal about stride and gait.  “Patients love when I look at the soles of their shoes,” she said enthusiastically.

Finally, Abraham Verghese, MD, MACP, Linda R. Meier and Joan F. Lane Provostial Professor of Medicine, closed out the first day by throwing his presentation out the window and speaking off the cuff about bedside medicine.  He said he’d been wanting to discuss joy, but so many of the other speakers had already covered it, so he focused instead on the power of story and ritual at the bedside. 

He began at the very beginning of bedside medicine, starting with Hippocrates in 400 BCE, and then moving on to the physician in 1700s whose father was an innkeeper who would tap barrels of wine to see when to re-order.  This physician used this observation and went on to translate it into medicine as the percussion technique. Verghese also spoke about the invention of the stethoscope and the meaning behind it, stating, “When physicians started carrying stethoscopes they were telling the world they were committed to finding a diagnosis."

He closed by emphasizing the centrality of “keeping the faith” to a physician, urging his listeners to “remain curious” and look for the new in medicine.  “This is a fertile frontier,” he concluded.  No one present, who witnessed the day of joy, intelligence, enthusiasm, and clinical knowledge bursting at the seams, would dare argue.