Medicine had early and humble beginnings based on a simple desire to help the sick and driven by a curiosity to understand the processes resulting in illness and disease. Medical education must have begun sometime after this and has, by and large, pursued a parallel course with the development of medical science. However by the middle years of our medical course, some members of my medical school class felt differently. The idealism of the entry student was crushed or momentarily misplaced under hours of didactic teaching. There was a growing sense of becoming more distant and displaced from the simple study of clinical medicine and a sense of rising panic at the flood of facts that needed to be memorised let alone understood.

 

Against this background of unease the Breakfast Club was formed. Some of us had read of the early physicians, in particular William Osler and Herman Boerhaave who had accumulated great knowledge through the performance of autopsies on their patients. These physicians focussed on the study of pathology and the correlation of the changes they saw in the dead with the clinical symptoms and signs they observed in the living, We were wary of the example set by Rudolf Virchow who was able to nurse his wife in her final illness before performing her post mortem and we were therefore careful not to become over zealous. We resolved to go to the Auckland City Morgue, which was part of the Department of Pathology at the Auckland Medical School, New Zealand, and observe a post mortem at 7 am Monday to Friday.

 

Our plan was to study a disease a week, based on what we had seen in the morgue, and to do this “holistically” integrating epidemiology, preventative medicine, pathology, pharmacology, basic science and whatever else applied to the area in question. Our group was initially unnamed although various titles were tried out and discarded. The Breakfast Club was chosen as it reflected our early morning starts and our necessarily empty stomachs at that hour. It was also the name of a popular film of the day starring the Hollywood ‘Brat Pack’ concerning a group of delinquent high school students. This gave us a slightly dangerous and rebellious aura that appealed.

 

Our lessons in the mortuary from the staff of the pathology department were conducted in a dignified and respectful manner, mindful of our surroundings. We were fortunate that on the staff was an accomplished clinician (TDK), who in addition to being a qualified pathologist, was also a charismatic teacher. Cases would begin with a student presenting the hospital clinical notes or more commonly the carefully written notes of a young constable recording the final moments of the deceased in simple non-medical terms. These were often disarmingly frank and described the symptoms and signs of many common diseases with startling clarity. Emphasis was on accurate pathological description and clinical correlation. Pathology was never viewed a phenomena isolated from the patient. and discussion progressed as the autopsy proceeded. Basic science relevant to the case was covered in depth and emphasis was on the integration of clinical signs and symptoms with pathological findings. Often this was purely verbal and required the development of oral presentation skills, disciplined thought, as well as the ability to logically develop an argument. With the conclusion of the case, attention was turned to the ‘homework board’ for follow up of previous sessions. The remainder of the day was employed in the medical library researching homework, in clinical rotations or in lectures.

 

As rates of hospital autopsies fell more and more cases seen by the Breakfast Club were forensic. Many pathological conditions were represented; Boerhaave syndrome, myocardial infarction, pneumonia, acute aortic dissection, untreated abdominal sepsis from perforated appendicitis, lung abscess, cerebrovascular accident and trauma. All levels of society and all facets of the human condition were seen by the Breakfast Club. This taught us the importance of listening to the patient, careful examination, and pursuing a clinical hunch. On a wider level the elderly or infirm who died from neglect and the effects of poverty committed us to seeing the health needs of the less fortunate addressed by the community.

 

This then is the method of medicine that evolved from the early morning sessions of the Breakfast Club. The system has been developed and refined by at least 10 generations of medical students in their clinical years and has evolved into a student-centred, problem based, evidence driven, self directed learning system. It has arisen not from research-led innovations but from a simple desire to learn medicine clinically. It represents a template that can be applied to any clinical situation to give structure to the search for a diagnosis and development of a management plan. It also provides the framework to successfully answer any question in any examination.