بي هام خدا
A brief literature review
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
Ann Intern Med.1995:155:1433-7.
Morning report:Focus and Methods
over the past three decades
Academic Medicine ,vol.75,No.10,October 2000
48 articles over 20 years.
The oldest article on MR was published in 1979.
80% of articles were published after 1990.
Just 52% of theses articles were based on studies.
Surveys and questionnaires were the most
frequently used tools to collect data.
Their major areas for review:
1-Purpose of MR
2-Organization of MR
Area 1 : Purposes:
1-Education(the main objective)
2- Evaluation of resident and quality of
services(attitudes,clinical skills and quality
3-Detection and reporting of adverse event
6-Better patient care
1-1- Case-based teaching (the most
1-2- Reviewing and planning patient
1-3- Fostering presentation skills
1-4- Developing intellectual curiosity
1-5- Promoting decision-making
1-6- Self-directed learning
Area 2 : Organization
2-Participants,leadership and tone
(morning distort! Morning retort!)
3-Case selection and presentation
Area 3: Instructional Methods
1-Sponge mode (passive learning;morning report
2-Search mode(self-directed scholarly inquiry).
case-based presentation was the
most frequent method.
There were two methods that deserves mentioning:
1-Format of Lawrence et al
2-Format of Reilly et al (evidence –based MR)
A Successful Format
Arch Intern Med Vol 145,May 1985 :897-899
A 692-bed hospital in Texas
Critical Features of an instructive
1-Internal monitoring system for content
2-Preconference determination of teaching
4-Orchestration by department chief
6-Timely review and update of prior cases
7-Generation of appropriate bibliographic
Evidence –based MR
A four-phase model of Reilly and lemon
Phase one:Report of search results from
the previous day(three reports over 15
Phase two:Report of admissions
During the preceding 24 hours.
Phase three:Detailed case
presentations (30 minutes)
Phase four:Formulating the new
questions for search and report on
the following day(final 5 minutes)
highlighted in MR’s:
Teaching in the MR is as a series of snapshots of inpatient
The continuity is often lacking and that educationally valuable
material is lost from the the inpatient Medicine service.
Outpatient Morning Report:
A New Educational Venue
onference for residents and medical students that is
dedicated to the presentation and discussion of
In 1995 ,Vanderbilt
of Medicine first
instituted the outpatient
morning report to meet
the needs of the
increasing number of
residents and medical
Malone Ml,Jackson Tc.
Educational characteristics of ambulatory morning report
J Gen Intern Med 1993;8:512-4
Advantages of Outpatient MR
1-Provides a locus to execute an outpatient
curriculum through case-based learning
2-Introduces learners to common medical
3-Allows residents and students who are
rotating in geographically different sites to
share their experience and learn from each
4-Exposes the trainees to natural history of
5-Exposes the trainees to curricular items such
as medical economics
,evidence – based medicine, and interviewing
وامابي هظر شما اساتيدگراهقدر
چي کويم تا گزارش صبحگاًي بٌتري داشتي
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
4-Definition of contribution of inpatient
versus outpatient cases presented in
5-Held an evidence-based search mode
MR.Try to develop the students’ ability
“to think on their feet” and solve
6-Do not held a morning distort or a
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-Develop log books , archives and
databases for MR to monitor
educational content ,to provide an
archive for review and study by
residents ,.. and to facilitate research
MR log book(helps to prevent
overrepetition and to ensure coverage of all
essential educational items and cases).
Develop database of
signs,laboratory data,DDX,final DX and a
review paper on each topic (this facilitates
search for researchers,provide subjects for
MR attendance log book.
10-Establish a fair rewarding
system(e.g.competition for the best
discussion of the faculty
11-Establish a regular ,valid and reliable
Evaluation of satisfaction level of
Quizzes(from the MR educational content)
Perform assessments to evaluate whether
MR contents succeed to meet the
educational needs of
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
13-Please do not be a “windbag”
14-Invite proportionate number of
generalists and subspecialtists
attend the MR.
The bottom line is:
Establishing the essential infrastructures
In our climate is vital for the practicability of
One of the most important and critical
the establishment of a system based on:
ى خيرا يرى ّفمن يعمل مثقال ذر
ّومن يعمل مثقال ذرى شر
8لزال ايي 7و
Part two :
Papers on MR and their
The culture of Morning Report:Ethnography of a Clinical
Source: Southern Medical Journal June 1997,Vol.90,No.6
In order to have a better MR:
2-Rotate those in – charge.
3- Improve the quality .
A Bitter Pill:Attempting change in a Pediatric
Source: Pediatrics Vol.113 No.2 February 2004
In order to have a better MR:
1-Return MR to a house-staff oriented
2-Increase chief resident leadership
3-N.B.Do not attempt to apply the
expectations of literature-driven
standards.That may not work!
Outpatient Morning Report:A New Educational
Source: Academic Medicine Vol.75,no.2
Outpatient MR is a popular
,learner-centered venue were
objectives are achieved.
2-Held four mornings each week
3-Facilitated by a faculty member in general internal
medicine or by chief resident
4-Participants are those residents and fourth-year
students ,who are taking part in ambulatory block
5-Every resident or medical student is assigned to
present a patient case at least once during the
6-Before MR ,the presenter enters the case into
Vanderbilt Outpatient Morning Report
Website(without revealing DX.).
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
9-The presenter adds the diagnosis and
handout information to the Web site to
archive learning points for future
Outpatient Morning Report:A New Conference for
Internal Medicine Residensy Progarms
Source: J Gen Intern Med 2000;15 :822-824.
The residents reported that the conference contributed
much to their education by meeting specific
Learning needs and covering topics not covered else
where in their residency training.
Characteristics of Outpatient MR
In US internal Medicine
Programs with 88(23.8%)
Frequency of sessions
1-2 times /month 12(13%)
Who attends the session?
Attending physician 82(93%)
Chief resident 59(67%)
Medical student 58(66%)
Who leads the session?
Attending physician 53(60%)
Chief resident 40(45%)
Medical student 1(1%)
Who chooses the cases?
Attending physician 32(36%)
Chief resident 32(36%)
Medical student 10(11%)
Who presents the cases?
Attending physician 20(23%)
Chief resident 13(15%)
Medical student 17(19%)
Ambulatory Morning Report
Source: J Gen Intern Med 2002;17 :207-209.
A general medicine clinic is capable of exposing house
staff to the wide breadth of internal medicine topics
previously thought to be unique to subspecialty
Resident Expectations of Morning Report
A multi-Institutional Study
Source: Arch Intern Med 1999;159 :1910-1914.
They expressed a desire for about 50% of the guest
attending physicians to be generalist .They preferred
a style in which challenging cases were presented in
a stepwise manner.
What teaching methods are preferred by residents?
What content should be discussed in the morning reports?
Proportion of respondents rating
each method as” Most Important”.
Source: Annals of Internal Medicine
Vol.119,Number 5 1993;159 :1910-1914.
These are the areas that they focus on them in MR:
1-Establishment of a positive learning climate
2-Control of the teaching session:
Review of Medical Knowledge Self-Assessment
Program Questions=10 minutes
Review of admitted patients,highlighting key
learning points and discussion of deaths=o-5
Case presenttaion and review of relevant journal
3-Communication of goals
4-Enhancement of understanding and retention(take
5-Evaluation and feedback
Pediatric Morning Report:An Appraisal
Source: Clinical Pediatrics
Oct 1997,Vol.36,Issue 10
MR is diagnostically inaccurate and
should not be seen as a free
consultation.It should be utilized as
an opportunity to develop problem
Revisiting cases is an important
educational tool and should be
integrated into MR format.
Morning Report in the Computer Era:Tradition meets technology
Source: Medical Teacher Sep.1995,Vol.17 Issue 3 ,p.327-335.
They present their experience and methods for
entering patient data into a computerized database
in order to construct an efficient searching tool with
indexing ,keyword and cross-referencing capabilities.
Evidence- Based Morning Report for Inpatient Pediatrics
Source:Academic Medicine ,Vol.75,No.12 December 2000
The first week session acquaints learners
,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
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.
After the rotation ,residents are more likely
to appropriately alter their beliefs when
exposed to strong contrary evidence than
they were before rotation.
An Analysis of Morning Report:Implications for Internal
Source:Ann Intern Med.1993;
294 diagnostic 36 management
Diagnosis reached during MR
25% 36% Dx.
The same different Uncertain
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.
Determinants of Case Selection at Morning ReportJ Source:
Gen Intern Med1997;12:263-266.
Cases were more likely to be
presented if they were:
1-unusual or rare in either or
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
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.