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بي هام خدا Morning Report: A brief literature review OMR Or EBMR AMR MR OMR=outpatient MR AMR=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 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 3-Instructional Methods 4-Educational outcomes Area 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 goals 1-1- 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 keeping 5-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: 1 A Successful Format Arch Intern Med Vol 145,May 1985 :897-899 A 692-bed hospital in Texas USA Critical Features of an instructive Morning Report Format: 1-Internal monitoring system for content 2-Preconference determination of teaching points 3-Subspecialist participation 4-Orchestration by department chief 5-Inquisitive,nonconfronting environment 6-Timely review and update of prior cases 7-Generation of appropriate bibliographic materials 2 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 minutes) Phase two:Report of admissions During the preceding 24 hours. Report(10 minutes). 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. MR GBL H Rx.:Revisiting cases Outpatient MR Outpatient Morning Report: A New Educational Venue Definition onference for residents and medical students that is dedicated to the presentation and discussion of outpatient cases. History: 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. Pioneer: 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 problems 3-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 diseases 5-Exposes the trainees to curricular items such as medical economics ,evidence – based medicine, and interviewing skills وامابي هظر شما اساتيدگراهقدر ما چي کويم تا گزارش صبحگاًي بٌتري داشتي 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-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 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-Please do not be a “windbag” attending. 14-Invite proportionate number of generalists and subspecialtists 11-Invite pharmacist,radiologist,…to attend the MR. The bottom line is: Establishing the essential infrastructures In our climate is vital for the practicability of these guides. One of the most important and critical infrastructures is the establishment of a system based on: ى خيرا يرى ّفمن يعمل مثقال ذر ايرى ّ ّومن يعمل مثقال ذرى شر ّسٍرى الز 8لزال ايي 7و Part two : Papers on MR and their succinct messages: No.1 Title: The culture of Morning Report:Ethnography of a Clinical Teaching Conference Source: Southern Medical Journal June 1997,Vol.90,No.6 Message: In order to have a better MR: 1-Shorten it. 2-Rotate those in – charge. 3- Improve the quality . No.2 No.2 Title: A Bitter Pill:Attempting change in a Pediatric Morning Report Source: Pediatrics Vol.113 No.2 February 2004 Message: In order to have a better MR: 1-Return MR to a house-staff oriented session. 2-Increase chief resident leadership 3-N.B.Do not attempt to apply the expectations of literature-driven standards.That may not work! No.3 No.3 Title: Outpatient Morning Report:A New Educational Venue Source: Academic Medicine Vol.75,no.2 Februaury 2000 Message: Outpatient MR is a popular ,learner-centered venue were important curricular objectives are achieved. Format 1-one-hour 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 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. 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.4 No.4 Title: Outpatient Morning Report:A New Conference for Internal Medicine Residensy Progarms Source: J Gen Intern Med 2000;15 :822-824. Message: 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 Residency Programs Programs with 88(23.8%) outpatient MR Frequency of sessions 1-2 times /month 12(13%) 1time/week 35(40%) 2-5times/week 41(47%) Who attends the session? Attending physician 82(93%) Chief resident 59(67%) Resident 88(100%) Medical student 58(66%) Who leads the session? Attending physician 53(60%) Chief resident 40(45%) Resident 24(27%) Medical student 1(1%) Who chooses the cases? Attending physician 32(36%) Chief resident 32(36%) Resident 64(73%) Medical student 10(11%) Who presents the cases? Attending physician 20(23%) Chief resident 13(15%) Resident 85(97%) Medical student 17(19%) No.5 No.5 Title: Ambulatory Morning Report Source: J Gen Intern Med 2002;17 :207-209. Message: 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 clinics. No.6 No.6 Title: Resident Expectations of Morning Report A multi-Institutional Study Source: Arch Intern Med 1999;159 :1910-1914. Message: 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? Teaching methods What content should be discussed in the morning reports? Proportion of respondents rating each method as” Most Important”. No.7 No.7 Title:Morning Report Source: Annals of Internal Medicine Vol.119,Number 5 1993;159 :1910-1914. Message: 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 minutes Case presenttaion and review of relevant journal articles=35-45 minutes 3-Communication of goals 4-Enhancement of understanding and retention(take home message) 5-Evaluation and feedback 6-Self-directed learning No.8 No.8 Title: Pediatric Morning Report:An Appraisal Source: Clinical Pediatrics Oct 1997,Vol.36,Issue 10 Message: MR is diagnostically inaccurate and should not be seen as a free consultation.It should be utilized as an opportunity to develop problem solving skills. Revisiting cases is an important educational tool and should be integrated into MR format. No.9 No.9 Title: Morning Report in the Computer Era:Tradition meets technology Source: Medical Teacher Sep.1995,Vol.17 Issue 3 ,p.327-335. Message: 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. No. 10 Title: Evidence- Based Morning Report for Inpatient Pediatrics Rotations Source:Academic Medicine ,Vol.75,No.12 December 2000 Format: 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. No. 11 Title: An Analysis of Morning Report:Implications for Internal Medicine Education Source:Ann Intern Med.1993; 119:395-399. 6540 patients admitted 6540 patients admitted 294 diagnostic 36 management cases cases Diagnosis reached during MR Yes:76% No:24% 39% 25% 36% Dx. The same different Uncertain at follow-up 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. No. 12 Title: Determinants of Case Selection at Morning ReportJ Source: Gen Intern Med1997;12:263-266. 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.
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