A Multicenter VA Study of the Format and Content of Internal Medicine Morning Report

"A safe, non-judgmental space where I can really challenge myself:" learner experiences in a virtual, case-based diagnostic reasoning conference for students

Case-based diagnostic reasoning conferences, like morning reports, allow undergraduate medical trainees to practice diagnostic reasoning alongside senior clinicians. However, trainees have reported discomfort doing so. Peer-assisted learning offers an alternative approach. We describe the design, implementation, and evaluation of a virtual, student-only diagnostic reasoning conference that leverages peer-assisted learning. Student virtual morning report's (VMR) design was informed by social and cognitive congruence and experience-based learning. We evaluated participant experiences using a survey focused on participant perceptions of Student VMR's value, their methods for participation, and their preferences for Student VMR compared with VMR with more senior clinicians. 110 participants (28.9%) completed the survey. 90 participants (81.2%) reported that Student VMR was educational. Compared to VMR, participants reported being more likely to participate in Student VMR by turning on their video (50.0%), presenting a case (43.6%), verbally participating (44.5%), or participating in the chat (70.0%). Strengths included a safe learning environment to practice DR and the opportunity to engage with an international learning community. When asked whether they preferred Student VMR or non-Student VMR, most respondents (64.5%, 71/110) identified that they did not have a preference between the two. A student-focused DR conference may offer a valuable complement to, but not a replacement of, apprenticeship-based DR case conferences.

Exploring formal and informal learning opportunities during morning report: a qualitative study

BACKGROUND

Morning reports are an essential component of physicians' daily work. Attending morning reports is prioritized by junior doctors as it provides them with an opportunity to learn diagnostic reasoning through discussion of cases. While teaching formats during morning reports have previously been reported, an in-depth analysis of what learning opportunities exist, e.g., how teaching is enacted during morning reports, is lacking. This qualitative study explores learning opportunities during morning reports.

METHODS

We used an explorative design based on video-recordings of 23 morning reports from two surgical departments, an internal medicine department and an emergency department. We used thematic analysis combined with and inspired by Eraut's theoretical framework of workplace learning.

RESULTS

Both formal and informal learning opportunities were identified. Formal learning opportunities had the character of planned teaching activities, and we identified four themes: (1) modes of teaching, (2) structure, (3) presenter role, and (4) participant involvement. Informal learning, on the other hand, was often implicit and reactive, while deliberate learning opportunities were rare. The data showed many missed opportunities for learning.

CONCLUSION

Both formal and informal learning opportunities are present during morning reports. However, a prevalent focus on medical topics exists, leaving other important aspects of the medical role under-discussed. Pedagogical methods could be employed more optimally, and harnessing the potential of missed opportunities should be encouraged.

An Opportunity for Change: Principles for Reforming Internal Medicine Inpatient Conferences

Inpatient educational conferences are a key part of internal medicine residency training. Many residencies made conferences virtual during the COVID-19 pandemic, and are now returning to in-person sessions. As we navigate this change, we can seize this opportunity to re-evaluate the role that inpatient conferences serve in resident education. In this paper, we briefly review the history of inpatient educational conferences before offering five recommendations for improvement. Our recommendations include grounding conference formats in educational theory, leveraging the expertise of all potential educators, broadening content to include health equity and justice throughout all curricula, and explicitly focusing on cultivating community among participants. Recognizing that each residency program is different, we anticipate that these recommendations may be implemented differently based on program size, available resources, and current institutional practices. We also include examples of prior successful curricular reforms aligned with our principles. We hope these recommendations ensure inpatient conferences continue to be a central part of residency education for future generations of internal medicine residents.

Chief resident behaviors that lead to effective morning reports, a multisite qualitative study

BACKGROUND

Morning report is a fundamental component of internal medicine training and often represents the most significant teaching responsibility of Chief Residents. We sought to define Chief Resident behaviors essential to leading a successful morning report.

METHODS

In 2016, we conducted a multi-site qualitative study using key informant interviews of morning report stakeholders. 49 residents, Chief Residents, and faculty from 4 Internal Medicine programs participated. Interviews were analyzed and coded by 3 authors using inductive reasoning and thematic analysis. A preliminary code structure was developed and expanded in an iterative process concurrent with data collection until thematic sufficiency was reached and a final structure was established. This final structure was used to recode all transcripts.

RESULTS

We identified four themes of Chief Resident behaviors that lead to a successful morning report: report preparation, delivery skills, pedagogical approaches, and faculty participation. Preparation domains include thoughtful case selection, learning objective development, content editing, and report organization. Delivery domains include effective presentation skills, appropriate utilization of technology, and time management. Pedagogical approach domains include learner facilitation techniques that encourage clinical reasoning while nurturing a safe learning environment, as well as innovative teaching strategies. Moderating the involvement of faculty was identified as the final key to morning report effectiveness. Specific behavior examples are provided.

CONCLUSION

Consideration of content preparation, delivery, pedagogical approaches, and moderation of faculty participation are key components to Chief Resident-led morning reports. Results from this study could be used to enhance faculty development for Chief Residents.

A Multicenter Observational Study Comparing Virtual with In-Person Morning Reports during the COVID-19 Pandemic

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic disrupted how educational conferences were delivered, leaving programs to choose between in-person and virtual morning report formats. The objective of our study was to describe morning reports during the COVID-19 pandemic, including the use of virtual formats, attendance, leadership, and content.

METHODS

A prospective observational study of morning reports was conducted at 13 Internal Medicine residency programs between September 1, 2020 and March 30, 2021, including a follow-up survey of current morning report format in January 2023.

RESULTS

In total, 257 reports were observed; 74% used virtual formats, including single hospital, multiple hospital, and a hybrid format with both in-person and virtual participants. Compared with in-person reports, virtual reports had more participants, with increased numbers of learners (median 21 vs 7; P < 0.001) and attendings (median 4 vs 2; P < 0.001), and they were more likely to involve medical students (83% vs 40%; P < 0.001), interns (99% vs 53%; P < 0.001), and program directors (68% vs 32%; P < 0.001). Attendings were less likely to lead virtual reports (3% vs 28%, P < 0.001). Virtual reports also were more likely to be case based (88% vs 69%; P < 0.001) and to use digital presentation slides (91% vs 36%; P < 0.001). There was a marked increase in the number of slides (median 20 vs 0; P < 0.001). As of January 2023, all 13 programs had returned to in-person reports, with only 1 program offering an option to participate virtually.

CONCLUSIONS

During the COVID-19 pandemic, virtual morning report formats predominated. Compared with traditional in-person reports, virtual report increased attendance, favored resident leadership, and approached a similar range of patient diagnoses with a greater number of case-based presentations and slides. In spite of these characteristics, all programs returned to an in-person format for morning report as pandemic restrictions waned.

The Morning Report Practice and Its Contribution to Education of Internal Medicine Residents: A Multicenter Cross-Sectional Survey in the Eastern Province, Saudi Arabia

Background

Morning Report (MR) is a ubiquitous traditional educational activity in internal medicine residency training. It is under-researched; hence, this study was conducted. It aimed to examine the practice of MR by internal medicine residents, their motivation to engage with it, and their perception of its contribution to education.

Methods

This was a multi-center cross-sectional study. The data was collected using an online self-administered 12-item questionnaire that covered MR practice, respondents' motivation for participation, MR contribution to education, and its impact on the practice of evidence-based medicine and quality improvement and patient safety.

Results

One hundred seventy residents returned the online questionnaire (54.7%). The respondents' gender and year of training were balanced (P > 0.05). The most common MR frequency and duration were five days per week (85.4%) and 45-60 minutes (47.1%), respectively. The most common format was handover combined with an emergency long case presentation (55.8%), and consultants were the most common facilitators (79.7%). The respondents' motivation to engage with MR was predominantly intermediate. The top reasons for attending and not attending MR were mandatory attendance and embarrassing questions, respectively. The perceived MR contribution to residents' different roles development was predominantly intermediate; however, it was predominantly very low/low (42%) for overall education. The perceived MR impact on the practice of EBM and QIPS were both predominantly intermediate.

Conclusion

MR was found to be a commonly practiced educational activity in internal medicine residency training programs in the eastern province of Saudi Arabia. The case discussion was the core format for education. The respondents' motivation to participate in MR and their perception of its contribution to education was predominantly intermediate. To our best knowledge, this is the first study in Saudi Arabia that examined MR. We hope its findings will be taken for further MR studies and actions for improvement.

What internal medicine attendings talk about at morning report: a multicenter study

BACKGROUND

Morning report is a core educational activity in internal medicine resident education. Attending physicians regularly participate in morning report and influence the learning environment, though no previous study has described the contribution of attending physicians to this conference. This study aims to describe attending comments at internal medicine morning reports.

METHODS

We conducted a prospective, observational study of morning reports conducted at 13 internal medicine residency programs between September 1, 2020, and March 30, 2021. Each attending comment was described including its duration, whether the comment was teaching or non-teaching, teaching topic, and field of practice of the commenter. We also recorded morning report-related variables including number of learners, report format, program director participation, and whether report was scripted (facilitator has advance knowledge of the case). A regression model was developed to describe variables associated with the number of attending comments per report.

RESULTS

There were 2,344 attending comments during 250 conferences. The median number of attendings present was 3 (IQR, 2-5). The number of comments per report ranged across different sites from 3.9 to 16.8 with a mean of 9.4 comments/report (SD, 7.4). 66% of comments were shorter than one minute in duration and 73% were categorized as teaching by observers. The most common subjects of teaching comments were differential diagnosis, management, and testing. Report duration, number of general internists, unscripted reports, and in-person format were associated with significantly increased number of attending comments.

CONCLUSIONS

Attending comments in morning report were generally brief, focused on clinical teaching, and covered a wide range of topics. There were substantial differences between programs in terms of the number of comments and their duration which likely affects the local learning environment. Morning report stakeholders that are interested in increasing attending involvement in morning report should consider employing in-person and unscripted reports. Additional studies are needed to explore best practice models of attending participation in morning report.

How doctors build community and socialize into a clinical department through morning reports. A positioning theory study

PHENOMENON

The morning report is one of the longest surviving hospital practices. Most studies of the morning report focus on the effectiveness of formal medical training, while focus on social and communicative aspects is rarer. This study explores the social interactions and communication in morning reports, examining the ways in which they contribute to the construction of professional identity and socialization into the community of the clinical department.

APPROACH

We used a qualitative explorative design with video observations of morning reports. Our data consisted of 43 video-recorded observations (in all, 15.5 hours) from four different hospital departments in Denmark. These were analyzed using the theoretical framework of positioning theory.

FINDINGS

A key finding was that each department followed its own individual structure. This order was not articulated as such but played out implictly. Two alternative storylines unfolded in the elements of the morning report: 1) being equal members of the specialty and department, and 2) preserving the hierarchical community and its inherent positions.

INSIGHTS

The morning report can be seen as playing an important role in community making. It unfolds as a "dance" of repeated elements in a complex collegial space. Within this complexity, the morning report is a space for positioning oneself and others as a collegial "we", i.e., equal members of a department and specialty, at the same time as "having a place" in a hierarchal community. Thus, morning reports contribute to developing professional identity and socialization into the medical community.

A Comparative Study of Scripted versus Unscripted Morning Reports: Results from a Prospective Multicenter Study

OBJECTIVES

Morning report is one of the central activities of internal medicine residency education. The two most common morning report formats are scripted reports, which use preselected cases with prepared didactics, and unscripted reports in which a case is discussed without preparation. No previous study has compared these two formats.

METHODS

We conducted a prospective observational study of morning report conducted at 10 academic medical centers across the United States.

RESULTS

A total of 198 case-based morning reports were observed. Of these, 169 (85%) were scripted and 29 (15%) were unscripted. Scripted reports were more likely to present a case with a known final diagnosis (89% vs 76%, P = 0.04), use electronic slides (76% vs 52%, P = 0.01), involve more than 15 slides (55% vs 3%, P < 0.001), and reference the medical literature (61% vs 34%, P = 0.02), including professional guidelines (32% vs 10%, P = 0.02) and original research (25% vs 0%, P = 0.001). Scripted reports also consumed more time in prepared didactics (8.0 vs 0 minutes, P < 0.001). Unscripted reports consumed more time in case history (10.0 vs 7.0 minutes, P < 0.001), physical examination (3.0 vs 2.0 minutes, P = 0.06), and differential diagnosis (10.0 vs 7.0 minutes, P = 0.01).

CONCLUSIONS

Most contemporary morning reports are scripted. Compared with traditional unscripted reports, scripted reports are more likely to involve a case with a known diagnosis, use extensive electronic presentation slides, and consume more time in didactics, while unscripted reports consume more time in the early diagnostic process, including history, physical examination, and differential diagnosis. Residency programs interested in emphasizing these aspects of medical education should encourage unscripted morning reports.

Internal Medicine Residents' Perceptions of Virtual Morning Report: a Multicenter Survey

IMPORTANCE

The COVID-19 pandemic disrupted graduate medical education, compelling training programs to abruptly transition to virtual educational formats despite minimal experience or proficiency. We surveyed residents from a national sample of internal medicine (IM) residency programs to describe their experiences with the transition to virtual morning report (MR), a highly valued core educational conference.

OBJECTIVE

Assess resident views about virtual MR content and teaching strategies during the COVID-19 pandemic.

DESIGN

Anonymous, web-based survey.

PARTICIPANTS

Residents from 14 academically affiliated IM residency programs.

MAIN MEASURES

The 25-item survey on virtual MR included questions on demographics; frequency and reason for attending; opinions on who should attend and teach; how the virtual format affects the learning environment; how virtual MR compares to in-person MR with regard to participation, engagement, and overall education; and whether virtual MR should continue after in-person conferences can safely resume. The survey included a combination of Likert-style, multiple option, and open-ended questions.

RESULTS

Six hundred fifteen residents (35%) completed the survey, with a balanced sample of interns (39%), second-year (31%), and third-year (30%) residents. When comparing their overall assessment of in-person and virtual MR formats, 42% of residents preferred in-person, 18% preferred virtual, and 40% felt they were equivalent. Most respondents endorsed better peer-engagement, camaraderie, and group participation with in-person MR. Chat boxes, video participation, audience response systems, and smart boards/tablets enhanced respondents' educational experience during virtual MR. Most respondents (72%) felt that the option of virtual MR should continue when it is safe to resume in-person conferences.

CONCLUSIONS

Virtual MR was a valued alternative to traditional in-person MR during the COVID-19 pandemic. Residents feel that the virtual platform offers unique educational benefits independent of and in conjunction with in-person conferences. Residents support the integration of a virtual platform into the delivery of MR in the future.

The State of Morning Report in the Current Healthcare Landscape: a National Survey of Internal Medicine Program Directors

BACKGROUND

Case-based Morning Report (MR) has long been the predominant educational conference in Internal Medicine (IM) residency programs. The last comprehensive survey of IM MR was in 1986. Much has changed in the healthcare landscape since 1986 that may impact MR.

OBJECTIVE

We sought to determine the current state of MR across all US IM programs.

DESIGN

In 2018, US IM program directors (PDs) were surveyed about the dynamics of MR at their institutions, perceived pressures, and realized changes.

KEY RESULTS

The response rate was 70.2% (275/392). MR remains highly prevalent (97.5% of programs), although held less frequently (mean 3.9 days/week, SD 1.2), for less time (mean 49.4 min, SD 12.3), and often later in the day compared to 1986. MR attendees have changed, with more diversity of learners but less presence of educational leaders. PD presence at MR is associated with increased resident attendance (high attendance: 78% vs 61%, p=0.0062) and punctuality (strongly agree/agree: 59% vs 43%, p=0.0161). The most cited goal for MR is utilizing cases to practice clinical reasoning. Nearly 40% of PDs feel pressure to move or cancel MR; of those, 61.2% have done so, most commonly changing the timing (48.5%), reducing the length (18.4%), and reducing the number of sessions per week (11.7%). Compared to community-based and to community-based, university-affiliated programs, university-based programs have 2.9 times greater odds (95% CI: 1.3, 6.9; p = 0.0081) and 2.5 times greater odds (95% CI 1.5, 4.4; p =0.0007), respectively, of holding MR after 9 AM, and 1.8 times greater odds (95% CI: 0.8, 4.2; p = 0.1367) and 2.0 times greater odds (95% CI: 1.2, 3.5; p = 0.0117), respectively, of reporting pressure to cancel or move MR compared to their counterparts.

CONCLUSIONS

While MR ubiquity reflects its continued perceived value, PDs have modified MR to accommodate changes in the healthcare environment. This includes reduced frequency, shorter length, and moving conferences later in the day. Additional studies are needed to understand how these changes impact learning.

Internal Medicine Residents' Perceptions of Morning Report: a Multicenter Survey

BACKGROUND

Residents rate morning report (MR) as an essential educational activity. Little contemporary evidence exists to guide medical educators on the optimal content or most effective delivery strategies, particularly in the era of resident duty-hour limitations and shifts towards learner-centric pedagogy in graduate medical education.

OBJECTIVE

Assess resident views about MR content and teaching strategies.

DESIGN

Anonymous, online survey.

PARTICIPANTS

Internal medicine residents from 10 VA-affiliated residency programs.

MAIN MEASURES

The 20-item survey included questions on demographics; frequency and reason for attending; opinions on who should attend, who should teach, and how to prioritize the teaching; and respondents' comfort level with participating in MR. The survey included a combination of Likert-style and multiple-choice questions with the option for multiple responses.

KEY RESULTS

A total of 497 residents (46%) completed the survey, with a balanced sample of R1s (33%), R2s (35%), and R3s (31%). Self-reported MR attendance was high (31% always attend; 39% attend > 50% of the time), with clinical duties being the primary barrier to attendance (85%). Most respondents felt that medical students (89%), R1 (96%), and R2/R3s (96%) should attend MR; there was less consensus regarding including attendings (61%) or fellows (34%). Top-rated educational topics included demonstration of clinical reasoning (82%), evidence-based medicine (77%), and disease pathophysiology (53%). Respondents valued time spent on diagnostic work-up (94%), management (93%), and differential building (90%). Overall, 82% endorsed feeling comfortable speaking; fewer R1s reported comfort (76%) compared with R2s (87%) or R3s (83%, p = 0.018). Most (81%) endorsed that MR was an inclusive learning environment (81%), with no differences by level of training.

CONCLUSIONS

MR remains a highly regarded, well-attended educational conference. Residents value high-quality cases that emphasize clinical reasoning, diagnosis, and management. A supportive, engaging learning environment with expert input and concise, evidence-based teaching is desired.