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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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posted:10/19/2011
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