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Environmental Health Perspectives Grand Rounds in Environmental Medicine 2003 Grand Rounds in Environmental Medicine edited by Howard Hu Preface Howard Hu Medical Editor Environmental Health Perspectives Occupational and Environmental Medicine, Harvard Schools of Public Health and Medicine, Boston, Massachusetts Brigham and Women’s Hospital, Boston, Massachusetts Northeast Specialty Hospital, Braintree, Massachusetts

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Address correspondence to H. Hu, Channing Laboratory Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, 181 Longwood Avenue, Boston MA 02115-5804. Telephone: (617) 525-2736. Fax: (617) 525-0362. E-mail: hhu@hsph.harvard.edu

Of all the changes that characterize modern life, perhaps none has been as radical a transformation as the current explosion of information brought on by the Internet and information technology. We have access to (are being bombarded by, and, alas, can scarcely avoid) information of every type and form, 24 hours a day, 7 days a week.
This certainly holds true for medicine and health care. Through the Internet, it is now possible to search for any topic, read journals and textbooks, and otherwise access an enormous and rapidly growing body of information on health and the medical sciences.

However, when it comes to learning how to deal with actual patients-the very essence of medicine-few would argue with the primacy of the “bedside” presentation and case discussion by an expert as a time-honored means of teaching practitioners how to effectively evaluate and manage patients. From this perspective, “Grand Rounds”-an event that takes place on a regular basis in most hospitals and patient care centers around the country, a staple in the schedule of every medical student, post-graduate resident and fellow, and the preferred teaching venue for senior medical staff-continues to hold a singularly cherished role as a means of using actual clinical material as a springboard for discussing optimal approaches to patient assessment and care (1–3), even as it, too, evolves to take advantage of technological advances such as videoconferencing (4).

Part of the value of Grand Rounds stems from the appreciation that in real life, patients rarely present with cut-and-dry cases of illnesses as they are described in medical school. Real people have unique combinations of preexisting health conditions, symptoms, and complaints. They take medications and eat food that might modify how they experience illness or respond to treatment; they often have multiple conditions that can act synergistically or unpredictably. In short, the value of Grand Rounds stems, in part, from the recognition that medicine is part science and part “art,” that is, the ability to extract from a mass of often contradictory symptoms, physical signs, and laboratory data those items that are of crucial significance in determining diagnoses and constructing a plan for managing a particular patient. It is a combination of medical knowledge, intuition, and judgment that reflects the fact that despite the rapid advances that have been made in medical research and, indeed, clinical epidemiology and decision-making science, the approach to any individual patient involves a synthesis of facts and intuition that is best taught through experience, and, in the case of Grand Rounds, through the sharing of experience.
It was thus with great anticipation that “Grand Rounds in Environmental Medicine” began in 1998 as a regular feature of Environmental Health Perspectives, the journal of the National Institute of Environmental Health Sciences. As noted when we launched this feature (5), all cases would be

drawn from real life that represent problems commonly encountered in environmental medicine. Some of the cases will be routine; others will have a twist, a twist that is not too unordinary, but rather is illustrative of some of the variations that might occur with a particular environmental illness. All cases will be discussed by a recognized expert in the field who will provide a concise but state-of-the-art appraisal of the scientific and medical issues surrounding the evaluation and management of the case.

Four and half years later, we now have 39 “Grand Rounds” that form the basis of this book. The very diversity of subjects covered in these cases is a reflection of the broad definition of “environment” that has begun to emerge as the bailiwick of environmental medicine. Many of these cases pertain to the toxicity of lead, mercury, asbestos, organophosphate pesticides, polychlorinated biphenyls, and other well-known hazards. However, others relate to more unusual exposures such as manganese, bromine, and carbon disulfide. Some involve hazards that, through paradigm shifts and new research, have begun to be seen as part of environmental health, such as violence and cockroach allergen. Some pertain to illnesses arising from occupations that entail combinations of exposures that may have acted synergistically. Some arise out of new research on illnesses and exposures that had not previously been linked together, such as infant pulmonary hemorrhage/Stachybotrys mold and possible estuary-associated syndrome. Others explore illnesses that are still of uncertain etiology and biology, such as multiple chemical sensitivities.

When we began Grand Rounds, many of the cases were solicited from the faculty and trainees of the Harvard School of Public Health Occupational/Environmental Medicine Residency based on patients seen in our academic training sites and presented in our own institution’s regular Grand Rounds. Now, however, as the popularity of this feature has grown, the cases and discussants come from all over the world. Although a few of these cases are representative of hazards that are region specific (such as the case of lung cancer in a uranium miner, or the case of arsenicism in a man living and working in a contaminated area of Turkey), most are notable for involving hazards that prevail everywhere-in developed as well as developing countries. Of greatest interest is the skill with which the authors approach each patient, drawing upon a panoply of information, much of it nonclinical, to assess the relationship between the patient’s environment and the patient’s condition. Indeed, some of the discussants or coauthors in these cases who provided the most crucial information are not clinicians but industrial hygienists, chemists, or marine biologists, which is a testament to the multidisciplinary nature of environmental medicine. In other cases, discussants have relied on state-of-the-art methods for measuring biological markers of dose or early toxic effects that have developed from their research, a reflection of some of the intense investigations and advances that are currently taking place in the field of environmental medicine as well as the growing portfolio of environmental research that has “translational” value to clinical medicine.

All in all, we hope you find this first compendium of “Grand Rounds in Environmental Medicine” to be a valuable and stimulating overview of environmental medicine as it actually occurs through the eyes of practitioner experts around the world. We look forward to soliciting many more of these cases from our colleagues and hope that they prove useful both in raising awareness in the general medical community as well as in raising the level of scholarship in Grand Rounds, journal club, and research seminars as they take place in academic centers of environmental health around the world.

References

1. McLeod PJ, Gold P. Medical grand rounds: alive and well and living in Canada. Can Med Assoc J 142:1053–1056 (1990).

2. Parrino TA, White AT. Grand rounds revisited: results of a survey of U.S. departments of medicine. Am J Med 89:491–495 (1990).

3. Bahner D, Hoekstra J. Evidence-based learning for the twenty-first century medical student. Acad Emerg Med 9:1059 (2002).

4. Allen M, Sargeant J, MacDougall E, O'Brien B. Evaluation of videoconferenced grand rounds. J Telemed Telecare 8:210–216 (2002).

5. Hu H. Grand rounds in environmental medicine. Environ Health Perspect 106:A262 (1998).

Last Updated: February 12, 2003