I was looking forward to this day with a mixture of dread and anticipation. Don’t fret; it will be over in less than an hour. Then you will learn whether your assumptions were correct. I tried to divert my attention to another subject: the unusually muggy September weather, the imminent collapse of the Red Sox pennant run, the upcoming ACR meetings. For the past five weeks, most of my precious free time was spent poring over every word of the case protocol, looking for any hidden clues. Now, it was time for me to step up to the podium and begin my oration. This was going to be a very formal presentation. The expansive lecture hall before me was nearly deserted, save for a few older physicians chatting amicably in the front row and a handful of somnolent medical students catching a few winks in the back row. Most likely they had been enticed by some form of bribery involving snacks and sodas.
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Explore This IssueFebruary 2015
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I began my discussion of The Case. It told the story of a 46-year-old man who presented with fever, asthma, neuropathy and a peripheral eosinophilia. Despite the sparse description, any rheumatologist with a pulse would have instantly deduced that the patient suffered from a systemic necrotizing vasculitis. But the whole point of this teaching exercise was for the discussant (me) to parse the patient’s presentation for critical clues and then carefully sketch a detailed roadmap that would ultimately direct the listener to the correct diagnosis. So why was I so nervous? I recalled a wizened colleague’s opinion about the clinical pathological conference (CPC): Half the audience comes to learn, and the other half to see you fail. Maybe I was anxious because my soon-to-be-delivered (and now impounded) narrative was slated to be published verbatim in an upcoming issue in that veritable repository of the CPC, the New England Journal of Medicine (NEJM).1
A Brief History of the CPC
The CPC’s origins can be traced to the late 19th century and Harvard Law School, where the idea of the case method of learning and instruction sprouted in the mind of a law professor named Christopher Langdell. Walter Cannon, MD, then a student in his final year of study at Harvard Medical School, was awed by his law school roommate’s enthusiasm for the case-history method of teaching law.2 So, in 1900, Dr. Cannon, the legendary physiologist who promulgated the flight or fight hypothesis and several other notable conjectures, published a landmark paper, titled “The Case System,” that proposed using the CPC as a teaching tool.3 According to Dr. Cannon, medical students dreaded their daily routine of four hours of continuous lectures every afternoon, which they considered, “a dreary and benumbing process.”