به نام خدا. Morning Report: A brief literature review

به نام خدا

Morning Report:Morning Report:

A brief literature A brief literature reviewreview

MRMREBMREBMR

OMROMROrOr

AMRAMR

OMR=outpatient MROMR=outpatient MRAMR=ambulatory MRAMR=ambulatory MR

Definition

Case-based conference where residents ,attending physicains and others meet

to present and discuss clinical cases.

Residents rank morning report as the most

important educational activity of their

residency training.

Ann Intern Med.1995:155:1433-7.

Morning report:Focus Morning report:Focus and Methods over and Methods over

the past three the past three decadesdecades

Academic Medicine ,vol.75,No.10,October 2000

4848 articles over articles over 2020 years. years.

The oldest article on MR was published in The oldest article on MR was published in 19791979..

80%80% of articles were published after of articles were published after 19901990..

Just Just 52%52% of theses articles were based on studies. of theses articles were based on studies.

Surveys and questionnaires were the most Surveys and questionnaires were the most frequently used tools to collect data.frequently used tools to collect data.

Their major areas for Their major areas for reviewreview::

1-Purpose of MR2-Organization of MR3-Instructional Methods4-Educational outcomes

Area 1 : PurposesArea 1 : Purposes:

1-Education(the main objective)2- Evaluation of resident and quality of

services(attitudes,clinical skills and quality of care).

3-Detection and reporting of adverse event

4-Non-medical issues

5-Social interaction

6-Better patient care

1-Educational goalsEducational goals1-1- Case-based teaching (the most

frequently cited)

1-2- Reviewing and planning patient management

1-3- Fostering presentation skills

1-4- Developing intellectual curiosity

1-5- Promoting decision-making skills

1-6- Self-directed learning

Area 2 : Organization

1-Frequency,time,duration

2-Participants,leadership and tone(morning distort! Morning retort)!

3-Case selection and presentation

4-Record keeping5-Patient follow-up

Area 3: Instructional Methods

1-Sponge mode (passive learning;morning report syndrome).

2-Search mode(self-directed scholarly inquiry).

case-based presentation was the most frequent

method.

However!..

There were two methods that deserves mentioning:

1-Format of Lawrence et al

2-Format of Reilly et al (evidence –based MR)

Morning report:

A Successful Format

Arch Intern Med Vol 145,May 1985 :897-899

A 692-bed hospital in TexasUSA

1

Critical Features of an instructiveMorning Report

Format:

1-Internal monitoring system for content2-Preconference determination of teaching

points3-Subspecialist participation

4-Orchestration by department chief5-Inquisitive,nonconfronting environment6-Timely review and update of prior cases7-Generation of appropriate bibliographic

materials

Evidence –based MR Evidence –based MR A four-phase model of Reilly and A four-phase model of Reilly and

lemonlemon

Phase one:Report of search results from the previous day(three reports over 15 minutes)

Phase two:Report of admissionsDuring the preceding 24 hours. Report(10 minutes).

2

Phase three:Detailed case presentations (30 minutes)

Phase four:Formulating the new questions for search and report on the following day(final 5 minutes)

A Deficiency

highlighted in MR’s:Teaching in the MR is as a series of snapshots of inpatient medical patients.

The continuity is often lacking and that educationally valuable material is lost from the the inpatient Medicine service.

GBL H

MR

Rx.Rx.::Revisiting casesRevisiting cases

Outpatient MROutpatient MR

OutpatientOutpatient Morning Morning Report:Report:

A New Educational A New Educational VenueVenue

DefinitionDefinitionConference for residents and

medical students that is dedicated to the presentation and discussion of outpatient

cases.

HistoryHistory::In 1995 ,Vanderbilt University Department of Medicine first instituted the outpatient morning report to meet the needs of the increasing number of residents and medical students rotating through ambulatory care settings.

PioneerPioneer::Malone Ml,Jackson Tc.

Educational characteristics of Educational characteristics of ambulatory morning reportambulatory morning reportJ Gen Intern Med 1993;8:512-4

Advantages of Outpatient MRAdvantages of Outpatient MR1-Provides a locus to execute an outpatient

curriculum through case-based learning2-Introduces learners to common medical problems3-Allows residents and students who are rotating in

geographically different sites to share their experience and learn from each other

4-Exposes the trainees to natural history of diseases5-Exposes the trainees to curricular items such as

medical economics,evidence – based medicine, and interviewing skills

وامابه نظر شما اساتيدگرانقدر

ما چه کنيم تا گزارش صبحگاهي بهتري

داشته باشيم؟

1-Definition of an organizer and leader in -charge of running the MR.2- Use of a structured format for MR and

a standardized format for report and archiving of cases.

3-Developing a core curriculum and specific educational objectives for our MR’s.

4-Definition of contribution of inpatient versus outpatient cases presented in MR.

5-Held an evidence-based search mode MR.Try to develop the students’ ability “to think on their feet” and solve problems.

6-Do not held a morning distort or a morning retort.

7-Held weekly or monthly revisiting sessions in order to follow-up the cases presented at previous MR’s(keep the continuity of learning on the natural history of diseases,do not expose residents just to snapshots of cases).

8-Case selection strategies should be based on core curriculum and targetted at achieving predefined educational goals for each session,week ,month and year.

9-9-Develop log books , archives and Develop log books , archives and databases for MRdatabases for MR to monitor educational content ,to provide an archive for review and study by residents ,.. and to facilitate research activities:

MR log book(helps to prevent overrepetition and to ensure coverage of all essential educational items and cases).

Develop database of cases:e.g.CC,symptoms and signs,laboratory data,DDX,final DX and a review paper on each topic (this facilitates search for researchers,provide subjects for CPC’s,journal club’s,..).

MR attendance log book.

10-Establish a fair rewarding system(e.g.competition for the best discussion of the faculty members,residents,interns,..:the best presenter,…)

11-Establish a regular ,valid and reliable appraisal system

Evaluation of satisfaction level of participants

Quizzes(from the MR educational content) Perform assessments to evaluate whether

MR contents succeed to meet the educational needs of residents,interns,medical students,..?

12-Each session ,provide a take home message in the form of a handout that is given to the participants or told to them(the more structured and written format,the better).

((

13-13-Please do not be a “windbag” Please do not be a “windbag” attending.attending.

14-14-Invite proportionate number of Invite proportionate number of generalists and subspecialtistsgeneralists and subspecialtists

11-11-Invite pharmacist,radiologist,…to Invite pharmacist,radiologist,…to attend the MR.attend the MR.

The bottom line is:The bottom line is:

Establishing the essential

infrastructuresinfrastructuresIn our climate is vital for

the practicability of these guides.

ه خيرا Hه خيرا فمن يعمل مثقال ذر Hفمن يعمل مثقال ذريرهيره

Hه شر Hومن يعمل مثقال ذر Hه شر Hومن يعمل مثقال ذرايرهايره

لزال آيه Hلزال آيه سوره الز H88وو77سوره الز

One of the most important and criticalOne of the most important and critical infrastructures is infrastructures is

the establishment of a system based onthe establishment of a system based on:

Part twoPart two::

Papers on MR Papers on MR and their and their succinct succinct

messages: messages:

No.1No.1

Title:Title:The culture of Morning The culture of Morning

Report:Ethnography of a Clinical Report:Ethnography of a Clinical Teaching ConferenceTeaching Conference

Source: Southern Medical Journal Source: Southern Medical Journal June 1997,Vol.90,No.6June 1997,Vol.90,No.6

Message:Message:In order to have a better MR:In order to have a better MR:

1-1-Shorten it.Shorten it.

2-2-Rotate those in – charge.Rotate those in – charge.

3-3- Improve the quality . Improve the quality .

No.2No.2

Title:Title:A Bitter Pill:Attempting A Bitter Pill:Attempting

change in a Pediatric change in a Pediatric Morning ReportMorning Report

Source: Pediatrics Vol.113 Source: Pediatrics Vol.113 No.2 February 2004No.2 February 2004

No.2No.2

Message:Message:In order to have a better MR:In order to have a better MR:

1-1-Return MR to a house-staff oriented Return MR to a house-staff oriented session.session.

2-2-Increase chief resident leadershipIncrease chief resident leadership

3-N.B.3-N.B.Do not attempt to apply theDo not attempt to apply the

expectations of literature-driven expectations of literature-driven standards.That may not work!standards.That may not work!

No.3No.3

Title:Title:

Outpatient Morning Report:A Outpatient Morning Report:A New Educational VenueNew Educational Venue

Source: Academic Medicine Source: Academic Medicine Vol.75,no.2 Februaury 2000Vol.75,no.2 Februaury 2000

No.3No.3

Message:Message:

Outpatient MR is a Outpatient MR is a popular ,learner-centered popular ,learner-centered

venue were important venue were important curricular objectives are curricular objectives are

achieved.achieved.

FormatFormat1-one-hour

2-Held four mornings each week3-Facilitated by a faculty member in general internal

medicine or by chief resident4-Participants are those residents and fourth-year

students ,who are taking part in ambulatory block rotation.

5-Every resident or medical student is assigned to present a patient case at least once during the rotation.

6-Before MR ,the presenter enters the case into Vanderbilt Outpatient Morning Report Website(without revealing DX.).

Format:Con.Format:Con.7-After presentation ,the facilitator solicits

participants’s learning goals related to the case and then lead a group discussion.

8-At the end there is a 5 minute summary of the topic and a review article or handout by the presenter.

9-The presenter adds the diagnosis and handout information to the Web site to archive learning points for future references.

No.4No.4

Title:Title:Outpatient Morning Report:A Outpatient Morning Report:A New Conference for Internal New Conference for Internal

Medicine Residensy ProgarmsMedicine Residensy ProgarmsSource: J Gen Intern Med Source: J Gen Intern Med

2000;15 :822-824.2000;15 :822-824.

No.4No.4

Message:Message:The residents reported that the The residents reported that the conference contributed much to conference contributed much to

their education by meeting their education by meeting specific specific

Learning needs and covering Learning needs and covering topics not covered else where in topics not covered else where in

their residency training. their residency training.

Characteristics of Characteristics of Outpatient MR In Outpatient MR In

US internal US internal Medicine Residency Medicine Residency

ProgramsPrograms

Programs with Programs with outpatient MRoutpatient MR

8888))23.8%23.8%((

Frequency of sessionsFrequency of sessions

1-21-2 times /monthtimes /month1212))13%13%((

1time/week1time/week3535))40%40%((

2-5times/week2-5times/week4141))47%47%((Who attends the sessionWho attends the session??

Attending physicianAttending physician8282))93%93%((

Chief residentChief resident5959))67%67%((

ResidentResident8888))100%100%((

Medical studentMedical student5858))66%66%((

Who leads the sessionWho leads the session??





Who chooses the casesWho chooses the cases??





Who presents the casesWho presents the cases??





No.5No.5

Title:Title:

Ambulatory Morning Ambulatory Morning ReportReport

Source: J Gen Intern Med Source: J Gen Intern Med 2002;17 :207-209.2002;17 :207-209.

No.5No.5

Message:Message:A general medicine clinic is A general medicine clinic is capable of exposing house capable of exposing house staff to the wide breadth of staff to the wide breadth of

internal medicine topics internal medicine topics previously thought to be previously thought to be

unique to subspecialty clinics.unique to subspecialty clinics.

No.6No.6

Title:Title:

Resident Expectations of Resident Expectations of Morning ReportMorning Report

A multi-Institutional StudyA multi-Institutional Study

Source: Arch Intern Med Source: Arch Intern Med 1999;159 :1910-1914.1999;159 :1910-1914.

No.6No.6

Message:Message:They expressed a desire for about They expressed a desire for about

50% of the guest attending 50% of the guest attending physicians to be generalist .They physicians to be generalist .They

preferred a style in which preferred a style in which challenging cases were challenging cases were

presented in a stepwise manner. presented in a stepwise manner.

What teaching methods are preferred by residents?

Teaching methods

Proportion of respondents ratingProportion of respondents rating

each method as” Most Importanteach method as” Most Important.”.”

What content should be discussed in the morning reportsWhat content should be discussed in the morning reports??

No.7No.7

Title:Morning ReportTitle:Morning Report

Source: Annals of Source: Annals of Internal Medicine Internal Medicine

Vol.119,Number 5 Vol.119,Number 5 1993;159 :1910-1914.1993;159 :1910-1914.

No.7No.7

Message:Message:These are the areas that they These are the areas that they

focus on them in MR:focus on them in MR:

1-Establishment of a positive 1-Establishment of a positive learning climatelearning climate

2-Control of the teaching session:2-Control of the teaching session:Review of Medical Knowledge Self-Review of Medical Knowledge Self-Assessment Program Assessment Program Questions=10 minutesQuestions=10 minutes

Review of admitted Review of admitted patients,highlighting key learning patients,highlighting key learning points and discussion of points and discussion of deaths=o-5 minutesdeaths=o-5 minutes

Case presenttaion and review of Case presenttaion and review of relevant journal articles=35-45 relevant journal articles=35-45 minutesminutes

33--Communication of goalsCommunication of goals

44--Enhancement of Enhancement of understanding and understanding and retention(take home retention(take home message)message)

55--Evaluation and feedbackEvaluation and feedback

66--Self-directed learningSelf-directed learning

No.8No.8

Title:Title:

Pediatric Morning Report:An AppraisalPediatric Morning Report:An Appraisal

Source: Clinical PediatricsSource: Clinical Pediatrics

Oct 1997,Vol.36,Issue 10Oct 1997,Vol.36,Issue 10

No.8No.8

Message:Message:

MR is diagnostically inaccurate and should MR is diagnostically inaccurate and should not be seen as a free consultation.It not be seen as a free consultation.It

should be utilized as an opportunity to should be utilized as an opportunity to develop problem solving skills.develop problem solving skills.

Revisiting casesRevisiting cases is an important is an important educational tool and should be integrated educational tool and should be integrated

into MR format.into MR format.

No.9No.9

Title:Title:

Morning Report in the Computer Morning Report in the Computer Era:Tradition meets technologyEra:Tradition meets technology

Source: Medical Teacher Source: Medical Teacher Sep.1995,Vol.17 Issue 3 ,p.327-335.Sep.1995,Vol.17 Issue 3 ,p.327-335.

No.9No.9

Message:Message:

They present their experience and They present their experience and methods for entering patient data methods for entering patient data into a computerized database in into a computerized database in order to construct an efficient order to construct an efficient

searching tool with searching tool with indexing ,keyword and cross-indexing ,keyword and cross-

referencing capabilities.referencing capabilities.

Title:Title:Evidence- Based Morning Report Evidence- Based Morning Report for Inpatient Pediatrics Rotationsfor Inpatient Pediatrics Rotations

Source:Academic Source:Academic Medicine ,Vol.75,No.12 Medicine ,Vol.75,No.12

December 2000December 2000

No. 10No. 10

FormatFormat::The first week session acquaints learners with the PICO(Patient,Intervention,Comparison ,Outcome)method for formulating an answerable clinical

question.… ..

During each of the following weeks ,a different resident-student team is responsible for identifying a current patient case,formulating the question using PICO,meeting with the librarian to perform a literature search and selecting an article that

they believe best answers their question.

Then they present the details of their research process,a critical appraisal of the article and a description of its application to the patient’s case.

A formal evaluation of the rotation’s effect on participants’ skills in applying evidence to clinical decision making is done.

Message:After the rotation ,residents

are more likely to appropriately alter their beliefs when exposed to strong contrary evidence

than they were before rotation.

Title:Title:An Analysis of Morning An Analysis of Morning

Report:Implications for Internal Report:Implications for Internal Medicine EducationMedicine Education

Source:Ann Intern Med.1993;Source:Ann Intern Med.1993;

119:395-399.119:395-399.

No. 11No. 11

6540 patients6540 patients admittedadmitted

36 management 36 management casescases

294 diagnostic294 diagnosticcasescases

6540 patients6540 patients admittedadmitted

Diagnosis reached during MRDiagnosis reached during MR

YesYes::76%76% NoNo::24%24%

25%25%The sameThe same

39%39%Dx.Dx.

Uncertain Uncertain at follow-upat follow-up

36%36%differentdifferent

Message:

Most patients without a firm diagnosis have one established by 6 months later-often with surprising results.

Postdischarge follow-up information could enhance the educational value of inpatient cases.

Title:Title:Determinants of Case Selection at Determinants of Case Selection at

Morning ReportJ Source:Morning ReportJ Source:

Gen Intern Med1997;12:263-266.Gen Intern Med1997;12:263-266.

No. 12No. 12

Message:Cases were more likely to be presented if

they were: 1-unusual or rare in either or

etiology . 2-Involoved diagnostic dilemmas.

3-Were associated with notable radiography or other visual aids.

4-If they disagreed with the attending physician on patient management plans.

Complete resident freedom in choosing MR cases may narrow the scope of MR and exclude common diagnoses and other important issues such as medical ethics or economics.

Documents

به نام خدا. Morning Report: A brief literature review