A Bitter Pill: Attempting Change in a Pediatric Morning Report
* Department of Pediatrics and Steele Memorial Children’s Research Center, University of Arizona Health Sciences Center, Tucson, Arizona
Office of Educational Development, University of Arizona College of Medicine, Tucson, Arizona
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ABSTRACT |
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Objective. To assess and address participants’ dissatisfaction with departmental morning report (MR).
Methods. Three consecutive MR sessions were observed, and those data, in combination with findings from the literature, were used to guide creation of a quantitative survey. The survey was administered to all faculty and housestaff. Survey items addressed the educational focus, leadership, and format of MR and the value of specific educational conferences. Subsequently, 2 interventions were developed to increase participants’ level of satisfaction with MR. The interventions’ effect was measured 1 year later using a second survey.
Results. Eighty-two percent of housestaff and 43% of faculty responded to the first survey. Our findings are contrary to those in the literature. For example, respondents rated the presence of all faculty at MR as desirable, and both subspecialty and general pediatric contributions were considered important. Housestaff assigned greater educational value to all teaching conferences than did faculty. Similarly, housestaff believed more strongly than faculty that MR leadership should be changed. A follow-up survey demonstrated a decrease in mean perceived value of MR after our interventions.
Conclusions. Despite aggressive research, we failed to identify the source of participants’ dissatisfaction. Although our interventions were based on research data and reflected participants’ perceptions and concerns related to MR, they were not supported by the faculty. This demonstrates the inherent difficulties in changing an "institution" such as MR. Thus, examination of MR goals and satisfaction by individual training programs should be conducted within the confines of the conference’s preexisting structure, without attempt to apply literature-driven expectations.
Key Words: medical education • pediatric morning report • teaching satisfaction
Abbreviations: MR, morning report
Morning report (MR) has been called "one of the finest examples of a one-room schoolhouse still in existence"1 and remains a fixture of the educational experience in most pediatric and internal medicine training programs.2 MR provides an interactive forum for housestaff to develop skills in presentation, diagnostic evaluation, and patient treatment. The success of this teaching tool has been measured previously, primarily in internal medicine training programs. Surveys of internal medicine housestaff attitudes reveal surprisingly uniform opinions about MR.3–5 These surveys indicate that most trainees prefer general medical topics and believe that subspecialist participation has the potential to detract from case discussion. Disease process, diagnostic workup, and evaluation of tests and procedures are considered important, whereas discussion of basic science, use of anecdotes, and subspecialty knowledge are less desirable. Presence of a single or core group of faculty under strong leadership is ideal, whereas multiple faculty members are not. The educational impact of MR is negatively affected by multiple interruptions, digression from the cases, and "windbag" attendings. Because these surveys were primarily administered to residents, they offer a 1-sided view of the "ideal" MR.
Although the literature presents numerous evaluations of internal medicine MR, there is a paucity of literature evaluating pediatric MR. The few studies of pediatric MR examine method of case selection, accuracy of diagnosis, and benefit of postdischarge follow-up.6,7 However, neither of these studies provides significant commentary on participants’ satisfaction or the educational value of MR. Little is known about MR participants’ goals and satisfaction.2 These issues were recently highlighted in our department of pediatrics, where both faculty and housestaff expressed significant, nonspecific dissatisfaction with the MR format. We undertook the present study to identify specific reasons for MR participant dissatisfaction and create data-driven interventions designed to improve levels of satisfaction.
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METHODS |
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Our pediatric residency program contains 38 housestaff and >60 faculty members, many of whom participate in graduate medical education. The program’s recognized strengths include excellence in clinical and basic science teaching in a supportive environment and maintenance of open, cordial relationships between housestaff and faculty. MR is held 3 days per week for 30 minutes. Two cases are chosen and presented by either the ward team senior residents or, occasionally, residents rotating through the intensive care units, outpatient pediatric clinics, or subspecialty electives. The department chairman, residency director, chief residents, multiple faculty from general pediatrics, subspecialties, and intensive care units and all available housestaff and medical students are present. MR is led by 1 of the chief residents who also writes details of the cases on an erasable board as they are presented. After a thorough review of existing MR literature, we designed our MR evaluation to include 3 analytical tools, 2 qualitative and 1 quantitative, with a follow-up analysis to assess impact of the interventions.
Step 1
A trained observer familiar with the format and expressed goals of MR performed qualitative observations of 3 consecutive MR sessions. Observations focused on time of arrival; quantity and quality of questions asked; the presence of private conversations; attention paid to presentation, quantity, and quality of observations/comments provided by housestaff versus faculty and subspecialist versus generalist faculty; quality of leadership present; and general level of interest of participants. Data collected from these observations was used to guide creation of survey items in step 2.
Step 2
Combining data from step 1 and our literature review, we created a 26-item survey. The survey contained both dichotomous and Likert scale questions with responses from 1 to 5 (1 = no value, 5 = very valuable.) The survey was administered in March 2001 to all pediatric housestaff and faculty. Questions examined attendance, educational focus, importance of MR components, leadership of MR, and educational value of individual educational conferences (MR, specialty and resident lectures, grand rounds, and attending rounds). Responses were anonymous, although the respondents were identified as housestaff or faculty via demographic questions. We entered the responses into a database created using SPSS v.11.0 and analyzed the data by use of independent samples t test.
Step 3
Although not originally part of the research plan, S.P.E. performed semistructured interviews of a subset of faculty and housestaff, using open-ended questions designed to explore and clarify further the survey results. We recorded and transcribed each interview and then analyzed the responses to provide support for survey responses.
Step 4
As a result of the data generated by steps 1 to 3, we designed 2 interventions to rectify the sources of discontent identified by our evaluation. We discussed these interventions with both chief residents and with their support; S.P.E. extensively oriented both housestaff and faculty to the new approach at their respective staff meetings. At orientation, housestaff and faculty discussed study results, the authors’ proposed goals for MR, and strategies for attaining the goals. The revised MR began in July 2001 with the arrival of new housestaff and was implemented primarily through the actions of the chief residents, who underwent formal training in education facilitation and questioning technique conducted by S.C.E. As a regular participant in MR, S.P.E. performed ongoing qualitative assessment of the success of implementation and provided additional feedback to the chief residents during the 1-year study period.
Step 5
We designed a second survey to assess the impact of our interventions. This survey contained both dichotomous and Likert scale questions and was administered in May 2002 to all faculty and those pediatric housestaff who were present the previous year. Questions addressed change or improvement in satisfaction with leadership, presentations, educational value, housestaff participation, and attendance, compared with the previous MR. Responses were anonymous, although demographic items were again included. We entered the responses into a SPSS v.11.0 database and performed statistical analysis by use of independent samples t test.
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RESULTS |
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Step 1
Initial qualitative observation of 3 sequential MR sessions identified several potential problems. Discussion of the presented cases was initially well focused but quickly became sidetracked by subspecialist minilectures. A lack of leadership thwarted attempts by the presenting housestaff physician to refocus the discussion. When such minilectures began, the level of interest expressed by all participants seemed to drop rapidly with many displaying "glazed looks" and inattentive posture. Several private conversations were conducted as the case discussion proceeded. Few housestaff ventured any questions, and ultimately the discussion was conducted between faculty with minimal housestaff involvement. In addition, the discussion tended to focus on subspecialty points with minimal general pediatric education occurring. The most prominent problem was a lack of leadership or structure, resulting in a lack of direction or educational focus.
Steps 2 and 3
Thirty-one (82%) of 38 housestaff and 26 (43%) of 60 faculty responded to the survey, for an overall response rate of 58%. All 3 years of housestaff education were similarly represented, and faculty responses mirrored departmental distribution (54% assistant professors, 27% associate professors, and 19% professors). The majority (77%.) of faculty respondents were subspecialists. MR attendance was similar between housestaff and faculty; most respondents attended "very often."
Housestaff believed more strongly than did faculty that all faculty should attend MR (mean perceived value: housestaff 2.62 versus faculty 1.75; P = .000). However, both groups were similar in their disagreement with inviting only a core group of faculty to MR (52% housestaff and 54% faculty strongly disagreed). Housestaff seemed to believe more strongly that MR should focus on general pediatrics issues (70% housestaff and 48% faculty strongly agreed), but the difference did not reach statistical significance. Both housestaff and faculty were much less supportive of a subspecialty focused MR; however, both faculty and housestaff agreed that the contributions of both general pediatric and subspecialist faculty were important. Ninety-four percent of housestaff and 85% of faculty believed that general contributions were important (P = .196). Ninety-seven percent of housestaff and 89% of faculty believed that subspecialty contributions were important (P = .219). No difference existed between housestaff and faculty in their view of the importance of uninterrupted presentations (rated "moderately important"), importance of discussing a differential diagnosis (rated "important"), or importance of understanding disease process (rated "important"). Faculty believed that understanding tests/procedures was much more important than did housestaff (P = .041). Housestaff assigned much more value to each of the department of pediatrics teaching sessions than did faculty (Fig 1). Sixty-five percent of housestaff but only 44% of faculty believed that the MR leadership should be changed. Of those who believed that leadership should be changed, 71% of housestaff and 82% of faculty believed the chief residents should become the new leaders. Ninety-two percent of housestaff and 90% of faculty chose the current MR format (30 minutes, 3 times per week) as their first preference. The second preference was 30 minutes, 5 times per week, followed by 60 minutes, 3 times per week, and 60 minutes, 5 times per week.
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Step 4
Findings from the observations, survey, and interviews were combined, creating 2 major goals for MR:
- Goal 1: Return MR to a housestaff-oriented session. Make participation more active and improve case preparation. Chief residents will identify educational goals for each case and solicit productive faculty comments during discussion after the case presentations.
- Goal 2: Increase chief resident leadership. Allow them to facilitate the discussion, thus minimizing faculty domination and encouraging resident contributions.
S.P.E. presented the study’s results, goals, and intervention strategies at the residents’ and faculty’s respective staff meetings. At the housestaff meeting, intervention strategies included techniques for more effective presentations and teaching skills (eg, "wait time") and definition of the scope of the chief residents’ role. The faculty’s session addressed the increased leadership role of the chief residents and suggested limits on spontaneous faculty contributions. In other words, the faculty were asked to "let the residents do the teaching." Although winning universal resident approval, the goals met with heated faculty opposition. Comments ranged from, "Censure? Absolutely not!" to, "This is a social occasion for us.... Don’t ruin it!" Despite S.P.E.’s multiple attempts to bring faculty to consensus regarding the educational goals and purpose of MR, little progress has been made.
On the basis of the goals developed from our investigation, we implemented a new approach to MR, faculty objections notwithstanding. The current approach, which began in July 2001, is to "let the chief residents do their job" in leading the discussion and to focus on active housestaff participation. Under improved chief resident leadership (eg, improved facilitation of contributors, more active participation in differential diagnoses development, increasing feedback regarding strength of presentations), housestaff are increasingly contributing to discussions of differential diagnosis and disease pathogenesis, while still benefiting from the presence of faculty "experts."
Step 5
We administered a follow-up survey in May 2002. Eighteen (69%) of 26 housestaff and 14 (23%) of 60 faculty responded, for an overall response rate of 37%. First-year housestaff were excluded from this survey as they had no exposure to the old MR format and thus could not assess change or impact of the interventions. Seventy percent of respondents believed that MR had changed. Of those reporting change, 80% believed that MR had improved. Sixty-five percent of all respondents believed that their satisfaction with MR overall had improved. Likewise, 58% believed that case presentations had improved, whereas 59% believed that MR leadership had improved. Sixty-three percent agreed that the educational value had improved, and 67% agreed that housestaff participation had improved. No statistically significant differences developed when requestioned about preferring the attendance of all available faculty versus only a core group. When requestioned about the educational value of MR, the mean perceived value decreased compared with the first survey responses (P = .000; Fig 2).
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DISCUSSION |
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MR remains one of the most traditional and important parts of residency training.8 Its success in this role has been investigated infrequently in the medical educational literature, most of which examines internal medicine programs. However, our review of this literature provided an initial background from which to explore the source of dissatisfaction with our MR.
Initial qualitative evaluation of our MR confirmed many of the sources of dissatisfaction expressed in existing literature: rapid loss of interest, few housestaff-generated questions or input, and lack of focus and leadership. The apparent lack of leadership or educational focus seemed to be the primary problem. We suspected the presence of multiple faculty members (including a majority of subspecialist faculty) contributed to the apparent disorganization. Many of these faculty "contributed" anecdotes and lengthy discussions of their own subspecialty’s rare diagnoses, thus shifting focus away from more general teaching points. We anticipated confirmation of these findings via the survey but found instead that the current practice of including both generalists and subspecialists in case discussions was preferred, although a slight trend existed to favor general topics over subspecialty topics. Thus, our MR participants seemed to prefer a large group of "experts" providing didactic-style education, despite the fact that the larger group and its disparate subspecialties seem to contribute to the lack of focus, leadership, or promotion of housestaff involvement present in our MR sessions.
Overall, the survey results were surprising because they were contradictory to those results found in the literature and did not fulfill the expectations based on our initial qualitative survey. In addition, the results confirmed that both faculty and resident participants found the format, choice of educational topics, and focus of MR to be satisfactory, thus doing little to explain the source of dissatisfaction expressed by faculty and housestaff alike. A significant difference in perception of educational value of teaching sessions existed between housestaff and faculty, suggesting that faculty believed that MR was substandard as a teaching tool. In fact, housestaff believed that all department of pediatrics teaching sessions had greater value than did faculty. This finding is likely explained by the difference in expertise between faculty and housestaff: trainees might attach more educational value to information that would seem simple or self-evident to faculty. Because MR is a significant part of housestaff education, we assumed the faculty would be very interested in any attempt to improve it. It was surprising that we instead encountered significant resistance to our research-driven goals for improvement. The one result clearly suggestive of a potential intervention was the finding that most housestaff believed the leadership should be changed and supported the chief residents as preferred leaders (a role they supposedly already filled). Our goal to allow the chief residents to reassume the leadership duties and power that they already held seemed to be a very reasonable intervention, yet it was met with considerable opposition from faculty.
Additional review of the survey results by directed interviews did little to clarify the source of dissatisfaction. Not surprisingly, differences arose between faculty and housestaff regarding how rigorous MR should be, extent of case preparation, and extent of faculty versus housestaff involvement. The only intervention that clearly was supported by our results was to increase the leadership of MR, although the directed interviews suggested that more involvement should be expected of the housestaff as well.
These goals met with strong support from housestaff. However, the faculty opposition to change was surprising. Admittedly, our interventions directed faculty to relinquish control of a teaching session and limit their input until requested, 2 very difficult acts to perform. The faculty seemed unable to put aside their personal preferences for the "old way" regardless of the chance to improve the MR session for all involved. Despite this, the chief residents have become better facilitators and housestaff seem to be much more actively involved, asking questions and contributing to differential diagnoses. In short, the goals seem to be partially accomplished, although the faculty still find it hard to refrain from contributing at length.
We expected an improvement in perceived value after accomplishing our interventions. We found instead that the perceived value of MR dropped in the follow-up survey, despite improvements in satisfaction with MR. Several explanations can be offered for our findings. First, despite rigorous evaluation for the sources of dissatisfaction, we were never able to identify clearly those sources. Second, hopes for a complete "fix" may have been created by our study and interventions; inability to attain complete cure may have created additional dissatisfaction. Third, we likely raised awareness of the quality of our program’s teaching tools simply by analyzing them. Our program is a frequent recipient of College of Medicine teaching awards, and our faculty and housestaff are frequently recognized for their attention to improvements in the education process. Our investigation may have prompted faculty and housestaff to become more acutely aware of their lack of satisfaction with MR. Ironically, the strong departmental focus on education was not associated with a positive response to our data-driven interventions. However, additional study of our MR session may now be more successful in identifying specific factors that cause dissatisfaction because MR participants have been stimulated to think critically about their educational experience.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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We can make several conclusions on the basis of our results and experiences. First, examination of goals of and satisfaction with a teaching tool is difficult to accomplish when the study subjects are unfamiliar with such subjective analysis. This may be because subjects are unable to assess or identify accurately the sources of their discontent without some knowledge of the ideal educational format. Second, our MR session has a different format from that reported in the literature, and, contrary to our expectations, our faculty and housestaff prefer this format. We therefore cannot use the literature-driven expectations as the standard to which we compare our large, multispecialty conference. Third, despite our research efforts and creating reasonable interventions, our attempts to bring faculty to consensus failed, demonstrating the difficulties inherent in changing such an institution as MR. Thus, examination of MR goals and satisfaction by individual training programs should be conducted with attention to the format and history of each program’s educational conferences, without attempting to apply the expectations of literature-driven standards.
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FOOTNOTES |
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Received for publication Jan 30, 2003; Accepted Apr 11, 2003.
Reprint requests to (S.P.E.) University of Arizona Health Sciences Center, Department of Pediatrics, 1501 North Campbell Ave, Tucson, AZ 85724. E-mail: selliott{at}peds.arizona.edu
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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- Stockman JA III. The morning report [editorial].
Clin Pediatr.1997; 36
:589
–590
[Free Full Text] - Amin Z, Guajardo J, Wisniewski W, Bordage G, Tekian A, Niederman LG. Morning report: focus and methods over the past three decades. Acad Med.2000; 75 :S1 –S5[CrossRef][Web of Science][Medline]
- Ways M, Kroenke K, Umali J, Buchwald D. Morning report: a survey of resident attitudes.
Arch Intern Med.1995; 155
:1433
–1437
[Abstract/Free Full Text] - Gross CP, Donnelly GB, Reisman AB, Sepkowitz KA, Callahan MA. Resident expectations of morning report: a multi-institutional study.
Arch Intern Med.1999; 159
:1910
–1914
[Abstract/Free Full Text] - Demopoulos B, Pelzman F, Wenderoth S. Ambulatory morning report: an underutilized educational modality. Teach Learn Med.2001; 13 :49 –52[CrossRef][Web of Science][Medline]
- Barton LL, Rice SA, Wells SJ, Friedman AD. Pediatric morning report: an appraisal.
Clin Pediatr.1997; 36
:581
–583
[Abstract/Free Full Text] - Gerard JM, Friedman AD, Barry RC, Carney MJ, Barton LL. An analysis of morning report at a pediatric hospital.
Clin Pediatr.1997; 36
:585
–588
[Abstract/Free Full Text] - Parrino TA, Villanueva AG. The principles and practice of morning report.
JAMA.1986; 256
:730
–733
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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