Precisely at 8 a.m. every Friday, Hopkins doctors in starched white coats converge on a small, oak-paneled amphitheater, finding seats on the long wooden benches to take part in a medical tradition that began a century ago.
Interns and residents peer over the balconies. World-renowned specialists are sitting in the audience of more than 200 doctors. A huge portrait of Dr. Henry Mills Hurd, superintendent when Johns Hopkins Hospital opened in 1889, stares out over the steep rows. Latecomers stand in the back, craning their necks to see.
With the words, "May I have the first slide, please?" the lights dim, and the ritual of grand rounds is under way. The teaching session, built around physicians presenting their patients' cases to their peers, has its roots at Hopkins and is practiced nationwide by medical schools and hospitals.
"At Hopkins, medicine is sort of a religion," said Dr. David Hellmann, deputy director of Hopkins' Department of Medicine, who has been a key organizer of the rounds for the past decade. "These buildings are the temples and churches in which people worship, and for us, our grand rounds is sort of our church service."
Many credit its genesis to Sir William Osler, the legendary first physician-in-chief, who believed that the patient was the source of medical knowledge. In Hopkins' original hospital, there was an octagonal ward, and when a team of physicians toured patients' bedsides, it was called "rounds." On days when Dr. Osler -- known for his encyclopedic knowledge and tough questioning of residents -- arrived unannounced, the sessions were dubbed "grand rounds."
Years later, the setting is less intimate but Dr. Osler's legacy persists. Row after row of the physicians are wearing navy ties or scarves designed to honor him with their pattern of white shields bearing the Latin word for equanimity. And the pressure to perform, as superiors and colleagues look on, is just as intense.
Yesterday morning, down in front, Dr. William Bell whispers to his patient, coaching her: "You just say, 'All these bruises were coming up.' You know all the answers. It won't be hard."
He quickly reviews details of her case with her. Harriet Boston, 68, glances back over her shoulder to see a packed hall. She had expected maybe 10 or 12 physicians.
After two presentations without patients, Dr. Bell takes the podium to make a few introductory remarks. Then he gently escorts Mrs. Boston, leaning on a cane, to center stage.
"There's absolutely no substitute for hearing this directly from the person who experienced the problems," Dr. Bell declares.
Sitting next to one another, they begin a dialogue about her case. She describes the morning she woke up with blood coming from her nose and mouth, how doctors had told her that her count of platelets -- the blood's clotting element -- had dropped.
A question comes from the audience. "Did you have a transfusion?"
"I donated my own blood," Mrs. Boston responds confidently.
Watching approvingly from the front row, her daughter, Phyllis Boston, beams.
"You feel like a parent, that all these people are really interested in what happened and what was the end result," the daughter says. "I'm just tickled."
Dr. Bell goes on to explain that another hospital had mistakenly removed Mrs. Boston's spleen, thinking that would control the ,, platelet problem. But later, Dr. Bell, a hematologist, discovered a severe infection was to blame. An abscess had eaten away a vertebra in her spine. After reconstructive surgery, and several months in the hospital, Mrs. Boston is doing better.
The case history leads into a discussion of lab results and possible causes of her condition. One of Dr. Bell's concluding comments: a doctor should not perform any irreversible procedures until making sure what is wrong.
Afterward, Dr. Hellmann shakes Mrs. Boston's hand and
exclaims, "You were terrific!"
Rounds are still routinely done in the hospital wards with small teams of young doctors, but the Department of Medicine's grand rounds, with two instructive cases each week, have been taking place for years in 63-year-old Hurd Hall, so more physicians may attend.
While most other hospitals have gradually turned the session into a lecture, Hopkins has hung on to its distinct spirit: bring in the patients and let them speak.
For the patients, it is a moment to revel in the attention, to marvel at the intricacies of their cases, and to hear the doctors' opinions.
Said Gerald Kirkendall, 41, an Essex man who appeared a week ago Friday: "It really didn't bother me a whole lot being up there, but Dr. Hellmann seemed to be real nervous."
Even though many presenters have worked at Hopkins for years, some confess their anxieties have subsided only slightly. For them, the grand rounds is more than a class. The session is a way to commune with colleagues, a 90-minute reprieve to contemplate the essence of medicine, even though pagers beep throughout. It is also a rite of passage. Every doctor wants to do an impeccable job.
The night before he was to present a case for the first time, Dr. Stephen Sisson worked the midnight to 8 a.m. shift in the emergency room. The resident had memorized the details of a liver abscess. He had practiced it over and over. Still, he was afraid he would blank out.
"All I could think of that night was what lay in store for me when I finished my shift," said Dr. Sisson, now a chief resident. He brought a change of clothes, excused himself from the $l emergency room at 7:55 a.m. and arrived at Hurd Hall in time to greet his patient.
But when he walked down the stairs to the stage, he wasn't prepared for the feeling. "You really get a different perspective when you're in the bottom," said Dr. Sisson. "It feels like you're in a pit."
Over the years, Hopkins doctors have affectionately nicknamed the experience "Going to the Pit." Dr. Simeon Margolis, now a professor of medicine and biological chemistry, said he was terrified his first time.
"The people seem to be almost plunging down upon you," he said. But once he started, he began to feel his confidence building -- until he glanced in the front row, where the revered chairman of the Department of Medicine sits.
Dr. A. McGehee "Mack" Harvey, chairman from 1946 to 1973, was known for his insistence on sticking to a tight schedule since in those days, patients were wheeled in on gurneys from their hospital rooms.
"Dr. Harvey was sitting there looking at not one, but two watches," said Dr. Margolis. "I almost completely forgot the rest of my presentation."
Equally stressful for Dr. Margolis was the time, as an intern -- the lowest rank -- he was expected to run up and give the patient a shot. The patient had myasthenia gravis, a neuromuscular disease, and had not been given his medication so the physician could demonstrate the patient's weakness.
"There I was, in front of 200 doctors. I was a nervous wreck. What if I couldn't find the vein? I would feel like an idiot," said Dr. Margolis, who nevertheless managed the procedure.
Another time he was not so lucky. He was responsible for pulling up and down the projection screen framed by gold curtains. But he'd just had a minor operation on his wrist, and he accidentally pulled the screen too hard.
"It just collapsed. The whole thing came down. This huge screen was draped over my head and I was looking at the audience," Dr. Margolis said. "Personally, it was very embarrassing."
Yet there have been many serious moments.
One patient described how he developed his heart attack. His dog had died, and on a cold morning, he went outside and began to dig a grave in the hard dirt. That's when his chest pain started.
"I don't think anybody there will ever forget that story," said Dr. Hellmann.
Dr. Harvey, 84, remembers how personal it was in his earlier years at Hopkins, with about 25 doctors going around to patients' bedsides. But after World War II, there were so many doctors in training that Dr. Harvey decided to move the rounds into Hurd Hall. For awhile, they were held in Turner Auditorium to accommodate even more people.
"It was a fixture from the beginning at Hopkins," said Dr. Victor A. McKusick, who was Dr. Harvey's successor.
Other changes in society and medicine have affected grand rounds, as they were moved to Saturdays to allow physicians not affiliated with Hopkins to attend, and several years ago, moved back to Friday so staff could be with their families on the weekend. But because demand from the community physicians was so great, a second set of rounds are held Saturday mornings.
Also, mirroring the shift toward more outpatient care, most of the cases presented are of people who were only briefly -- if ever -- in the hospital. Cost is an increasingly important factor as well. Last week, one physician made sure to put the price of every lab test next to the results.
But despite the solemnity of the ceremony, the physicians will sometimes break from their intense discussions of antigens and cell membranes.
On Sept. 15, at the first grand rounds of the year, the new chairman of the Department of Medicine, Dr. Edward J. Benz Jr., was introduced. After the first case, the presenting physician said everyone wanted to welcome him.
Then, to rousing applause, a slide appeared on the screen -- "Welcome to Baltimore, hon!"