Morning Report

Abstract

Residents rank morning report as the most important educational activity of their residency training.1 Although there is a lack of documented evidence as to the educational value of morning report, the practice is ubiquitous across almost all primary care residency programs in North America. The ever-changing practice of medicine and ongoing demands for evidence in medical education force us to examine essential aspects of morning report in order to base future decisions about morning report on sound educational evidence. Thus, a systematic review of the published literature on morning report was done in order to identify the various purposes and modalities of morning report, to find evidence in support of its educational value, and to discuss possible future directions for research on morning report. The term “morning report” is used to describe case-based conferences where residents, attending physicians, and others meet to present and discuss clinical cases. The term includes resident reports, morning or housestaff conferences, and morning sessions but excludes work rounds or teaching rounds. In a typical morning report, the team on duty during the night presents recently admitted patients, followed by a general discussion of the cases and related topics. Data Collection Data Identification and Study Selection. Four complementary approaches were used to locate articles about morning report. The goal was to retrieve all published articles. First, Medline, ERIC, and PsycINFO were searched using the key words morning report, morning session, residents' report, morning conference, education, and teaching. The key words were used in various combinations and in different search modes (e.g., titles and subject headings). The search covered articles written between 1966 (start of Medline) and December 1999. No limitation was set on the search parameters. All journals, languages, and types of articles, including original articles, surveys, opinions, and letters to the editor, were included. Second, a manual search was conducted through non-indexed medical education journals. All relevant articles not previously identified by computerized searches were included. Third, the reference section of each article was reviewed and all pertinent articles not previously found were also retrieved and included for review. Finally, knowledgeable educators in the field were consulted in an effort to locate any additional articles not previously detected. As a result, 48 articles were found related to morning report. Although the search began with articles dating back to 1966, the oldest article on morning report was published in 1979. Most articles (80%) were published after 1990. Forty-one articles are discussed; seven other articles, mostly letters to the editor, addressed issues already covered elsewhere.2,3,4,5,6,7,8 Data Extraction. The selected articles were reviewed according to a three-step method as described by Gordon,9 namely identification of key issues for review, selection of relevant information from various articles related to each issue, and critical synthesis and generalizations. The focus was primarily on the educational aspects of morning report and areas of possible improvement. We identified four major areas for review: purpose of morning report, organization, instructional methods, and educational outcomes. Each topic area is presented, followed by an overall discussion at the end. Purpose of Morning Report Historically, morning report probably was created to meet the demands of the hierarchical systems of public hospitals. In many cases, there were no ward attendings, and the chief of service had to ensure the health and safety of all the patients. Morning report provided the chief of service with the information needed to achieve this level of oversight.10 Both the purpose and the audience of morning report have evolved over the years, and morning report is now conducted for diverse purposes with a wide variety of audiences. The various purposes were evident in the literature reviewed, with education becoming the main objective.10 Other purposes were also mentioned, such as evaluating residents and the quality of services, detecting adverse events, and social interaction. The multiple purposes were evident in Parrino and Villanueva's survey of faculty and chief residents from 124 departments of medicine. Half of the respondents considered morning report “an important case-oriented teaching session” and a fifth believed that morning report “allow[ed] the chief of medicine or program director to keep tabs on medical services.”11 The importance of education was also reiterated in a recent survey where the majority of internal medicine residents indicated that education should be the primary purpose of morning report.12 The various purposes of morning report are presented according to five subheadings: education, evaluation of residents and quality of services, detection and reporting of adverse events, non-medical issues, and social interaction. Education. The educational goals pursued during morning report varied widely, ranging from case-based teaching1,13,14,15,16,17,18 to reviewing and planning patient management,1,15,16,17 fostering presentation skills,15,19 highlighting the unique approach of the generalist physician,19 developing intellectual curiosity and research,15,19 promoting decision-making skills,20 and self-directed learning.20,21 Morning report was also used to teach residents selected topics that are not usually part of the curriculum, such as ethics.22 Case-oriented teaching was the most frequently cited educational purpose of morning reports.11 Evaluation of Residents and Quality of Services. Most of the programs surveyed used morning report as a mean of evaluating residents' performances.11,12,13,14,15,16,17,18,19,20,21,22,23 In Parrino and Villanueva's survey, faculty in many programs used morning report to evaluate residents' attitudes (84%), clinical skills (63%), and quality of care (93%).11 A majority of respondents (82%) reported that morning report was also an effective means of case management.11 Although morning report was used to evaluate residents and quality of care, no structured instrument or rating scale to conduct such evaluations was reported. Detection and Reporting of Adverse Event. Morning report was sometimes used to detect and report adverse events.24,25,26 Kaufmann reported that a pharmacy intern regularly attended morning report and considered whether admissions were related to medication problems.24 Sivaram et al. reported that adverse drug reactions were discussed in the business portion of morning report and were later reviewed by the Pharmacy and Therapeutic Committee.25 Welsh et al. explored the effect of prompting residents to report adverse events.26 All three studies concluded that morning report can be an effective means to detect and report adverse events such as drug reactions. Non-medical issues. Although the discussion of non-medical issues during morning report was seldom reported, most programs addressed these issues on a regular basis. Schiffman et al. found that 85% of programs addressed a variety of non-medical issues such as social, personal, ethical, political, and economic topics, as well as cost-effectiveness and administrative matters.27 Actual time spent on these issues during morning report was not reported. Social Interaction. Although social interaction was not an explicitly stated goal, morning report provided an opportunity for residents and faculty to socialize. Eighty-five percent of the respondents in Parrino and Villanueva's survey indicated that morning report was an important social event for both residents and faculty.11 Two thirds of the programs in Schiffmann's study served food and drinks during morning report and conducted business in an informal atmosphere that fostered social interaction.27 In summary, residency programs used morning report for multiple purposes, including education and a variety of other goals. Residents favor morning report as an educational activity. The relative importance of each purpose of morning report depends on individual programs and, in turn, may determine the way morning report will be organized and conducted. Organization of Morning Report Most of the articles that addressed the organizational aspects of morning report came from internal medicine residency programs. Other programs included pediatrics, family medicine, and neurology. The organization of morning report is presented according to five subheadings: frequency, time, and duration; participation, leadership, and tone; case selection and presentation; record keeping; and patient follow up. Frequency, Time, and Duration. The frequency of morning report was fairly uniform across programs. Most were held on a regularly scheduled basis, with 80% of internal medicine programs holding morning report five times or more a week. Only a handful of programs held morning report less than three times a week.27 Morning report usually began before 9 AM and lasted for an hour.27 Some programs (4%) actually held “morning” report during the afternoon.27 In most programs, work rounds preceded morning report to facilitate data collection prior to morning report. Schiffman et al. argued that conducting morning report after ward rounds may be more useful because attending physicians can contribute significantly to the quality of the session.27 Participants, Leadership, and Tone. The mix of participants and leaders varied greatly across programs. The chief of medicine or the director of medical education was present in more than half of the sessions.27 Third-year service residents were the most regular participants, while the presence of first-year residents varied, with about 60% of the programs requiring their participation on a regular basis.27 Gross et al. reported that internal medicine residents prefer the presence of generalist physicians at morning report, possibly because of the renewed interest in general internal medicine.12 Carruthers described an Australian program where general practitioners from the community regularly attended morning report. She argued that a more widespread participation of general practitioners during morning report would lead to a better understanding of the strengths and weaknesses of general practice.28 Finally, the presence of non-physician participants helped to broaden the scope of knowledge and experience of the residents. For example, pharmacists increased the detection of adverse drug reactions24,25 and librarians increased the use of online searches by residents.13 Some have argued against the presence of non-service personnel, junior residents, or medical students at morning report because their presence might inhibit the spontaneity of case presentation and discussion.27 Studies of verbal interactions during morning report consistently showed that participants tend to be rigid in their roles and in their ways of asking for or providing information. Most of the information exchanged was low-level factual information. Few questions were asked that required synthesis of patient information and medical knowledge.29,30 The person leading morning report was either a faculty member (70%) or a chief resident (30%).11 Many openly criticized the role of the leaders and the tone they set during morning report.10,19,31,32 Comments such as “morning retort or morning distort,” “where bottom line is style above substance,”31 and “secretive closed-door session”32 were reported frequently. McGaghie et al. described the menacing atmosphere that prevailed in one institution as “… housestaff defining and defending mishaps using mechanisms such as denials, discounting, and distancing.”32 Case Selection and Presentation. The selection and mode of presentation of cases also varied greatly among programs, reflecting most often the chief resident's or attending physician's preferences.27 Case presentations varied from brief presentations of all cases with equal emphasis on each case to elaborate presentations of one or two “interesting” cases. Accordingly, times allotted for each case presentation varied widely. Westman prospectively compared the nature of the cases presented in internal medicine at a university center with those at an affiliated Veterans Administration hospital. The case mixes were similar in the two institutions; most cases (88%) were those of inpatients.33 Gerard et al. reported that pediatrics residents were more likely to select cases whose diagnosis changed during hospitalization.34 Other unorthodox methods of case selection and presentation included the selection of cases one to two days in advance,35 the selection of simple cases at the beginning of the academic year and more complex ones later in the year,27 and the presentation of cases prior to discharge.20,36 Record Keeping. Record keeping was done for different purposes during morning report.15,17,18,27,37,38 Records were kept for educational purposes, such as the evaluation of content coverage15 and patient follow ups,18 or as data sources for research.17 The availability of computers enabled many programs to use the data from morning report for a variety of purposes. Rouan et al. described a computer program to generate information from hospital admissions. They used the information for patient follow up, patient distribution among housestaff, residents' evaluation, and quality assurance.37 Recht et al. also described a computerized data management program and its use in clinical research and quality assurance.17 Patient Follow Up. Most internal medicine programs allowed for patient follow ups.27 Wegner and Shpiner showed that a final diagnosis was not always available at the time of discharge.18 Similarly, Barton et al. compared pediatrics morning reports from a community hospital and a university hospital. In both settings, significant numbers of patients, 28% and 58%, respectively, were not diagnosed at the time of presentation at morning report.39 Both investigators concluded that provision of patient follow up in morning report was important to maximize education. In summary, there was a fair amount of regularity and similarity among programs in the frequency, time, and duration of morning report. There was more variability in the mix of participants and leaders, case selection, record keeping, and patient follow up. Many openly criticized the type of leadership used in conducting morning report. There was a lack of evidence in the literature on how the different purposes of morning report might affect its organization and the educational and clinical outcomes. Instructional Methods The most frequent instructional method used during morning report was case-based presentation, followed by discussion. Over three fourths of the programs surveyed by Malone and Jackson used such an approach.40 Variations of case-based presentations were also used in an effort to improve educational effectiveness. For example, the chairman and chief resident would meet prior to morning report to review cases and preselect critical points for discussion.15 The limitations of case-based presentations were also discussed in the literature, most notably by Parrino and Villanueva,11 Mehler et al.,41 and Hill et al.42 Mehler et al. argued that “the standard format of case presentation may be less than optimal and can become a hackneyed experience.”41 Some shortcomings of case-based presentations have been addressed through innovative methods such as the presentation of prepared topics, photographic materials,43 and learner-centered learning approaches.40 In learner-centered approaches, the residents would determine the goals of the session once the cases were presented and then formulate questions based on these goals.40 Parrino and Villanueva further proposed that “new techniques at morning report could be based on existing models of problem-based learning.”11 Battinelli echoed this view and advised learners to be creative and try new approaches.44 Like medical education, morning report faces a dilemma over its educational focus. Two main orientations emerged from the review. One focused on the need to increase the residents' knowledge level, the other on the need to improve their problem-solving and data-gathering skills. DeGroot and Siegler described the dilemma by using the analogy of the retentive “sponge mode” versus the inquisitive “search mode.”19 Years later, Richardson and Smith revisited this issue and reemphasized the importance of learning the process of information gathering and analysis rather than simply acquiring content knowledge.45 Reilly and Lemon described a fourphase (similar to evidence-based medicine) morning report to foster active learning.46 The first phase was devoted to the discussion of assigned questions from the previous day. Next, residents briefly presented all admission cases and the chief resident used didactic methods to emphasize important teaching issues. The participants then discussed in detail one case for its educational Finally, the five were spent on questions and to residents for presentation the day. Reilly and Lemon reported a the of this In residents the and of evidence-based medicine and how to formulate and relevant In an of evidence-based medicine, evidence is also needed in education to existing educational and to new Half of the 48 articles on morning report were based on and were used most often to data other data-gathering methods were and hospital Most studies were based on four were conducted with multiple Some articles were based on reports any data stated that and analysis of hospital of selected in in of and Similarly, Mehler et al. described a of morning report that in less and for They reported that the level of during the academic year and that more discussion of cases more as time et al. in morning as presentation of articles, by a computer and regular the level of discussion and data for et al. reported that both and increased as by a later, the format in better information and reported the use of at pediatrics morning report as a means of residents' Finally, reported that morning report covered a of topics included in published (e.g., and by the of and in major medical (e.g., internal medicine All programs that reported as by in residents' or Some key emerged from the on morning report articles over First, the purposes of morning report varied widely, education was most frequently cited and by residents. Other important purposes were also mentioned, such as patient management and program and resident Second, of the organization of morning report, such as frequency, and were fairly similar across programs. the other mix of participants, case selection and presentation, leadership, record keeping, and patient varied across programs. leadership, and the learning were often Third, various that were to improve the educational and clinical of morning report in and further of these is most of the published studies were from programs, in internal medicine. There were studies on medical students and morning report. there is renewed interest in morning report as an educational as by the of published articles during the The evidence available on morning report to but of the models used to and morning report were based on sound educational For example, Reilly and of morning report is unique in that active and research in the models can as the on to sound educational that can be to the of the educational There is a lack of studies to the of morning report. may be to the of research in the of a and such as the multiple purposes, and in morning report. is also to the of morning report from those of other and informal educational Finally, the lack of also to the of research on morning report. should not be as but as to be research is needed in four key First, there is a need to the types of learning and teaching that on during morning report. are the unique teaching and learning of morning report compared with other educational such as work rounds or teaching Second, is about the of participants and the that are during morning report. Although residents value morning report as their most important learning they also about the atmosphere that the quality of morning report be by more the and of the residents and the is also needed to the of morning report on residents' and as well as on health care outcomes. Finally, there is a need for research on the of new to conduct morning report in order to the of the and Although the main focus of morning report been on topics, there is a need to the of morning report in the of The work by Malone and Jackson indicated that the educational of morning reports are significantly different from those of morning simple of from modalities to care is not morning report is new and for including the identification of the learning of the are the unique of the residents' education that should and can be addressed during morning are the unique educational of morning can the between morning report and morning report be Other research areas studies of the of the cases presented and their to educational and clinical outcomes. The majority of studies on morning report came from internal medicine programs, with a handful of reports from pediatrics, family medicine, and There is a need to studies across to one about the of the Although morning report is primarily focused on residents, there are other important participants present during morning report, such as medical and There was focus in the literature on the participation of these types of participants during morning report. The educational and learning of this diverse audience are different from those of residents and need to be as Morning report is a is not a of morning social gathering or a opportunity for program to keep tabs on the is a time for residents, an of set from the morning for Morning report is an opportunity for residents to and improve their knowledge and their leadership, presentation, and problem-solving skills. reports of its educational are mostly and its purpose often or not explicitly Each individual program to achieve with morning report and the activity from rounds or rounds. is needed to the educational and clinical of morning report and to the relative of various ways of conducting morning report such that evidence and can in

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