Morning report: focus and methods over the past three decades.

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 particular case chosen for its educational value. Finally, the last five minutes were spent on formulating questions and assigning them to residents for presentation the next day. Reilly and Lemon reported a department-wide, positive impact following the introduction of this format. In addition, residents learned the principles and procedures of evidence-based medicine and how to formulate precise and clinically relevant questions. Educational Outcomes In an era of evidence-based medicine, evidence is also needed in education to enlighten existing educational practices and to plan new ones. Half of the 48 articles on morning report (52%) were based on studies. Surveys and questionnaires were used most often to collect data (nine studies); other data-gathering methods were observations, video recordings, quizzes, logbooks, and hospital records. Most studies were based on single programs; only four were conducted with multiple programs.11,12,17,27 Some articles were based on anecdotal reports without any detailed data presented. Wartman stated that detailed discussions, chart reviews, and analysis of hospital bills of selected discharged patients resulted in subsequent reductions in lengths of stay and controllable costs.20,36 Similarly, Mehler et al. described a model of morning report that resulted in less test ordering and fewer requests for consults.41 They reported that the participants' level of enthusiasm declined during the academic year and that more in-depth discussion of single cases became more attractive as time went on. Bassiri et al. introduced changes in morning report—such as presentation of articles, comments by specialists, a computer database, and regular followups—that improved the level of discussion and generated data for research.14 Potyk et al. reported that both quizzes and mini-lectures increased learning, as measured by a true-false test administered later, although the quiz format resulted in better information retention.47 D'Allessandro and D'Allessandro reported the use of radiology slides at pediatrics morning report as a means of increasing residents' interest.48 Finally, several authors reported that morning report covered a broad range of topics included in published curricula (e.g., Pediatrics Review and Education Program by the American Academy of Pediatrics)49 and in major medical references (e.g., internal medicine textbooks).16 All programs that implemented innovations reported positive results as measured by increases in residents' knowledge47 or desired behaviors.13,24,25,26 Discussion Some key findings emerged from the diverse, albeit limited number of, publications on morning report (48 articles over 20 years). First, the purposes of morning report varied widely, although education was most frequently cited and favored by residents. Other important purposes were also mentioned, such as patient management and program and resident evaluation. Second, certain characteristics of the organization of morning report, such as frequency, timing, and duration, were fairly similar across programs. On the other hand, mix of participants, case selection and presentation, leadership, record keeping, and patient followup varied widely across programs. Tone, leadership, and the learning environment were often criticized. Third, various interventions that were implemented to improve the educational and clinical outcomes of morning report generally resulted in positive and promising results, although further validation of these findings is needed. Fourth, most of the published studies were from single programs, especially in internal medicine. There were very few studies on medical students and morning report. Encouragingly, there is renewed interest in morning report as an educational activity, as evidenced by the steady growth of published articles during the past decade. The limited evidence available on morning report makes it difficult to make grounded recommendations, but some of the models used to plan and implement morning report were based on sound educational principles. For example, Reilly and Lemon's model of morning report is unique in that it encourages active learning, maintains continuity, and improves research activities in the program.46 Such theory-based models can serve as the foundation on which to develop sound educational interventions that can be submitted to the scrutiny of the educational researchers. There is a clear lack of studies to document the effectiveness of morning report. This paucity may be due to the difficulties of doing research in the context of a multifaceted and multifactorial situation such as the multiple purposes, organizations, and audiences involved in morning report. It is also difficult to isolate the effects of morning report from those of other formal and informal educational activities. Finally, the lack of validated assessment instruments also adds to the difficulty of doing research on morning report. These difficulties should not be seen as insurmountable obstacles but as challenges to be met. Future research is needed in four key areas. First, there is a need to characterize the types of learning and teaching that go on during morning report. What are the unique teaching and learning characteristics of morning report compared with other educational activities such as work rounds or teaching rounds? Second, little is known about the satisfaction levels of participants and the motivational factors that are operative during morning report. Although residents value morning report as their most important day-to-day learning activity, they also harbor strong negative feelings about the atmosphere that prevails. Could the quality of morning report be enhanced by analyzing more closely the positive and negative feelings of the residents and the faculty? Research is also needed to document the effects of morning report on residents' knowledge, behaviors, and attitudes, as well as on patients' health care outcomes. Finally, there is a need for multi-institutional research on the effectiveness of new strategies to conduct morning report in order to verify the robustness of the interventions and thus move beyond program-specific effects. Although the main focus of morning report has been on inpatient topics, there is a need to address the specifics of morning report in the context of ambulatory care. The pioneering work by Malone and Jackson indicated that the educational characteristics of ambulatory morning reports are significantly different from those of inpatient morning reports.40 Consequently, simple generalization of results from inpatient modalities to ambulatory care is not recommended. Ambulatory morning report is relatively new and offers ample opportunities for high-quality research, including the identification of the specific learning needs of the participants. What are the unique components of the residents' education that should and can be addressed during ambulatory morning report? What are the unique educational attributes of ambulatory morning report? How can the continuity between ambulatory morning report and inpatient morning report best be ensured? Other priority research areas include studies of the natures of the cases presented and their relationships to educational and clinical outcomes. The majority of studies on morning report came from internal medicine programs, with only a handful of reports from pediatrics, family medicine, and surgery. There is a need to plan studies across specialities to inform one another about the effectiveness of the innovations. Although morning report is primarily focused on residents, there are other important participants present during morning report, such as medical students, ethicists, and pharmacists. There was little focus in the literature on the participation of these types of participants during morning report. The educational needs and learning characteristics of this diverse audience are different from those of residents and need to be studied as well. Morning report is a time-honored tradition. It is not just a ritual of early morning social gathering or a one-stop opportunity for program directors to keep tabs on the program. It is a valued time for residents, an uninterrupted flow of priceless minutes set aside from the hectic morning schedule for learning. Morning report is an opportunity for residents to exercise and improve their knowledge and their leadership, presentation, and problem-solving skills. Yet reports of its educational effectiveness are mostly anecdotal and its purpose often implicit or not explicitly defined. Each individual program must decide what it wants to achieve with morning report and structure the activity accordingly, distinguishing it from sitting rounds or patient-management rounds. Research is needed to document the educational and clinical effectiveness of morning report and to assess the relative merits of various ways of conducting morning report such that evidence and tradition can go hand in hand.