In 1975 two psychologists, Michael Scaife and Jerome Bruner, published a short paper in Nature on what they called the capacity for joint visual attention in the infant. They had sat facing babies, caught their attention, and then turned their own heads to look at something else. Many of the infants turned to look where the adult was looking, and they did so at younger ages than had been supposed. The finding helped start a large body of research on what developmental psychologists now call joint attention: the ability to follow another person’s gaze to its object, which appears early in infancy and underlies much of what a child learns from others, including the names of things. Before a child can be told what matters, it learns to look where the people who know are looking.
A medical student on a ward round is in a curiously similar position. He knows a great deal of medicine from books, and almost nothing about which of the hundred things in front of him matter. So he watches. He watches where the senior physician’s eyes go when they reach a bed: to the face before the chart, or the chart before the face; to the breathing, the hands, the colour of the lips; to the bag hanging from the bedside, to the untouched tray, to the relative standing a little apart. Long before he can explain what the senior is doing, he learns to look where the senior looks. Learning by watching where the senior physician looked is one of the oldest methods in clinical education, and it is worth asking what exactly that method teaches, and what it leaves out.
I studied medicine at Sri Guru Ram Das Institute of Medical Sciences and Research in Amritsar from 1997 to 2002, and the institute’s own present account is that its clinical teaching is conducted at Sri Guru Ram Das Charitable Hospital at Vallah, on the edge of Amritsar. This essay describes no hospital, ward or round from those years, and no senior physician or patient; the patients of a teaching hospital are the last people whose illnesses should be borrowed for a memoir. What follows is about the teaching round as a form: a strange gathering in which several people, at the same bedside, are trying to do different things at once. The patient is trying to be cared for. The consultant is trying to care for him and to teach. The residents are trying to manage the ward and to be seen managing it well. The students are trying to learn, and to avoid being asked a question they cannot answer. The question is how these purposes fit together, and what happens when they do not.
Where the Senior Looked #
There is now good evidence that expertise in medicine is partly a matter of where attention goes, and that it can be seen in the eyes.
In a study published in 2007, Harold Kundel and colleagues at the University of Pennsylvania tracked the eye movements of radiologists of differing experience, from residents to full-time mammographers, as they read twenty normal and twenty subtly abnormal mammograms. The median time for observers to fixate a cancer was a little over a second. The faster an observer’s eyes first landed on the abnormality, the better he was at recognising it as cancer, and this rapid initial fixation was most developed in the most proficient observers. The authors read it as evidence that experts shift from a slow search-to-find mode of looking to a fast holistic one, taking in the whole image and going straight to what is wrong. A study published in 2012 by Thomas Balslev and colleagues in Denmark extended the idea from still images to moving ones. Forty-three clinicians of varying experience watched short videos of children, two having seizures and two with movements that imitate seizures, while their eye movements were recorded and they thought aloud. The more experienced clinicians were more accurate, spent more of their time looking at the relevant parts of the video, explored less, and generated and tested more diagnostic hypotheses.
These are small studies of particular visual tasks, and neither says anything directly about a ward round. But they confirm what students have always sensed. The expert does not look at everything. He looks at the right things, early, and the pattern of his looking is itself a kind of knowledge. A student who follows it is learning something real.
He is also at risk of learning something false, and the risk is the method’s great weakness. A gaze shows the direction of attention without its reason. A student who sees a senior glance at a patient’s ankles learns that ankles matter; unless someone says why, he does not learn what was being looked for, or what finding would have changed the plan. Students who imitate the gestures of experts without their reasons develop a kind of clinical superstition: the ritual tap on the chart, the habitual glance at the monitor, the phrase recited at every bed. The remedy is old and simple, and it is the senior’s to provide. He has to narrate. I am looking at her neck because…; I want to see him walk because…; I am not worried by this number because…. Narration turns a gaze into a lesson. Without it, joint attention gives the student the object and withholds the meaning.
Punjabi, which took the word from Persian, has a word for the senior’s look that holds more than English does. ਨਿਗਾਹ, nigāh, means a look or glance, and in Persian the same word also carries the senses of observation, custody, watch and care. To keep nigāh on someone is to look after them. A related Persian word gave Punjabi and Urdu ਨਿਗਰਾਨੀ, nigrānī, supervision; and in modern Persian the adjective from the same family, negarān, has come to mean worried, anxious. A gaze that supervises and a gaze that worries are, in that family of words, close relatives. That is a fair description of what a good senior’s look on a ward round contains. It is not only diagnostic. It is the look of someone who is responsible for what he sees, and who is anxious about it in the precise way that responsibility requires.
Who Knows What #
A ward round is usually organised by rank. The consultant leads; the residents follow in order; the interns carry the files; the students stand at the back. It is easy to assume that knowledge is distributed the same way, and that the person at the front knows the most about the patient in the bed. On any particular morning this is almost never true.
The patient knows things no one else knows: what the pain is like, what he was doing when it began, what he is afraid of, which medicines he has actually been taking, what he wants. In Indian wards there is very often someone else at the bedside who knows a great deal more: the relative or attendant who has stayed through the night, fed the patient, helped him to the toilet, watched him sleep or fail to sleep, and noticed when he became confused at three in the morning. The nurse knows the trend of the temperature, the dose that was refused, the dressing that was wet, the night that went badly. The intern knows the results that came back last evening. The resident knows the plan and its complications. The consultant knows patterns: what this picture usually becomes, what was missed the last time a case looked like this. Each of these is real knowledge. The round is the one moment in the day when they could all be brought together, and its organisation by rank often prevents it.
André Brouillet’s large painting A Clinical Lesson at the Salpêtrière, shown at the Paris Salon of 1887, is one of the most famous images of medical teaching ever made, and it records the hierarchy with painful clarity. The neurologist Jean-Martin Charcot stands demonstrating a patient, Marie “Blanche” Wittman, who has swooned backwards into the arms of his chief house officer, Joseph Babinski. Around them, according to those who have identified the thirty figures, the inner circle of listeners contains sixteen of Charcot’s current and former physician associates arranged in reverse order of seniority, and an outer group contains older colleagues, philosophers, writers and friends. Beside the patient, at the edge of the group, are two women: a nurse, Mlle Ecary, and the Salpêtrière’s director of nursing, Marguerite Bottard. They were very likely the people in the room who had spent the most hours with her, and they stand at the margin of the scene while the men discuss her.
The painting is a portrait of how a teaching round can arrange knowledge so that the people who hold the most of it are least likely to be heard. A round that works well does the opposite on purpose. The senior asks the nurse how the night was before he asks the intern for the results. He asks the relative what has changed. He asks the patient what he thinks is happening. They are courtesies, and they are also the fastest way to the facts, and a student who sees them asked learns that the hierarchy of titles is not the hierarchy of information.
An Old Form #
The teaching round is old enough that it is easy to forget it was invented. Medical students in early modern Europe learned mostly from books and lectures, and the habit of taking them to the bedside of hospital patients, to examine and reason in front of a teacher, spread slowly. The usual story assigns its invention to Herman Boerhaave, who took the chair of practical medicine at Leiden in 1714. Even that story shows the habit this essay keeps meeting. The attribution is contested; one medical historian has written that Boerhaave was neither an innovator of the practice nor an especially energetic practitioner of it, though he did much to popularise it, and others had taught at the bedside before him, at Padua among other places. Credit gathers around a famous name, and the less famous people who did the work recede, in the history of the round as on the round itself.
What is not contested is the line of descent. Every founding member of the medical school at Edinburgh had studied at Leiden, and Edinburgh in turn shaped medical education across the British world, including the colonial medical colleges of India, beginning with the medical college founded in Calcutta in 1835. A round on a ward in Amritsar is, by this genealogy, a distant descendant of a bedside in eighteenth-century Leiden, carried across two centuries and two continents by people who learned it by watching others do it. Like most inheritances it arrived with things worth keeping and things worth leaving behind: the bedside as the place where medicine is learned, and also the arrangement of rank around the bed, the language of the teachers rather than the patient, and the assumption that the poor patients of a public ward would be available for instruction.
The Screen at the Foot of the Bed #
The method of learning by following a senior’s gaze assumes something that can no longer be assumed: that the senior is looking at the patient.
In 2013 Chad Stickrath and colleagues published a direct observation of attending rounds on the general medical wards of four teaching hospitals affiliated with a public medical school in Colorado. Research assistants followed 56 attending physicians and 279 trainees over 90 days of rounds, during which the teams cared for 807 patients. A typical day consisted of one attending and three trainees seeing a median of nine patients in about two hours. Teams discussed the care plan for nearly every patient and reviewed diagnostic studies for nine in ten. They communicated with the patient for about three-quarters of patients, but they communicated with nurses for only 12 per cent, discussed nursing notes for about 6 per cent, and taught physical examination skills for under 15 per cent. Most of the activities of rounds, the authors concluded, did not take place at the bedside. In the same year Lauren Block and colleagues reported a time-and-motion study of 29 internal medicine interns at two academic medical centres in Baltimore, observed for 873 hours in January 2012. The interns spent 12 per cent of their time in direct patient care, talking with and examining patients, and 40 per cent of their time using computers.
These are American studies of a particular period, and they say nothing about any hospital in Punjab, then or now. But they describe a direction of travel that electronic records have imposed on hospital medicine in many places, and they bear on the method this essay began with. A student who learns by watching where the senior looks will learn, in such a hospital, that the patient lives in the computer. The senior’s eyes go to the screen on its wheeled stand at the end of the corridor, to the trend lines and the imaging viewer and the medication list, and the student’s eyes follow, and the lesson is absorbed without a word: this is where the facts are. The bed becomes a place one visits afterwards, briefly, to confirm what the screen has already said.
The paper record had its own faults, and I have no wish to romanticise it; a thick file of illegible notes at the foot of a bed was a poor instrument in many ways. But it had one property that mattered for teaching. It lived at the bedside. To read it, a doctor had to stand next to the patient, and while he read, the patient was in the corner of his eye, breathing, wincing, watching him read. Gaze and patient were in the same place. The migration of the record to a screen in another room, or on a cart in the corridor, separated them, and the separation is easy to underestimate because each step of it made sense. It is faster to review results at a workstation. It is quieter to discuss a plan away from other patients. It is more private, in one sense, not to discuss a diagnosis within earshot of the next bed. The cumulative effect is a round in which the patient is consulted last and nurses scarcely at all, which is the effect the Colorado observers recorded.
The same essays on this site that worry about the computer moving between doctor and patient in the consulting room, such as one about that move, apply with double force on a teaching round, because the round is where young doctors learn where to look. A senior who reviews the screen and then goes to the bed and looks first at the patient’s face, before saying anything about the numbers, is teaching something no curriculum will list. He is showing that the numbers are about a person, and that the person is the place where they are checked.
The Presentation #
At most beds, the round begins with a presentation: a student or a junior doctor tells the patient’s story to the group, in a set form, in a few minutes. The form is one of medicine’s great inventions. It forces a disorderly experience into an order the listener can reason with: who the patient is, what brought him, how it developed, what has been found, what is thought, what is planned. Without it, a ward of thirty patients could not be reviewed in a morning. But every format keeps some things and loses others, and it helps to see the loss in a single case.
Consider a hypothetical patient, invented for this purpose. A farmer in his late fifties is brought from a village outside Amritsar by his son. Asked in Punjabi what has happened, he says that for a month he has felt a weight on his chest when he walks to the fields, that he thought it was gas, that it went away when he sat under the tree, that he came only because his son insisted, and that he cannot stay long because the wheat must be cut. In the presentation at the bedside the next morning, in English, this becomes something like: fifty-eight-year-old male, presenting with exertional chest discomfort of one month’s duration, relieved by rest. Everything clinically essential has been kept, and kept well; a listener can begin reasoning at once. Lost are the tree, the son’s insistence, the belief that it was gas, and the wheat. Each of those is clinically important too. The belief tells you what the patient will think of your explanation; the son tells you who makes decisions in this family; the wheat tells you why he may leave before the tests are done.
Two things happen to the story in that compression. It is translated, and it is made generic. The translation matters wherever the language of the case presentation is not the language of the bed. A round conducted in English, with the vocabulary of Latin and Greek, about a patient whose language is Punjabi, is a conversation held over a man’s body in terms he may not follow. Research on bedside presentations bears directly on this. In a randomised study at Johns Hopkins published in 1997, Lisa S. Lehmann and colleagues compared patients whose cases were presented at the bedside with patients whose cases were presented in a conference room. Those with bedside presentations reported that their doctors spent more time with them on rounds, ten minutes against six, and were somewhat more likely to view their care favourably. But patients who had not completed high school were more likely to report that the doctors used confusing terminology and explained tests and medications inadequately, and the authors advised that at the bedside of less educated patients physicians should be especially careful to avoid jargon and to explain their plans fully. An earlier survey at a Wisconsin medical school, published in 1989, found that 85 per cent of patients liked having their case discussed at the bedside while 95 per cent of students and residents felt more comfortable discussing it elsewhere, and that 88 per cent of patients opposed rounds held in the hallway.
Patients, in other words, generally want to be present when they are discussed. What they need, if their presence is to mean anything, is to understand what is being said. A presentation given at the bedside in a language the patient does not follow is a presentation given in his absence with his body present. Moving the round to a conference room would solve the wrong problem. The remedy is to remember that the patient is part of the audience, and to give him, at the end, a version of the story in his own language, which is also the best test of whether the student actually understood it.
The Question at the Bedside #
Teaching rounds run on questions. The senior asks; the students answer, or fail to. At its best this is the oldest and best form of clinical teaching: a question that makes a student commit to a view, examine the evidence for it, and discover where his reasoning breaks. At its worst it is a ritual of rank, in which questions are asked to display the asker’s knowledge and the learner’s ignorance.
American medical slang has a crude word for the second kind, and in 1989 the physician Frederick Brancati wrote a satirical essay for JAMA, “The art of pimping,” that described the practice with mock solemnity and gave the word wide currency. The satire worked because everyone recognised the thing. In 2015 two family physicians at the University of Washington, Amanda Kost and Frederick Chen, published a serious reply under the title “Socrates was not a pimp.” They argued that the term is harmful and unprofessional, that teachers sometimes defend humiliating questioning as Socratic method, and that the two should be separated. They proposed to define the bad practice narrowly, as “questioning with the intent to shame or humiliate the learner,” in order to maintain the hierarchy of medical education; and they recommended that teachers examine the purpose of every question they ask, use Socratic methods that promote critical thinking, and draw on what is known about how adults learn.
The distinction they draw is the right one, and the bedside sharpens it. A question asked on a ward round has an audience that a classroom question does not: the patient. When a senior asks a student, in front of a frightened man, what the prognosis of his condition is, the student’s answer is heard by the person whose prognosis it is. When a student is humiliated at the bedside for not knowing something, the patient learns that the people looking after him include one who does not know, and may wonder what else is not known. When a question about a grave possibility is asked casually over a bed, the patient hears the grave possibility. None of this means that questions should not be asked at the bedside. It means that the patient’s presence is a reason for asking them well: about reasoning rather than trivia, in words chosen with the listener in mind, with the most frightening matters saved for the corridor, and with the patient brought back into the conversation before the group moves on.
Hard questioning has its advocates among good teachers, and their reasons are not trivial. Medicine, they argue, is practised under pressure, at night, in emergencies, with nobody to ask; a student who has never been made to think on his feet in front of others will freeze when it matters; rigorous public questioning is a kind of inoculation against panic. There is something in this. Retrieval under mild pressure does fix knowledge, and being asked to commit to an answer is more instructive than being told one. But the argument proves the value of pressure, not of humiliation, and the two can be separated. A question such as what would make you change your mind? is harder than a question about a statistic, and it can be asked without contempt. The student who is asked it in front of a patient learns two things at once: how to reason under pressure, and how to do it in a way the patient can bear to hear.
The Patient Is Listening #
Brouillet’s painting has a second subject, and it is the patient. Marie Wittman, demonstrated to an audience of physicians and also of novelists, journalists and politicians, is shown in the attitude of a hysterical attack, her bodice slipping, her body arched. On the back wall of the lecture room hangs a large drawing by the physician and artist Paul Richer, made in 1878 from a photograph, showing a woman in the arched posture that Charcot’s school regarded as characteristic of the disorder. Commentators have noticed the uncomfortable symmetry: the patient in the room appears to be reproducing the picture on the wall. The painting, which its historians describe as an imagined scene based on real demonstrations, was reproduced many times; Sigmund Freud, who had studied with Charcot, kept a lithograph of it in his consulting rooms in Vienna, and it hangs today above the couch in the Freud Museum in London.
The image raises the question every teaching round raises in a milder form: on whose behalf is the patient being shown? Teaching hospitals long taught on those least able to refuse, and gratitude for free care still makes refusal hard, a history another essay on this site takes up at the bedside.
International professional ethics has addressed this directly. The World Medical Association’s Declaration of Lisbon on the Rights of the Patient, first adopted in 1981, amended in 1995 and since revised and reaffirmed, states in its current text that the patient “has the right to refuse to participate in research or the teaching of medicine.” It also requires that the patient’s dignity and privacy be respected in teaching as in care, and that information be given in a way suited to the patient’s culture and in terms the patient can understand. These are statements of principle by an international professional body, not a description of what any particular hospital did, then or now. But they set out what a teaching round owes the person at its centre: to be asked, not merely informed; to be able to say no without fear for his care; to be spoken about in a manner he would not be ashamed to overhear; and to understand what was decided.
In a charitable hospital the duty to ask falls more heavily on the team, precisely because the patient is less likely to object. Asking does not have to be elaborate. A senior who greets the patient by name, explains who the students are and why they are there, asks whether they may listen to his chest, and accepts a refusal without visible annoyance has done most of what the principle requires. Punjabi has an idiom, ਨਜ਼ਰ ਲੱਗਣਾ, nazar laggṇā, for harm that arrives through a look: the evil eye, in the old belief, that falls on a child or a house admired too openly. One need not share the belief to see what the idiom knows. Being looked at by many people, closely, without one’s consent, can be felt as an injury, and a teaching round is a great many eyes.
After the Group Moves On #
A round moves. It arrives at a bed, gathers, talks, decides, and leaves, and the leaving is the part least often taught.
Punjabi distinguishes, informally, between a visit and a ਗੇੜਾ, geṛā: a round, a turn, a quick swing past. Geṛā mārnā is to drop by, look in, and go. Every ward round is at risk of becoming a geṛā from the patient’s side of the bed. A group of white coats arrives, speaks among itself for some minutes, perhaps examines, perhaps asks a question or two, and moves on to the next bed, and the patient is left with fragments: a word he caught, a look exchanged between doctors that he could not read, a decision he is not sure was made. Very often it is the relative who follows the group to the next bed, or waits for the junior doctor in the corridor, to ask what the senior doctor said. That person’s question is a measure of the round’s failure to finish its work.
The work that remains after the group moves on is considerable. Someone has to explain the plan to the patient in words he understands. Someone has to answer the question he did not dare to ask in front of the group. Someone has to carry out the tasks the round generated: the test ordered, the referral sent, the dose changed, the relative called. On a busy ward these jobs fall, by default, to the most junior members of the team, and when nobody is assigned to them they can disappear into the assumption that someone else has done them. A teaching round that leaves responsibility in its wake without distributing it has taught its students something unfortunate: that the important part of medicine is the discussion, and the rest is administration.
This is also where students can be most useful, and where they can learn most. A student who returns to the bedside after the round, sits down, and explains to the patient and his family, in Punjabi, what was decided and why, is doing the hardest test of understanding there is. If he cannot explain it simply, he did not understand it. If he can, he has given the patient something the round itself did not, and he has practised the part of medicine that no examination measures and every patient remembers. The Johns Hopkins investigators closed the summary of their study with exactly this advice: explain the plans fully. It is advice about how a round should end.
What Deserves Carrying Forward #
A teaching round has always taught two curricula at once. One is clinical: signs, patterns, reasoning, the knowledge of what to look at. The other is moral and social, and it is taught without anyone announcing it: how doctors speak to patients and about them, who is consulted and who is ignored, whether a question is an invitation or an ambush, whether a refusal is respected, whether anyone goes back to explain. Students absorb the second curriculum as thoroughly as the first, and they carry it longer, because it becomes their manner.
The theatre of the old teaching round can be left behind. Brouillet’s painting is a magnificent record of a kind of medical teaching that should not be repeated, with its audience of the curious, its patient on display, and its nurses at the edge. What should be carried forward is the method at its core: a group of people at different stages of learning gathered around a real patient, looking together, reasoning aloud, correcting one another, with the most experienced among them showing, by where he looks and what he says, what matters. That method can coexist with every protection the patient is owed. It is improved by them. A round that asks the nurse first, addresses the patient by name, explains itself in his language, questions students about their reasoning without shaming them, accepts a refusal, and assigns someone to return afterwards is a better teaching round for all of it, because it shows students the whole of the work.
Learning by watching where the senior looked is a good way to begin. The student follows the gaze to the face, the breathing, the hands, the drip, and learns that these are the places where illness shows itself. The next lesson, which no one can teach by gaze alone, is to notice where the senior did not look: at the son in the corner who has not slept, at the untouched plate, at the nurse who was about to speak and stopped, at the patient’s expression when the English began. A good senior’s nigāh, in the old sense of a look that is also a form of care, includes those places too. A student who learns to look there has learned what the round was for.
Evidence and Editorial Note #
Documented findings. Public biography relied on: MBBS at Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, 1997–2002; Punjabi as first language. The institute’s present statement that its clinical teaching is conducted at Sri Guru Ram Das Charitable Hospital, Vallah: the institute’s website (sgrdimsr.in). Michael Scaife and Jerome Bruner, “The capacity for joint visual attention in the infant,” Nature 1975;253:265–266 (PubMed record, PMID 1113842); the design and finding as summarised, and the later literature on joint attention: standard reference knowledge. Harold Kundel and colleagues, “Holistic component of image perception in mammogram interpretation: gaze-tracking study,” Radiology 2007;242(2):396–402 (PubMed abstract, PMID 17255410): observers from residents to mammographers; 20 normal and 20 subtly abnormal mammograms; median 1.13 seconds to fixate a cancer; detectability related to time to first fixation; holistic mode in proficient observers. Thomas Balslev and colleagues, “Visual expertise in paediatric neurology,” European Journal of Paediatric Neurology 2012;16(2):161–166 (PubMed abstract, PMID 21862371): 43 clinicians, four videos, eye tracking and think-aloud; experts more accurate, more time on relevant areas, less exploration, more hypotheses. Lisa S. Lehmann and colleagues, “The effect of bedside case presentations on patients’ perceptions of their medical care,” New England Journal of Medicine 1997;336(16):1150–1155 (PubMed abstract, PMID 9099660): 95 bedside and 87 conference-room patients; 10 versus 6 minutes; non-significant favourable trend; confusing terminology reported more by less educated patients; advice to avoid jargon and explain plans fully. R. M. Wang-Cheng and colleagues, “Bedside case presentations: why patients like them but learners don’t,” Journal of General Internal Medicine 1989;4(4):284–287 (PubMed abstract, PMID 2760696): 85% of patients liked bedside discussion; 95% of students and housestaff preferred elsewhere; 88% of patients opposed hallway rounds. Frederick L. Brancati, “The art of pimping,” JAMA 1989;262(1):89–90 (PubMed record, PMID 2733128; its satirical character is standard reference knowledge). Amanda Kost and Frederick M. Chen, “Socrates was not a pimp,” Academic Medicine 2015;90(1):20–24 (PubMed abstract, PMID 25099239): proposed definition (one short quotation) and three recommendations. World Medical Association, Declaration of Lisbon on the Rights of the Patient (adopted 1981; amended 1995; editorially revised 2005; reaffirmed 2015), text on the WMA website (wma.net): the right to refuse participation in research or teaching (quoted), and dignity and privacy in care and teaching and information given so that the patient can understand (paraphrased). André Brouillet, A Clinical Lesson at the Salpêtrière (1887): Wikipedia article of that title, for the Salon of 1887, Marie Wittman and Babinski, the two nurses (Mlle Ecary and Marguerite Bottard), the inner circle in reverse order of seniority, the outer group including writers and politicians, Richer’s 1878 drawing on the back wall, the description as an imaginary scene based on real life, and Freud’s lithograph now in the Freud Museum, London. Chad Stickrath and colleagues, “Attending rounds in the current era: what is and is not happening,” JAMA Internal Medicine 2013;173(12):1084–1089 (PubMed abstract, PMID 23649040): 56 attendings, 279 trainees, 807 patients, 90 days at four hospitals; median nine patients over about two hours; communication with patients 73.4%, with nurses 12.0%; nursing notes 6.2%; physical-examination teaching 14.6%; most activities away from the bedside. Lauren Block and colleagues, “In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?” Journal of General Internal Medicine 2013;28(8):1042–1047 (PubMed abstract, PMID 23595927): 29 interns, 873 hours, January 2012; 12% direct patient care; 40% computer use. Bedside teaching at Padua before Boerhaave: standard reference knowledge. Herman Boerhaave’s appointment to the chair of practical medicine at Leiden in 1714, the contested attribution of clinical teaching to him (with the historian’s assessment paraphrased), and the Leiden training of every founding member of the Edinburgh medical school: Wikipedia, “Herman Boerhaave,” and the sources it cites. The founding of the medical college at Calcutta in 1835 and the influence of Edinburgh on British colonial medical education: standard reference knowledge. Government Medical College, Amritsar, established at Lahore in 1864 and moved to Amritsar in 1920: Wikipedia, “Government Medical College, Amritsar.” The historical dependence of teaching hospitals on poor patients in public and charitable wards: standard reference knowledge. Persian negāh (look; observation; custody, watch, care) and negarān (worried, anxious; dated: watchful): Wiktionary. The benefit of retrieval practice under mild pressure (the testing effect): standard reference knowledge. The Punjabi ਨਿਗਾਹ, ਨਿਗਰਾਨੀ, ਨਜ਼ਰ ਲੱਗਣਾ and ਗੇੜਾ, and the presence of relatives or attendants at the bedside in Indian wards: standard reference knowledge of Punjabi usage and Indian hospital practice, stated as general. Vendor representations. None.
Recollection and tradition. Beyond the public biography and the institute’s own published account of where its clinical teaching takes place, the essay asserts no remembered round, ward, senior physician, nurse, student or patient, and it describes no practice at any particular hospital in the author’s years. The farmer whose story is compressed into a case presentation is a hypothetical patient, invented for illustration and introduced as such. The Salpêtrière scene is Brouillet’s painting, described as a painting.
Analysis and forecast. The comparison of the round with infant joint attention, the reading of gaze studies as evidence about clinical teaching, the reading of Brouillet’s painting, the argument about consent and gratitude in charitable hospitals, the use of Punjabi words for looking, and the recommendations for how a round might be conducted are the author’s interpretation and ethical preference. Independence. This essay is not sponsored by any institution, company, health system or technology developer. It is personal reflection, not medical advice; readers seeking care should contact their own physician’s office.
About the Author #
Kanwar Partap Singh Gill, MD, traces his family roots to Khadur Sahib in Punjab’s Majha region and grew up in Amritsar. He attended Spring Dale School and completed pre-medical studies at Khalsa College in 1994–1996. He earned his MBBS from Sri Guru Ram Das Institute of Medical Sciences and Research in Amritsar in 2002.
He completed PGY-1 at the University of Arkansas for Medical Sciences in Little Rock in 2007–2008, and PGY-2 and PGY-3 with UCSF Fresno at Community Regional Medical Center from 2008 through 2010. He has practiced medicine in California since 2010.
His career has crossed four distinct information eras: predominantly paper-based medicine, early and fragmented electronic records, the integrated-EHR era, and the emerging age of generative and agentic artificial intelligence.