Morning Report A Primer for Chief Residents

Annual Chief Residents Workshop Association of Program Directors in Internal Medicine San Diego, April, 2007 Prepared by the APDIM Morning Report Workshop Facilitator Group

Dear Soon-To-Be Chief Medical Resident, Congratulations! We wish to extend our sincere congratulations to you on your selection as Chief Medical Residents. Your selection by your Program Directors and Chairs of Medicine - more importantly, by your mentors - reflects their high regard for your leadership skills and knowledge of Internal Medicine. The crucial element in our selection of a chief resident, however, is to pick individuals in whom we have complete trust and confidence that they will care for the program, as well as its residents, with the same degree of commitment and high standards as the program directors. This handout should serve as a reference for ideas on how to organize, run and/or improve Morning Report at your institution(s). It is a workbook version of the chapter in the new version of the APDIM Chief Residents Manual. It will used to varying degrees by small group facilitators and will hopefully pride you with ideas for your own AM Report. This chapter will hopefully empower you to "take ownership" of one central aspect of your chief resident role - that of Morning Report leader/facilitator/moderator. Morning Report is a wonderful focal point of medical teaching and learning that we hope you will learn a bit about during these workshops. We encourage your active participation and hope that you take home some ideas and thoughts for making your program's Morning Report truly "yours". Please feel free to contact any of us if you have questions on what we will cover today. Our names and email addresses are below. We wish you success and fulfillment in your new roles! Dominick Tammaro, MD on behalf of The APDIM Morning Report Workshop Facilitator Group

I. 1. 2. 3. 4. 5. 6. 7.

Goals for this Chapter Develop goals for your morning reports. Evaluate the structure and content of your morning report. Develop a framework for planning, conducting and evaluating morning report. Learn new ways to conduct morning report from your colleagues and other programs. Identify the barriers to having a successful morning report session. Empower yourself as a chief resident to take ownership of morning report and change it to fit your personal and institutional goals. Learn useful skills for running a successful morning report, ranging from moderating and promoting discussion to the role of audiovisual and computer aids. (Objectives were written in the eyes of the resident not us.)

II.

Important Questions to Consider before July 1.

What are your own goals for Morning Report? 1.

2.

3.

What would you like to change about your program's Morning Report?

What are some of the obstacles to changing AM Report that you anticipate? "Morning report is a ritual handed down by the giants and a tradition not to be tinkered with"

What would you like to keep the sa me about your program's Morning Report?

How will you know if you are successful in meeting your goals? Your residents' goals? Your program's goals?

III.

Essential Components to Consider in All Teaching Interactions Define each of the following concepts in terms of your goals for Morning Report: Copyright, 1988, Stanford Development Program (Skeff, Stratos)

Learning climate.

Control of the session.

Communication of goals.

Promoting understanding and retention.

Evaluation.

Feedback.

Promoting self-directed learning.

IV.

Stanford Clinical Teaching Model MORNING REPORT AS A TEACHING EXERCISE: THE STANFORD APPROACH 7 Step approach to enhance teaching effectiveness, enthusiasm and vitality:

LEARNING CLIMATE: Tone or atmosphere of the clinical teaching setting including whether it is stimulating and whether learners can comfortably identify and address their limitations. if the teacher is enthusiastic, they can stimulate the residents to be ready to learn learner must feel one of the group before they will participate learners need to feel respected in order to comfortably identify and address their limitations everyone wants to believe they are suffering like no group before them admit ones own errors and limitations CONTROL OF SESSION (How to run Morning Report despite the Attending) manner in which the teaching interaction is paced and focused by the teachers leadership style planning and organization is always the responsibility of the chief resident regardless of the format variety is important COMMUNICATION OF GOALS establishment and explicit expression of a teachers and/or learners expectations for the learners be prepared to negotiate adjust as you go PROMOTING UNDERSTANDING AND RETENTION extract at least one major teaching point from materials presented as a take-home message What is the likelihood that the learner could explain it tomorrow? there are no rules for how to do this-the gold standard is the educational outcome do whatever it takes but dont try to do too much SUMMARIZE EVALUATION: The process by which the teacher assesses the learners knowledge, skills and attitude as based on educational goals. easier said than done because of the risk of being perceived as pimping be up front about the role of evaluation AVOID HUMILIATION AT ALL COSTS Assess the success of your morning report in meeting the goals of the learners, as well as your own goals. FEEDBACK chief residents must give positive as well as negative feedback - not just one or the other. can and sometimes should be given in groups ask for feedback on morning report from a variety of sources - the learners, department chair, program director SELF-DIRECTED LEARNING morning report is an unparalleled opportunity to foster self-directed learning stimulate individual learners to identify gaps in their knowledge. the discussion about a case or question need not end with the end of that day's morning report - give homework, seek follow-up on questions or patients. Ask the residents caring for the patients bring something to the table and apply positive feedback and public praise when they do so without prompting from you.

V.

Taking Ownership of Your Morning Report: Empowering Yourself for Change

When planning your Morning Report, use the 5 Ps to create a framework early on in the year: Purpose People Process Paper Passion 1. Purpose Elements of AM Report Whats the Purpose? Prerequisite for discussing all other elements.

q Plan ahead. Meet with your PD to discuss objectives for the year and for individual morning reports. Come q q q q
A. with a list with specific ideas and objectives. Determine: timing, audience, leaders, faculty preceptors, cases selection. Ongoing planning with regular meetings about objectives, method and evaluation. Format should match your goals. Use a monthly/yearly curriculum to keep your plan on track. Goals Program - Determine the Goals that your program values Increase resident knowledge (content driven) Increase resident skills (process driven) in presentation, EBM, literature review Quality Improvement Keep tabs on inpatient service Review all admissions/discharges Review and critique resident decision-making Assist in management of complex patients Case-oriented teaching session Professional development Board review M&M (review management decisions including bad outcomes) Social function Radiology conference Tracking Duty Hours Compliance Teaching/tracking/evaluating ACGME Competencies Forum for Evidence-Based Medicine. Goals - Chief Residents - What do you want to get out of Morning Report? Increase your knowledge (content driven) Increase your leadership skills Evaluate residents Provide advice and guidance to ward residents Track Morbidity and Mortality Get cases for Physical Diagnosis Communicate expectations Discussion of how to change morning report if it doesnt fit your personal goals Goals - Target Audience & Others - Determine the needs of your target audience(s). Ward Residents Other residents Interns Students Faculty

B.

C.

2.

People Elements of AM Report

Who are the People? A. B. Determine the Primary Target Audience - See above Secondary Audiences - Will your Morning Report be closed, open, or somewhere in the middle? Program directors Faculty Fellows - Are they allies & contributors? Pharmacists and pharmacy students Librarians Intern applicants - November through January, as well as second looks. Patients Faculty D. Leadership Central or peripheral player? Invited or rotating or constant presence? Does subspecialist in attendance give diagnostic category away? Invited participant or unwelcome lecturer?

C.

Who runs the show? Same or rotate? Socratic - do you call on folks? Control of Session Conspiracy - select allies & prepare in advance Reinforcements - who to turn to

3.

Proces s Elements of AM Report

By What Process is the Purpose is Achieved? The format should be learner-centered and based on principles of active, adult learning theory You must set the goals and purpose for Morning Report before you can decide on the format Different formats can be used on different days-variety is good Time should be protected for the residents Determine the size/place/time; will food be provided? A. Responsibilities Presenters Prepare and select cases and topics Work with CMRs Prepare brief review of topic Bring Xray, slides Copy articles Invite faculty Chief Residents - Who is in charge? Needs Assessment Start and End on Time Select cases & plan number of cases discussed Protocol for presentation Even out participation among learners Calibrate discussion Ask the tough questions NOT know all info or be the primary teacher Everything else not mentioned above 8

Residents Discussion Teach each other Disagree in a professional and constructive manner Faculty - Who is invited? Offer expertise Validate correct observations and comments Correct incorrect observations and comments Contribute without dominating discussion

B.

Create a positive learning environment. Set up a productive learning environment. Make the topics relevant, useful and timely. Know your audience. Direct attention to important facts. You need to know this for the Boards. Be a leader - not a friend or foe. Offer suggestions about what you would do. Ask questions directly to the residents and give them time to answer. Simplify and teach concepts. Help them to visualize concepts. Use diagrams, pictures, graphs. Teach pathophysiology. Let the experts speak. You dont have to know everything. Have the presenter be the role model. Supporting Data X-Rays Slides EKGs Other Data (Echo & Gait videos) Photos (Polaroid, digital) Patients (History, PEx, Unknowns) Real-time EBM searches using PC connected to projector computer driver of the day Clinical Material - Who decides and how? ALL patients admitted last 24 hours SELECTED (by whom?) patients on wards Other patients All discharged patients Interesting or Very Sick Patients Topics unrelated to patients Lead-time? Vary the stimulus. Dont use the same format every day. Capitalize on what works. Involve the residents and maintain their interest. Take a step back and re-think how a clinical topic or concept can be approached. Use an evidence-based approach. Include bedside teaching by bringing the patient to MR. Consider: clinical problem solving, didactic content, traditional case presentations, start from the end and then work forward. Pick non-traditional topics: Alternative medicine, ambulatory cases, preoperative evaluations, clinical pathways, E&M coding, morbidity and mortality issues Use different formats: Quality assurance, professional development and teaching workshops, pathology conference, ethics, trouble shooting (Town Meetings), discussing adverse outcomes, dealing with administrative issues, indirect evaluation of residents knowledge base (not pimping) Use computers creatively Internet searches

C.

D.

E.

F.

Feedback and Evaluation Timely & Specific Daily Corrective Action Chronological Record Going the Extra Mile Examples

4.

Paper Elements of AM Report

How do we communicate our intent and record what weve done?

A.

Documentation and Evaluation Background tracking of admissions/census Spot data collection Recording of Patients presented Follow-up - How to manage & recall M&M, QA Research Feedback in annual program evaluation/needs assessment Administrative Functions Orientation Packet Inform new residents of convention & policy Announcements Resident Evaluation & Feedback Multiple institutions, PGY-2 residents Passionate Elements of AM Report What keeps you and the learners involved and excited?

B.

5.

A.

Fun End of Month Jeopardy questions Open with Question of the Day the resident with the most correct at the end of the month gets a prize (can only play if you arrive on time). Presenting the unknown Withholding information Invite patients to attend as mystery guest - group takes a history.

B.

Creativity Involve other services & departments Involve patients Non-Medical Topics Journal Club Faculty authors & experts

C.

Pride Resident Contributions everyone brings something to the table Good Competition CMR praise PD, COM praise Give credit where credit is due Research 10

D.

Building/Reinforcing Relationships Residents helping residents Disagreements Crisis debriefing (the blackout) M&M - the play-by-play & resident cooperation Lifelong Learning Literature Review Cultural expectations Critical review Self-reliance and Teamwork

E.

6. A Sixth "P" to Consider - Problems How to deal with inevitable bumps along the road to Morning Report Bliss VI. 1. Latecomers The reluctant resident No Interesting Cases Not speaking loudly enough to be heard The alpha resident who dominates, whether or not they know the answers Disagreements out of control CMR Burnout Faculty that dominate Getting feedback on how "we used to run AM Report" from many unsolicited sources

Leadership Advice for the Chief Resident ATTRIBUTES FOR THE CHIEF RESIDENT LEADING MORNING REPORT: *The leader should have good general knowledge base, good interpersonal skills, the ability to ask effective questions and be a good facilitator *The leader should teach process rather than content *The main teaching tool should be the question *The leader must guide the group to think through to the answers *Use of the Educational Prescription (Richardson & Smith): 1. Question 2. Search 3. Answer 4. Critical appraisal 5. Use

2.

Get yourself ready every day. Prepare yourself for the cases to be discussed. See patients, read, check labs. Define your teaching points. Seek the teachable moment. Take the lead. Be creative. Bite off less than you can chew. Have back-up case ready. Continue the learning process outside of Morning Report. Bring current literature or patients when appropriate. Leave them wanting more. Promote self-directed learning. Assign homework. See the patient yourself. Follow-up the clinical course with the team and have them report back to the group.

2.

11

4.

Be bold. Look for new and creative opportunities. Enlist feedback from residents about Morning Report. What are the best and worst features of Morning Report? What would you change about the format or content? Why do you attend? Why dont you attend? Get written feedback through annual needs assessment. Use your MR techniques in other settings. How about Afternoon Report in medical clinic? Always have a take home message. R E P O R T Relaxing, social function with peers, Program Director and faculty Educational with positive reinforcement Patient centered focus Organized and planned with varied stimulus Revisit your style, technique and content Take home tips, handouts, articles with self-directed learning

5.

VII.

References

Cook RI. Learning theories implicit in medical school lectures. JAMA 1989;261:2244-2245. Light review of different learning styles in helping you recognize the various learners in your audience. Parrino TA, Villanueva AG. The principles and practice of morning report. JAMA 1996;256:730-733. Study examining chairmens opinions about the good and bad aspects of morning report. Sackett DL, Rosenberg WM, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isnt. Brit Med J 1996;13:71-72. Short description of the value of using an evidence-based approach in your clinical discussions. Schiffman FJ. Mayo-Smith MF, Burton MD. Resident report: a conference with many uses. Rhode Island Med J 1990:73:95-102. Reviews the basic elements necessary for a successful morning report, including goals, setting, content and food. Skeff KM. Enhancing teaching effectiveness and vitality in the ambulatory setting. J Gen Intern Med 1988;3:S26-33. Basic discussion of the 7 concepts for being an effective teacher whether it is in the ambulatory or inpatient setting. Wartman SA. Morning report revisited: A new model reflecting medical practice of the 1990s. J Gen Intern Med 1995;10:271-272. Interesting new ideas for morning report. Ways M, Kroenke K, Mali J, Buchwald D. Morning report: a survey of resident attitudes. Arch Intern Med 1995;155:1433-1437. Residents believe that morning report is a valuable educational experience. Prefer clinically based, openended interactive discussions led by attendings with broad knowledge base. Wenger NS, Shipner RB. An analysis of morning report: Implications for internal medicine education. Ann Intern Med 1993;119:395-399. Follow-up with post-discharge diagnoses was useful as an educational tool. Gross CP, Donnelly GB, Reisman AB, Sepkowitz KA, Callahan MA. Resident expectations for morning report: A multi-institutional study. Arch Intern Med 1999;159:1910-1914. Strong interest in having generalists participate in morning report. Residents preferred challenging cases that were presented in a stepwise manner. 12

Appendix A. A Morning Report Clinical Vignette with Questions Its August and your have finally hit your stride as the leader of Morning Report. You have renewed confidence in your ability to teach the residents all that you know. Its about 45 minutes before Morning Report is going to start and you run up to the team room to get a case. You find the post-call intern gathering their cards for work rounds. You hurriedly ask the intern about the admissions that came in the night before and pick out a patient who was admitted with jaundice. You tell the intern to present the case at Morning Report. On your way back to your office, you stop by the library and pull out a citation from Ovid about obstructive jaundice and make copies for the residents. You arrive in the conference room a few minutes late and find only 2 residents there. You wait another 5 minutes and begin paging the teams. Finally, the intern who is supposed to present arrives. The intern is not very organized and is unable to relate the full history. You review the differential diagnosis of jaundice for the group and hand out copies of the article. The residents do not ask any questions and when you ask them questions, they are hesitant to respond. You are glad when the hour is over.

What did the Chief Resident do well?

What could the Chief Resident have done better?

13