Daily Rounds: Socrates at The Bedside

By Dick Thompson

Almost six hours after it began, the daily ritual of morning rounds finally comes to an end. Since 7:30 a.m., eight new young doctors have been pelted with a steady stream of questions from Magnus Ohman, the senior cardiologist, who is leading the group this morning: Which famous painter suffered from digoxin poisoning? (Van Gogh.) How does a chest X ray look when a breast implant leaks? (Trick question: it looks the same.) Which episode of ER fits the patient in 7206? The dazed residents protest that they have no time for television. "You've got to watch ER," Ohman lectures. "Patients come in and ask you about it."

The questions are endless; the process that engenders them is one of medicine's oldest teaching tools. In this cardiac ICU and all over the hospital, young doctors are presenting cases and being interrogated about their observations, interpretations and plans. Tired residents, stethoscopes slung around their neck, dressed in new white coats (short for interns, knee-length for the more senior residents), are questioned--and questioned some more. They will never know enough, but Ohman hopes they will come to hear these questions, even when no one is asking. "I'm trying to create a mind that is inquisitive," he says.

Each room the doctors visit is a living lesson in modern medicine. In 7213 the heart of a 71-year-old woman is pumping a dangerously low volume of blood. "What is the right therapy?" asks Ohman. They agree that a drug is required to slow the beat, giving the woman's heart more time to fill. Right, pronounces Ohman. Which drug? They stumble with answers until Ohman says it's Esmolol. That surprises one of the young physicians. Esmolol, he notes, could cost as much as $200 a day, while alternatives can be had for $1.50 a pill. Ohman casts an eye toward the clinical pharmacologist accompanying the group. "How am I going to battle him down?" he asks his colleague.

The right answer eventually emerges from their Socratic discourse: if the patient starts to have problems, Esmolol can be stopped and, within minutes, so will its chemical effect. Cheaper drugs can't be turned off so quickly. "It will cost more, but that's O.K.," says Gary Dunham, the pharmacologist who is sharing rounds with Ohman. If the woman gets in trouble with one of the cheaper drugs, he says, her health-care costs will soar. Dunham lectures again in the language of cost-based pharmacotherapy: "It's the most effective drug at the least societal cost."

In 7201 is one of the many smokers on the heart unit. Ben Blalock, 65, not only smokes tobacco, he also grows it. Tobacco, he says, has been his family's ticket out of poverty. He simply doesn't buy the health warnings. His heart problems, he says, are inherited from his "mother's people."

In 7204 a 50-year-old heart-attack victim is given less than a 5% chance of surviving. Outside her room, Ohman examines a box belonging to the patient. It's filled with nutritional supplements. There are medications that could have prevented her heart attack; none are in the box. "This is a sign we have failed," says Ohman.

Room 7205: since his March heart attack, Wesley Duncan, 41, has been readmitted nine times with chest pain. Each time, after costly workups, no disease has been found. Ohman suspects stress. If they can't prove he has a disease, managed-care organizations might not pay for his hospitalizations. How many people go to the ER with chest pains each year? Ohman asks, then answers: 9 million. How many are admitted? Six million. That's $15 billion. How many have heart attacks? One million. "Who pays for these admissions?" he asks.

Now that rounds are over, the students must find answers to Ohman's questions, eat, see more patients and perhaps even sleep. Evening rounds begin in six hours.

--By Dick Thompson