- Email: [email protected]
Morning report: Combining education with patient handover
REVIEW H. Sanfey B. Stiles T. Hedrick R. G. Sawyer
Department of Surgery University of Virginia Health System, Charlottesville, USA Correspondence to: Ms Hilary Sanfey, Professor of Surgery, PO Box 800709, Department of Surgery University of Virginia Health System, Charlottesville VA 22908 Tel: +1 434 982 441 Email: [email protected]
MORNING REPORT: COMBINING EDUCATION WITH PATIENT HANDOVER Introduction: The advent of resident work hour restrictions has challenged us to train residents within a shorter working week, while ensuring continuity of patient care. We instituted morning report (MR) at the University of Virginia primarily as a means to accomplish these objectives. Serendipitously MR has become an integral educational tool for the surgical residents. The rationale for the format and instructional design are discussed in the context of learning theory. Methods: The chief residents as primary stakeholders were strongly encouraged to play a leadership role in designing MR. A faculty- led didactic format was rejected because of the importance of focusing on resident team building, and leadership, but poor faculty participation was also an issue. Results: The initial obstacles included timing, and designing the format. Conclusions: MR is an opportunity for residents to exercise and improve their knowledge, leadership, presentation and problem-solving skills. We would hypothesise that the advantages for teaching are many and include that residents are prepared for actual clinical problems in a supportive environment with opportunities for immediate feedback and assessment. Reports of educational effectiveness of MR are mostly anecdotal and further studies are needed to characterise the types of learning and teaching that occur during MR and to document educational effectiveness. keywords: morning report, continuity of care Surgeon, 1 April 2008 94-100 INTRODUCTION The introduction of resident working hour restrictions in the USA has challenged educators to teach surgical residents within a shorter work week, while ensuring continuity of patient care. At the University of Virginia we instituted a morning report (MR) to facilitate handover of patient care between duty periods. Historically, MR was created to provide the chief of service with the information needed to oversee patient care in the hierarchical systems of public hospitals.1,2 The term ‘morning report’ is used to describe case based conferences where physicians meet to present and discuss clinical cases. It is ubiquitous across primary care and internal medicine residency programmes, but has not been well described in surgery programmes.1-19 The purpose has evolved over the years to include resident education, evaluation, detection of adverse events and discussion of non-medical issues.1,20,21 In this paper we will describe how MR was introduced in our department to facilitate handover of patient
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care and serendipitously provided an opportunity for residents to develop their leadership and teaching skills. BACKGROUND MR participants frequently report that the format is not conducive to learning; students may be afraid to waste time or delay presentations by asking questions, many teaching opportunities are lost and the environment has been described as hostile, intimidating and threatening.22 -25 Comments such as morning ‘retort’ or ‘distort’ appear frequently in the literature.24,25 In addition, the unpredictable nature of the cases discussed impeded the residents’ ability to prepare material ahead of time.1,23 Organisational characteristics such as frequency, timing and duration are similar in other institutions (Table 1). However Elliott et al. noted that participants seemed to prefer a large group of ‘experts’ providing didactic style education, © 2008 Surgeon 6; 2: 94-100
Table 1. Organisation of morning report: literature summary from Amin et al.1 Source
Time
Amin et al.
Participants, leadership, tone
Case selection
Records kept
Follow-up
80% held daily 50% Chief of Usually 9.00am medicine present Mostly third year residents (60% rst year attendance) Preference for generalists Presentations were factual with rare synthesis Led by faculty (70%), chief resident (30%)
Varied from all to interesting only Inpatient (88%)
Occasionally for resident evaluation
Inconsistent although 28–58% of cases did not have a diagnosis at presentation
UVA preintervention
6.30am to 7.00am
Surgery residents, medical students and faculty No clear leadership
All surgical admissions/ consults from previous 24 hours
No
Inconsistent
UVA post– intervention
6.30am to 7.00am
Surgery residents, medical students, faculty Led by post-call chief resident
All surgical admissions/ consults from previous 24 hours, with focus on teachable cases Literature search
No
Yes, if diagnosis unclear at presentation
contradictory to those results found in the literature.1,12,26 In contrast to core curriculum lectures, in which learning is generally passive, MR can provide a forum for active learning through group discussions about interesting cases, diagnostic and management dilemmas and other relevant issues. Participants are asked to identify additional data that they would find helpful, and then become involved in a realistic reconstruction of the dilemmas facing the admitting team. In this way, hypotheses are generated and tested in an iterative manner and clinical problem-solving skills are fostered. Designing morning report In designing the MR, we built upon the format postulated by Reilly and Lemon (Table 2).23 This model is unique in that it is based on sound educational theory and encourages active learning. In our institution, MR occurs daily from 6.30 to 7.00am and is attended by medical students (20–30), residents (20–30), and a small number of interested faculty (2–4). The post-call third year resident presents a brief summary of all cases admitted and consultations obtained during the previous 24 hours. The residents identify cases worthy of more detailed discussion prior to MR and perform a brief literature search using a selection of photographs and appropriate x-rays to highlight teaching points. The third year resident presents the case while the chief resident moderates discussion of pertinent clinical, laboratory and radiological findings, and asks © 2008 Surgeon 6; 2: 94-100
Research Patient care Quality assurance
appropriate ‘what would you do next’ questions to the audience, beginning with the medical students and working up through the hierarchy. Case presentations are structured to build upon prior learner knowledge. Finally, follow-up is provided on cases discussed during previous meetings, if the diagnosis was incomplete or new information has been obtained. When time permits, pertinent MCQs are presented in preparation for the surgery board examinations. The goals of this instructional design are to structure knowledge in a clinical context to facilitate resident development of problem-solving and self-directed learning skills, as well as to provide intrinsic motivation through the use of group dynamics. These objectives were extrapolated from those proposed for problem based learning by Barrows and are summarised in Table 3. Content specific learning objectives were prohibited by the unpredictable nature of the cases to be presented. The current design provided an opportunity to cover all six competencies Accreditation Council for Graduate Medical Education of:27,28 • medical knowledge • patient care • interpersonal skills and communication • professionalism • systems based practice • practice based learning.
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Table 2. Reilly and Lemon model for morning report
Phase 1
Reilly and Lemon model (1 hour)
University of Virginia (30 minutes)
Search report of literature based on previous day’s case
List admissions and consults
Phase 2 Review of admissions log
Detailed discussion of ‘interesting’ cases
Phase 3
Review of radiological ndings
Detailed case presentations
Phase 4 Formulating the search for the next day
Patient handover, review of teaching points with literature search Follow-up on previous day’s cases
The use of group learning and of formative evaluations of explicit objective-based outcomes allows for early intervention and correction of error or misunderstanding. Discussions may lead to learners seeking out more evidence if there is disagreement, although there is a risk that tired post-call residents may not see the benefit to seek out the information.29 These higher levels of intrinsic interest could positively influence the way one practises medicine and how self-directed learning is approached. Rationale for resident led format We chose to adopt a resident-led as opposed to the more didactic attending-led format, often preferred in internal medicine programmes, in order to encourage resident teaching and leadership skills. This decision was also taken in part because of the timing of MR. Since MR began at 6.30am, much of the planning was done during the night shift when faculty were less readily available for discussion on non-urgent issues. It is not an easy task, even for an experienced educator, to extemporaneously identify and exploit several ‘teachable moments’ per session. Having the post-call resident (who had seen and examined the patients) prepare and present the cases, and develop the management plan, has a number of educational advantages congruent with the principles of adult learning. By having a concrete experience (admitting and examining the patient), the opportunity to reflect (preparing the case for presentation), actively presenting the case and then reflecting on this experience will complete all steps of the Kolb cycle.30-32 Planning for application (scheduling a patient for surgery) prepares the learner to move from active experimentation back to concrete experience. To promote learning, the teacher presents new information so that it fits within the learners’ existing conceptual frameworks. Through open-ended questions and dialogue, teachers attend to their learners’ cognitive frameworks and determine if there is any transfer effect such as prior knowledge interfering with or influencing new learning. Teachers provide ongoing formative feedback to assist learners revise their understanding (key to cognitivist theory) and then facilitate learning by helping learners readjust their thinking and by pushing their understanding depending on the learner’s performance.33 This promotes independent problem solving. The higher level motivating factors of self-esteem and self-actualisation determine whether what is taught or experienced results in learning.34 Finally, by participating actively, students develop an ability to ‘think on their feet’ and solve problems, important attributes of the general surgeon.35-37 96
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Table 3. Morning report objectives Objective
Advantage
Supporting theory
Structuring knowledge for use in clinical contexts
Facilitate learning in context of future tasks building on past knowledge Learning driven by challenge of practice
Spiral curriculum (Bruner) Experiential (Dewey) Gagne’s conditions of learning (hierarchy of
and integrated into clinical reasoning
sequencing instruction) Zone of proximal development (Vygotsky)
Development of effective clinical reasoning process
Shape and perfect problemsolving skills through repeated practice and feedback
Instructional alignment Feedback is key to guide and support learner Practice improves retention
Development of effective selfdirected learning skills and learning needs
Allows student to locate and use appropriate information resources
Reect in action and on action (Schon)
Increased motivation for learning
Motivation enhances Motivate through self efcacy (Bandura) of student learning self-esteem and selfactualisation (Maslow)
Resident as teacher Studies have shown that residents contribute substantially to the education and clinical training of medical students and that the knowledge and professional competency of residents correlate positively with their perceived teaching abilities.38,40,42 Surprisingly, therefore, training in teaching, and frequent and constructive feedback in teaching are lacking in most educational settings.41 MR could be a unique platform for residents to improve their teaching skills and confidence. Apker et al. noted that MR involves a highly public display of professional identity expectations.43 Case presentations turn into self-presentations as residents develop skills and strategies ascribed to the role of doctor in front of an evaluative audience.44 The participative nature necessarily involves residents in discussion so that the faculty can evaluate their case knowledge, mastery of medical information and clinical skills.43 The goal is for residents to solve a case, gather relevant information, challenge theories and decisions and defend their own perspective. By interacting with peers and role models residents learn the culture of medicine and how to develop their professional identities within it.43 MR allows house staff and attending physicians to interact in an intellectually stimulating and comfortable environment, and is an important setting in which residents encounter potential role models. Rationale for instructional design Gagne has described the arrangement of nine specific instructional events to achieve optimum learning outcomes. These consist of learner and teacher activities and are summarised in Table 4.45-47 The first three (gaining attention, informing the learner of the objectives and stimulating recall) collectively prepare the
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Table 4. Gagne conditions for learning (from Dent & Harden)49 Preparation for learning Gaining attention
Informing learners of objectives
Stimulating recall of prior learning
Teacher
Student
Learning phase
Provokes interest by statement/ questions
Tunes into correct wavelength
Attending
Case presentation provides resident with stimulus
Claries objectives and direction
Recalls relevant prior knowledge
Expectancy
Resident informed of objective, e.g. to make a diagnosis in a patient with abdominal pain
Refers to earlier relevant learning and indicates links with new topic
Starts to create ideational scaffolding
Retrieval
Residents prompted to relate what was previously learnt to case
Acquisition and performance Presenting the content
Providing learner guidance
Teacher
Student
Learning phase
Instructional event
Concepts and principles presented in organised, structured way
Builds up knowledge structure
Selective perception of stimulus features
Attending draws attention to key points
Explanations provided
Exercises thinking abilities to work things out, nd meaning, and build links between ideas
Semantic coding
Attending explains why key points are relevant to patient care
Tries to envisage how the new knowledge can be applied
Retrieval and responding
Links suggested back to other subjects/ projected to application
Team engages in discussion
Transfer of learning Elicits performance Provides feedback Assesses performance Enhances transfer Teacher
Student
Learning phase
Instructional event
Checks that students have learnt what was supposed to have been learnt
Responds to questions by checking his/ her understanding
Reinforcement
Attending restates major teaching points
Provides corrective/ supplementary guidance
Corrects misunderstanding
Cueing retrieval
Residents prompted to explain what has been taught
Conrms that teaching has taken place
Monitors understanding (metacognition)
Summarises and encourages thinking about application
Thinks about how knowledge can be applied
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Residents prompted to self-assess/ feedback Generalisation
learner for instruction. The next two (presenting the information and providing learner guidance) are the core of the teaching/ learning process and are designed to help the student understand the topic. The final four events, eliciting performance, providing feedback, assessing performance, and enhancing transfer, give the student the opportunity to check and enhance learning, correct misunderstanding and think about how knowledge can be applied in other contexts. The MR case presentation provides a stimulus for learning and sets the stage for contextual learning. The ensuing discussion and teaching points can potentially impact the learner’s understanding of patient related issues and foster a new perspective of how illnesses progress. The incorporation of key and relevant radiological findings encourages abstraction and conceptualisation, both important phases of experiential learning.48 There is dialogue between the team members and the attending reinforces the teaching points. However, 30 minutes is limited time for reflection, discussion of ethical issues, professionalism, self-directed learning and humanism. Hopefully, the faculty members model some of these behaviors. This instructional design was based on the general principles of Kern et al. in that we employed multiple educational methods and instructional strategies (cases, visual aids, some didactic and question and answer sessions) to provide opportunities for learners with diverse learning and cognitive styles to gather and organise information.49 Each case presentation was sequenced to take learners through the Kolb learning cycle to promote experiential learning. Cooperative learning was emphasised to enhance understanding and improve communication skills through reciprocal peer-teaching.50 The key elements of the instructional design and method of implementation are summarised in Table 5. Table 6 summarises the design based on the Stanford Faculty Development Model.51 OUTCOME MEASURES It is too soon to say whether or not the goals and objectives have been achieved. Potential outcome measures will include resident assessment, programme evaluation and overall determination of improved learner satisfaction. While the faculty assesses the residents during MR, this assessment is part of the global assessment and not a separate entity. Therefore, MR provides only a small sample of the data used by faculty to assess the residents. The most important characteristics of a welldesigned assessment procedure are validity and reliability.52 Both require clearly defined learning outcomes, a representative sample of instructionally relevant tasks and a sound scoring system. Performance based assessment could be undertaken during MR using an oral examination format; however, standardisation requires that each resident (examinee) be exposed to equivalent tasks, under equivalent conditions and with objective scoring. This would be impossible with unpredictable content (case selection dictated by admissions). In addition, for reasons that defy a scientific explanation, certain residents are ‘black clouds’ and appear to invite a deluge of critically ill patients. If we assume that the purpose of the assessment is not primarily to assess factual knowledge, but rather to evaluate a more general goal of clinical reasoning, then content under-representation becomes less of an issue. Scoring could be addressed by the development of strict scoring criterion checklists related to broad case scenarios, for example management of a trauma patient or a patient with abdominal pain. Presenter anxiety could be a threat to validity in this situation as in oral examinations.53-54 In addition, where the assessor has prior knowledge of the other (as in this situation), this introduces a potential bias. We the royal colleges of surgeons of edinburgh and ireland | 97
Table 5. Key elements of the instructional design process Instructional problems
Learner characteristics
Task analysis
Instructional objectives
Content sequencing
Instructional strategies
Designing the message
Development of instruction
Evaluation of instruments
1.Needs assessment 2.Goal analysis 3.Performance analysis
Learner
Topic Case Critical incident
Attitude Skills Cognitive Metacognitive
Learning related World related Concept related Content expertise Task expertise
Recall Integration Organisation Elaboration Examples/ technique Media Level of concreteness/abstraction Grouping Learner control Reinforcement
Pre-test Objectives Overview Advance organizer Signals Pictures
Concrete Step size Pacing Consistency Cues
Formative Summative Conrmative
Case presentation X-ray evaluation Pathology from teaching les
Presentation Analysis Key points Feedback
Didactic followed by Q and A
Continuous formative feedback
analysis Cognitive Physiological Affective Social Entry competencies Contextual analysis Orienting Instructional Transfer
Method(s) by which key elements were addressed in morning report Survey and direct observation
Individual characteristics not specically identied
Case
Attitudes Skills Cognitive Metacognitive
Chief resident dened core content
Key points reinforced by attending
Table 6. Stanford Faculty Development Model53 Learning climate
Supportive, respectful, conducive to learning
Call residents by name, avoid humiliation, top down questioning
Control of session
Assign responsibility
Avoid lengthy diatribes or sidetracking
Communication of goals
Set expectations
Chief resident assigns roles at onset
Promote understanding and retention
Level specic questioning and encourage synthesis
Evaluation
Conrm ndings
Feedback
Use teachable moment
Promote self-directed learning
Encourage self study
hope that although our instructional design did not teach students self-assessment per se, the resident led hands-on approach together with formative feedback will serve to foster self-esteem and self-efficacy, two attributes linked to deeper learning.55 Reliability refers to the consistency or reproducibility of outcomes over time and is a characteristic of the results or outcomes and not of the measuring instrument itself.56 Performance assessment under the conditions described for MR poses challenges to reliability analysis because of a lack of case specificity and violation of the assumption of local independence.56-58 Performance on one case may not predict performance on other similar cases or rater ratings of a case may be different over time (intra-observer), by learner or by rater (‘hawk’ or ‘dove’), and, as such, each of these impact consistency and therefore reliability. One effort to estimate the variance of these variables is to use generalisability theory analysis to calculate the generalisability coefficient.59 Such a coefficient properly estimates the sources of measurement error variance simultaneously and thus estimates how consistently our results can be generalised. However, one statistical assumption of all reliability analyses is that items are independent of each 98
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Provide follow-up Ensure follow-up other. In a clinical case where items are actually linked, this creates a problem. Therefore we will almost certainly not use resident performance assessment in MR independently of our global resident assessment. Programme evaluation The lack of studies to document the effectiveness of MR may be due to the difficulties of doing research in the context of the diverse purpose, content and audience involved in MR. It is also difficult to isolate the effects of MR from those of other formal and informal educational activities. Finally, the lack of validated assessment instruments compounds the difficulty. These difficulties should not be seen as insurmountable obstacles but as challenges to be met. Our data suggest that MR is an effective educational tool.22 As a direct result of stimulating the chief residents to play a leadership role in improving the educational focus of MR, a number of other educational projects have been undertaken. In addition, the medical students have nominated a record number of our surgery residents (7/28 or 25%) this year for institutional teaching awards. Finally, this conference has been shown to enhance resident education.60
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CONCLUSIONS The advent of resident work hour restrictions has challenged us to train residents within a shorter work week, while ensuring continuity of patient care. We instituted MR primarily as a means to improve continuity of patient care. The initial obstacles included timing, setting this as a priority and designing the format. The chief residents as primary stakeholders were strongly encouraged to play a leadership role in designing MR. Serendipitously, MR has become an integral educational tool for the surgery residents at our institution, while also ensuring continuity of patient care. It is an opportunity for residents to exercise and improve their knowledge, leadership, presentation and problem-solving skills. A faculty led didactic format was rejected because of the importance of focusing on resident team building and leadership, but poor faculty participation was also an issue. The lack of interest from the faculty may be because MR is not a traditional educational venue in surgical programmes or the 6.30am start may have been a disincentive. Reports of educational effectiveness of MR are mostly anecdotal and further studies are needed to characterise the types of learning and teaching that occur during MR and to document educational effectiveness. This presents unique methodological challenges, including the objective measurement and verification of study outcomes and the potential biases introduced by the Hawthorne effect, crosscontamination of study groups and unintended co-interventions. We would hypothesise that the advantages for teaching are many and include that residents are prepared for actual clinical problems in a supportive environment with opportunities for immediate feedback and assessment.
Copyright © 1 April 2008 REFERENCES 1. Amin Z, Guajardo J, Wisniewski W et al. Morning report: focus and methods over the past three decades. Acad Med 2000; 75(10 Suppl): S1-5 2. Parrino TA. The social transformation of medical morning report. J Gen Intern Med 1997; 12: 352-3 3. Barton LL, Rice SA, Wells SJ et al. Pediatric morning report: an appraisal. Clin Pediatr 1997; 36(10): 581-83 4. Bassiri A, Kassen BO, Mancini GB. Improving the format of morning report. Acad Med 1995; 70: 343-43 5. Carruthers A. General practitioner participation in ‘Morning Report’ at a major teaching hospital. Australian Family Physician 1997; 26 Suppl 2: S96-98 6. D’Alessandro DM. Documenting the educational content of morning report. Arch Pediatr Adolesc Med 1997; 151(11): 1151-56 7. D’Alessandro DM, D’Alessandro MP. Radiologic education of pediatric residents during morning report. Acad Radiol 1997; 4(7): 534-38 8. D’Alessandro DM, Qian F. Do morning report format changes affect educational content? Med Educ 1999; 33(9): 648-54
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9. Durning SJ, Sweet JM, Cation LJ. Morning Report: an analysis of curricular content and comparison to national guidelines. Teach Learn Med 2003; 15(1): 40-4 10. Gerard JM, Friedman AD, Barry RC et al. An analysis of morning report at a pediatric hospital. Clin Pediatr 1997; 36(10): 585-88 11. Hill RF, Tyson EP, Riley HD Jr. The culture of morning report: ethnography of a clinical teaching conference. South Med J 1997; 90(6): 594-600 12. Parrino TA, Villanueva AG. The principles and practice of morning report. JAMA 1986; 256(6): 730-33 13. Reisman AB, Gross CP. Gender differences in the ability to identify a mentor at morning report: a multi-institutional survey. Teach Learn Med 2002; 14(4): 236-39 14. Schwartz A, Hupert J, Elstein AS et al. Evidence-based morning report for inpatient pediatrics rotations. Acad Med 2000; 75(12): 1229 15. Solet DJ, Norvell JM, Rutan GH et al. Lost in translation: challenges and opportunities in physician–to-physician communication during patient handoffs. Acad Med 2005; 80(12): 1094-99 16. Spickard A 3rd, Hales JB, Ellis S. Outpatient morning report: a new educational venue. Acad Med 2000; 75(2): 197 17. Ways M, Kroenke K, Umali J et.al. Morning report: a survey of resident attitudes. Arch Intern Med 1995; 155: 1433-37 18. Welsh CH, Pedot R, Anderson RJ. Use of morning report to enhance adverse event detection. J Gen Intern Medn 1996; 11(8): 454-60 19. Wenderoth S, Pelzman F, Demopoulos B. Ambulatory morning report: can it prepare residents for the American Board of Internal Medicine Examination? Journal of General Internal Medicine 2002; 17(3): 207-9 20. Gross CP, Donnelly GB, Reisman AB et al. Resident expectations of morning report: a multi-institutional study. Arch Intern Med 1999; 159(16): 1910-14 21. Mehler PS, Kaehny WD, Fraser V et al. Clinical effect of morning report. Acad Med 1993; 68: 547 22. Stiles BM, Reece TB, Hedrick TL et al. General surgery morning report: a competency-based conference that enhances patient care and resident education. Curr Surg 2006, 63(6): 385-90 23. Reilly B. Lemon M. Evidence-based morning report: a popular new format in a large teaching hospital. Am J Med 1997; 103(5): 419-26 24. Brancati F. Morning distort. JAMA 1991; 266: 1627 25. McGaghie WC, Engel JD, Wolf K et al. Morning report: a descriptive view from two different settings. Res Med Educ 1985; 24: 157 –62
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26. Elliott SP, Ellis SC. A bitter pill: attempting change in a pediatric morning report. Pediatrics 2004; 113(2): 243-47 27. Barrows HS. A taxonomy of problem based learning methods. Med Educ 1986; 20: 481-86 28. Accreditation Council for Graduate Medical Education. http://www.acgme.org/outcome/comp/ compHome.asp. Accessed 2/7/06 29. Dolmans DHJM, De Grave W, Wolfhagen IHAP et al. Problem based learning: future challenges for educational practice and research. Med Educ 2005; 39: 732-41 30. Gelula M. M. Kolb’s Learning Style Inventory and Experiential Learning Cycle. MPHE: 2003, 502 31. Kolb D. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs: Prentice-Hall, 1984 32. Schon D. The Reective Practitioner. San Francisco, CA: Jossey-Bass, 1983 33. Vygotsky LS. Mind in Society. Cambridge: Harvard University Press, 1978 34. Maslow AH, A theory of human motivation. Psychol Rev 1943. 50: 370-96 35. Bateman W. Open to Question. San Francisco: Jossey-Bass, 1990: 15-16 36. Cotton J. The Theory of Learning Strategies: an Introduction. Philadelphia: Kogan Page, 1995: 19: 113-14 37. Morgan R, Ponticell J, Gordon E. Enhancing Learning in Training and Adult Education. Westport: Praeger, 1998: 15-16 38. Barrow MV. Medical students’ opinions of the house ofcer as a medical educator. Jr Med Educ 1996; 41: 807-10 39. Busari JO, Prince KA, Scherpbier AJ et al. How residents perceive their teaching role in the clinical setting-a qualitative study. Med Teach 2002; 24: 57-61 40. Busari JO, Scherpbier AJ. Why residents should teach: a literature review. J Postgrad Med 2004; 50: 205-10 41. Steward DE, Feltovich PJ. Why residents should teach; the parallel processes teaching and learning. In: Edwards JC, Marier RL, eds. Clinical Teaching for Medical Residents, Roles, Techniques and Programs. New York: Springer-Verlag, 1988: 3-14 42. Remmen R, Denekens J, Scherpbier AJ et al. An evaluation study of the didactic quality of clerkships. Med Educ 200; 34: 460-64 43. Apker J, Eggly S. Communicating professional identity in medical socialization: considering the ideological discourse of morning report. Qual Health Res 2004; 14(3): 411-29 44. Arluke A. Roundmanship: inherent control on a medical teaching ward. Soc Sci Med 1978; 14: 297-302
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45. Gredler M.G. Learning and Instruction. Theory into Practice. Columbus: Pearson Merrill Prentice Hall 2005 46. Anspach RR. The language of the case presentation. In: Conrad P, Kern R eds. The sociology of Health and Illness: Critical Perceptions. 3rd ed. New York St Martins, 1990: 319-38 47. Dent L, Harden R. A Practical Guide for Medical Teachers. Oxford, Elsevier: 2005 48. Svinicki MD, Dixon NM. The Kolb model modied to classroom activity. Coll Teach 35(4): 141-46 49. Kern DE, Thomas PA, Howard DM et al. Step 3: goals and objectives. Curriculum development for Medical Education. A Six-step Approach. John Hopkins University Press. Baltimore, 1998: 29 50. Krych AJ, March CN, Bryan RE et al. Reciprocal peer teaching: students teaching students in the gross anatomy laboratory. Clin Anat 2005; 18: 296-301 51. Litzelman DK, Stratos GA, Marriott DJ, Skeff KM. Factorial validation of a widely disseminated educational framework of evaluating clinical teachers. Acad Med 1998; 73: 688-95 52. Gronlund NE. Assessment of student achievement. Boston: Allyn and Bacon, 1968 53. Guerin RO. Disadvantages to using the oral examination. In: Marcell EL, Bashook PG, eds. Assessing Clinical Reasoning: the Oral Examination and Alternative Methods. Evanston: American Board of Medical Specialties, 1995: 41-8 54. Davis MH. The place of oral examination in today’s assessment systems. Med Teach 2005; 27: 294-97 55. Williams SM. Putting case-based instruction into context: examples from legal and medical education. J Learn Sci 1992; 2(4): 367-427 56. Downing SM. Reliability: on the reproducibility of assessment data. Med Educ 2004; 38: 1006-12 57. Downing SM. Validity: on the meaningful interpretation of assessment data. Med Educ 2003; 37: 30-7 58. Downing SM, Haladyna TM. Validity threats: overcoming interference with proposed interpretations of assessment data. Med Educ 2004; 38: 327-33 59. Crossley J, Davies H, Humphris G et al. Generalisability: a key to unlock professional development. Med Educ 2002; 36: 972-78 60. Stiles B, Reece TB, Hedrick T et al. General surgery morning report: a competency-based conference that enhances patient care and resident education. Curr Surg 2006; 63(6): 385-90
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Department of Surgery University of Virginia Health System, Charlottesville, USA Correspondence to: Ms Hilary Sanfey, Professor of Surgery, PO Box 800709, Department of Surgery University of Virginia Health System, Charlottesville VA 22908 Tel: +1 434 982 441 Email: [email protected]
MORNING REPORT: COMBINING EDUCATION WITH PATIENT HANDOVER Introduction: The advent of resident work hour restrictions has challenged us to train residents within a shorter working week, while ensuring continuity of patient care. We instituted morning report (MR) at the University of Virginia primarily as a means to accomplish these objectives. Serendipitously MR has become an integral educational tool for the surgical residents. The rationale for the format and instructional design are discussed in the context of learning theory. Methods: The chief residents as primary stakeholders were strongly encouraged to play a leadership role in designing MR. A faculty- led didactic format was rejected because of the importance of focusing on resident team building, and leadership, but poor faculty participation was also an issue. Results: The initial obstacles included timing, and designing the format. Conclusions: MR is an opportunity for residents to exercise and improve their knowledge, leadership, presentation and problem-solving skills. We would hypothesise that the advantages for teaching are many and include that residents are prepared for actual clinical problems in a supportive environment with opportunities for immediate feedback and assessment. Reports of educational effectiveness of MR are mostly anecdotal and further studies are needed to characterise the types of learning and teaching that occur during MR and to document educational effectiveness. keywords: morning report, continuity of care Surgeon, 1 April 2008 94-100 INTRODUCTION The introduction of resident working hour restrictions in the USA has challenged educators to teach surgical residents within a shorter work week, while ensuring continuity of patient care. At the University of Virginia we instituted a morning report (MR) to facilitate handover of patient care between duty periods. Historically, MR was created to provide the chief of service with the information needed to oversee patient care in the hierarchical systems of public hospitals.1,2 The term ‘morning report’ is used to describe case based conferences where physicians meet to present and discuss clinical cases. It is ubiquitous across primary care and internal medicine residency programmes, but has not been well described in surgery programmes.1-19 The purpose has evolved over the years to include resident education, evaluation, detection of adverse events and discussion of non-medical issues.1,20,21 In this paper we will describe how MR was introduced in our department to facilitate handover of patient
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care and serendipitously provided an opportunity for residents to develop their leadership and teaching skills. BACKGROUND MR participants frequently report that the format is not conducive to learning; students may be afraid to waste time or delay presentations by asking questions, many teaching opportunities are lost and the environment has been described as hostile, intimidating and threatening.22 -25 Comments such as morning ‘retort’ or ‘distort’ appear frequently in the literature.24,25 In addition, the unpredictable nature of the cases discussed impeded the residents’ ability to prepare material ahead of time.1,23 Organisational characteristics such as frequency, timing and duration are similar in other institutions (Table 1). However Elliott et al. noted that participants seemed to prefer a large group of ‘experts’ providing didactic style education, © 2008 Surgeon 6; 2: 94-100
Table 1. Organisation of morning report: literature summary from Amin et al.1 Source
Time
Amin et al.
Participants, leadership, tone
Case selection
Records kept
Follow-up
80% held daily 50% Chief of Usually 9.00am medicine present Mostly third year residents (60% rst year attendance) Preference for generalists Presentations were factual with rare synthesis Led by faculty (70%), chief resident (30%)
Varied from all to interesting only Inpatient (88%)
Occasionally for resident evaluation
Inconsistent although 28–58% of cases did not have a diagnosis at presentation
UVA preintervention
6.30am to 7.00am
Surgery residents, medical students and faculty No clear leadership
All surgical admissions/ consults from previous 24 hours
No
Inconsistent
UVA post– intervention
6.30am to 7.00am
Surgery residents, medical students, faculty Led by post-call chief resident
All surgical admissions/ consults from previous 24 hours, with focus on teachable cases Literature search
No
Yes, if diagnosis unclear at presentation
contradictory to those results found in the literature.1,12,26 In contrast to core curriculum lectures, in which learning is generally passive, MR can provide a forum for active learning through group discussions about interesting cases, diagnostic and management dilemmas and other relevant issues. Participants are asked to identify additional data that they would find helpful, and then become involved in a realistic reconstruction of the dilemmas facing the admitting team. In this way, hypotheses are generated and tested in an iterative manner and clinical problem-solving skills are fostered. Designing morning report In designing the MR, we built upon the format postulated by Reilly and Lemon (Table 2).23 This model is unique in that it is based on sound educational theory and encourages active learning. In our institution, MR occurs daily from 6.30 to 7.00am and is attended by medical students (20–30), residents (20–30), and a small number of interested faculty (2–4). The post-call third year resident presents a brief summary of all cases admitted and consultations obtained during the previous 24 hours. The residents identify cases worthy of more detailed discussion prior to MR and perform a brief literature search using a selection of photographs and appropriate x-rays to highlight teaching points. The third year resident presents the case while the chief resident moderates discussion of pertinent clinical, laboratory and radiological findings, and asks © 2008 Surgeon 6; 2: 94-100
Research Patient care Quality assurance
appropriate ‘what would you do next’ questions to the audience, beginning with the medical students and working up through the hierarchy. Case presentations are structured to build upon prior learner knowledge. Finally, follow-up is provided on cases discussed during previous meetings, if the diagnosis was incomplete or new information has been obtained. When time permits, pertinent MCQs are presented in preparation for the surgery board examinations. The goals of this instructional design are to structure knowledge in a clinical context to facilitate resident development of problem-solving and self-directed learning skills, as well as to provide intrinsic motivation through the use of group dynamics. These objectives were extrapolated from those proposed for problem based learning by Barrows and are summarised in Table 3. Content specific learning objectives were prohibited by the unpredictable nature of the cases to be presented. The current design provided an opportunity to cover all six competencies Accreditation Council for Graduate Medical Education of:27,28 • medical knowledge • patient care • interpersonal skills and communication • professionalism • systems based practice • practice based learning.
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Table 2. Reilly and Lemon model for morning report
Phase 1
Reilly and Lemon model (1 hour)
University of Virginia (30 minutes)
Search report of literature based on previous day’s case
List admissions and consults
Phase 2 Review of admissions log
Detailed discussion of ‘interesting’ cases
Phase 3
Review of radiological ndings
Detailed case presentations
Phase 4 Formulating the search for the next day
Patient handover, review of teaching points with literature search Follow-up on previous day’s cases
The use of group learning and of formative evaluations of explicit objective-based outcomes allows for early intervention and correction of error or misunderstanding. Discussions may lead to learners seeking out more evidence if there is disagreement, although there is a risk that tired post-call residents may not see the benefit to seek out the information.29 These higher levels of intrinsic interest could positively influence the way one practises medicine and how self-directed learning is approached. Rationale for resident led format We chose to adopt a resident-led as opposed to the more didactic attending-led format, often preferred in internal medicine programmes, in order to encourage resident teaching and leadership skills. This decision was also taken in part because of the timing of MR. Since MR began at 6.30am, much of the planning was done during the night shift when faculty were less readily available for discussion on non-urgent issues. It is not an easy task, even for an experienced educator, to extemporaneously identify and exploit several ‘teachable moments’ per session. Having the post-call resident (who had seen and examined the patients) prepare and present the cases, and develop the management plan, has a number of educational advantages congruent with the principles of adult learning. By having a concrete experience (admitting and examining the patient), the opportunity to reflect (preparing the case for presentation), actively presenting the case and then reflecting on this experience will complete all steps of the Kolb cycle.30-32 Planning for application (scheduling a patient for surgery) prepares the learner to move from active experimentation back to concrete experience. To promote learning, the teacher presents new information so that it fits within the learners’ existing conceptual frameworks. Through open-ended questions and dialogue, teachers attend to their learners’ cognitive frameworks and determine if there is any transfer effect such as prior knowledge interfering with or influencing new learning. Teachers provide ongoing formative feedback to assist learners revise their understanding (key to cognitivist theory) and then facilitate learning by helping learners readjust their thinking and by pushing their understanding depending on the learner’s performance.33 This promotes independent problem solving. The higher level motivating factors of self-esteem and self-actualisation determine whether what is taught or experienced results in learning.34 Finally, by participating actively, students develop an ability to ‘think on their feet’ and solve problems, important attributes of the general surgeon.35-37 96
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Table 3. Morning report objectives Objective
Advantage
Supporting theory
Structuring knowledge for use in clinical contexts
Facilitate learning in context of future tasks building on past knowledge Learning driven by challenge of practice
Spiral curriculum (Bruner) Experiential (Dewey) Gagne’s conditions of learning (hierarchy of
and integrated into clinical reasoning
sequencing instruction) Zone of proximal development (Vygotsky)
Development of effective clinical reasoning process
Shape and perfect problemsolving skills through repeated practice and feedback
Instructional alignment Feedback is key to guide and support learner Practice improves retention
Development of effective selfdirected learning skills and learning needs
Allows student to locate and use appropriate information resources
Reect in action and on action (Schon)
Increased motivation for learning
Motivation enhances Motivate through self efcacy (Bandura) of student learning self-esteem and selfactualisation (Maslow)
Resident as teacher Studies have shown that residents contribute substantially to the education and clinical training of medical students and that the knowledge and professional competency of residents correlate positively with their perceived teaching abilities.38,40,42 Surprisingly, therefore, training in teaching, and frequent and constructive feedback in teaching are lacking in most educational settings.41 MR could be a unique platform for residents to improve their teaching skills and confidence. Apker et al. noted that MR involves a highly public display of professional identity expectations.43 Case presentations turn into self-presentations as residents develop skills and strategies ascribed to the role of doctor in front of an evaluative audience.44 The participative nature necessarily involves residents in discussion so that the faculty can evaluate their case knowledge, mastery of medical information and clinical skills.43 The goal is for residents to solve a case, gather relevant information, challenge theories and decisions and defend their own perspective. By interacting with peers and role models residents learn the culture of medicine and how to develop their professional identities within it.43 MR allows house staff and attending physicians to interact in an intellectually stimulating and comfortable environment, and is an important setting in which residents encounter potential role models. Rationale for instructional design Gagne has described the arrangement of nine specific instructional events to achieve optimum learning outcomes. These consist of learner and teacher activities and are summarised in Table 4.45-47 The first three (gaining attention, informing the learner of the objectives and stimulating recall) collectively prepare the
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Table 4. Gagne conditions for learning (from Dent & Harden)49 Preparation for learning Gaining attention
Informing learners of objectives
Stimulating recall of prior learning
Teacher
Student
Learning phase
Provokes interest by statement/ questions
Tunes into correct wavelength
Attending
Case presentation provides resident with stimulus
Claries objectives and direction
Recalls relevant prior knowledge
Expectancy
Resident informed of objective, e.g. to make a diagnosis in a patient with abdominal pain
Refers to earlier relevant learning and indicates links with new topic
Starts to create ideational scaffolding
Retrieval
Residents prompted to relate what was previously learnt to case
Acquisition and performance Presenting the content
Providing learner guidance
Teacher
Student
Learning phase
Instructional event
Concepts and principles presented in organised, structured way
Builds up knowledge structure
Selective perception of stimulus features
Attending draws attention to key points
Explanations provided
Exercises thinking abilities to work things out, nd meaning, and build links between ideas
Semantic coding
Attending explains why key points are relevant to patient care
Tries to envisage how the new knowledge can be applied
Retrieval and responding
Links suggested back to other subjects/ projected to application
Team engages in discussion
Transfer of learning Elicits performance Provides feedback Assesses performance Enhances transfer Teacher
Student
Learning phase
Instructional event
Checks that students have learnt what was supposed to have been learnt
Responds to questions by checking his/ her understanding
Reinforcement
Attending restates major teaching points
Provides corrective/ supplementary guidance
Corrects misunderstanding
Cueing retrieval
Residents prompted to explain what has been taught
Conrms that teaching has taken place
Monitors understanding (metacognition)
Summarises and encourages thinking about application
Thinks about how knowledge can be applied
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Residents prompted to self-assess/ feedback Generalisation
learner for instruction. The next two (presenting the information and providing learner guidance) are the core of the teaching/ learning process and are designed to help the student understand the topic. The final four events, eliciting performance, providing feedback, assessing performance, and enhancing transfer, give the student the opportunity to check and enhance learning, correct misunderstanding and think about how knowledge can be applied in other contexts. The MR case presentation provides a stimulus for learning and sets the stage for contextual learning. The ensuing discussion and teaching points can potentially impact the learner’s understanding of patient related issues and foster a new perspective of how illnesses progress. The incorporation of key and relevant radiological findings encourages abstraction and conceptualisation, both important phases of experiential learning.48 There is dialogue between the team members and the attending reinforces the teaching points. However, 30 minutes is limited time for reflection, discussion of ethical issues, professionalism, self-directed learning and humanism. Hopefully, the faculty members model some of these behaviors. This instructional design was based on the general principles of Kern et al. in that we employed multiple educational methods and instructional strategies (cases, visual aids, some didactic and question and answer sessions) to provide opportunities for learners with diverse learning and cognitive styles to gather and organise information.49 Each case presentation was sequenced to take learners through the Kolb learning cycle to promote experiential learning. Cooperative learning was emphasised to enhance understanding and improve communication skills through reciprocal peer-teaching.50 The key elements of the instructional design and method of implementation are summarised in Table 5. Table 6 summarises the design based on the Stanford Faculty Development Model.51 OUTCOME MEASURES It is too soon to say whether or not the goals and objectives have been achieved. Potential outcome measures will include resident assessment, programme evaluation and overall determination of improved learner satisfaction. While the faculty assesses the residents during MR, this assessment is part of the global assessment and not a separate entity. Therefore, MR provides only a small sample of the data used by faculty to assess the residents. The most important characteristics of a welldesigned assessment procedure are validity and reliability.52 Both require clearly defined learning outcomes, a representative sample of instructionally relevant tasks and a sound scoring system. Performance based assessment could be undertaken during MR using an oral examination format; however, standardisation requires that each resident (examinee) be exposed to equivalent tasks, under equivalent conditions and with objective scoring. This would be impossible with unpredictable content (case selection dictated by admissions). In addition, for reasons that defy a scientific explanation, certain residents are ‘black clouds’ and appear to invite a deluge of critically ill patients. If we assume that the purpose of the assessment is not primarily to assess factual knowledge, but rather to evaluate a more general goal of clinical reasoning, then content under-representation becomes less of an issue. Scoring could be addressed by the development of strict scoring criterion checklists related to broad case scenarios, for example management of a trauma patient or a patient with abdominal pain. Presenter anxiety could be a threat to validity in this situation as in oral examinations.53-54 In addition, where the assessor has prior knowledge of the other (as in this situation), this introduces a potential bias. We the royal colleges of surgeons of edinburgh and ireland | 97
Table 5. Key elements of the instructional design process Instructional problems
Learner characteristics
Task analysis
Instructional objectives
Content sequencing
Instructional strategies
Designing the message
Development of instruction
Evaluation of instruments
1.Needs assessment 2.Goal analysis 3.Performance analysis
Learner
Topic Case Critical incident
Attitude Skills Cognitive Metacognitive
Learning related World related Concept related Content expertise Task expertise
Recall Integration Organisation Elaboration Examples/ technique Media Level of concreteness/abstraction Grouping Learner control Reinforcement
Pre-test Objectives Overview Advance organizer Signals Pictures
Concrete Step size Pacing Consistency Cues
Formative Summative Conrmative
Case presentation X-ray evaluation Pathology from teaching les
Presentation Analysis Key points Feedback
Didactic followed by Q and A
Continuous formative feedback
analysis Cognitive Physiological Affective Social Entry competencies Contextual analysis Orienting Instructional Transfer
Method(s) by which key elements were addressed in morning report Survey and direct observation
Individual characteristics not specically identied
Case
Attitudes Skills Cognitive Metacognitive
Chief resident dened core content
Key points reinforced by attending
Table 6. Stanford Faculty Development Model53 Learning climate
Supportive, respectful, conducive to learning
Call residents by name, avoid humiliation, top down questioning
Control of session
Assign responsibility
Avoid lengthy diatribes or sidetracking
Communication of goals
Set expectations
Chief resident assigns roles at onset
Promote understanding and retention
Level specic questioning and encourage synthesis
Evaluation
Conrm ndings
Feedback
Use teachable moment
Promote self-directed learning
Encourage self study
hope that although our instructional design did not teach students self-assessment per se, the resident led hands-on approach together with formative feedback will serve to foster self-esteem and self-efficacy, two attributes linked to deeper learning.55 Reliability refers to the consistency or reproducibility of outcomes over time and is a characteristic of the results or outcomes and not of the measuring instrument itself.56 Performance assessment under the conditions described for MR poses challenges to reliability analysis because of a lack of case specificity and violation of the assumption of local independence.56-58 Performance on one case may not predict performance on other similar cases or rater ratings of a case may be different over time (intra-observer), by learner or by rater (‘hawk’ or ‘dove’), and, as such, each of these impact consistency and therefore reliability. One effort to estimate the variance of these variables is to use generalisability theory analysis to calculate the generalisability coefficient.59 Such a coefficient properly estimates the sources of measurement error variance simultaneously and thus estimates how consistently our results can be generalised. However, one statistical assumption of all reliability analyses is that items are independent of each 98
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Provide follow-up Ensure follow-up other. In a clinical case where items are actually linked, this creates a problem. Therefore we will almost certainly not use resident performance assessment in MR independently of our global resident assessment. Programme evaluation The lack of studies to document the effectiveness of MR may be due to the difficulties of doing research in the context of the diverse purpose, content and audience involved in MR. It is also difficult to isolate the effects of MR from those of other formal and informal educational activities. Finally, the lack of validated assessment instruments compounds the difficulty. These difficulties should not be seen as insurmountable obstacles but as challenges to be met. Our data suggest that MR is an effective educational tool.22 As a direct result of stimulating the chief residents to play a leadership role in improving the educational focus of MR, a number of other educational projects have been undertaken. In addition, the medical students have nominated a record number of our surgery residents (7/28 or 25%) this year for institutional teaching awards. Finally, this conference has been shown to enhance resident education.60
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CONCLUSIONS The advent of resident work hour restrictions has challenged us to train residents within a shorter work week, while ensuring continuity of patient care. We instituted MR primarily as a means to improve continuity of patient care. The initial obstacles included timing, setting this as a priority and designing the format. The chief residents as primary stakeholders were strongly encouraged to play a leadership role in designing MR. Serendipitously, MR has become an integral educational tool for the surgery residents at our institution, while also ensuring continuity of patient care. It is an opportunity for residents to exercise and improve their knowledge, leadership, presentation and problem-solving skills. A faculty led didactic format was rejected because of the importance of focusing on resident team building and leadership, but poor faculty participation was also an issue. The lack of interest from the faculty may be because MR is not a traditional educational venue in surgical programmes or the 6.30am start may have been a disincentive. Reports of educational effectiveness of MR are mostly anecdotal and further studies are needed to characterise the types of learning and teaching that occur during MR and to document educational effectiveness. This presents unique methodological challenges, including the objective measurement and verification of study outcomes and the potential biases introduced by the Hawthorne effect, crosscontamination of study groups and unintended co-interventions. We would hypothesise that the advantages for teaching are many and include that residents are prepared for actual clinical problems in a supportive environment with opportunities for immediate feedback and assessment.
Copyright © 1 April 2008 REFERENCES 1. Amin Z, Guajardo J, Wisniewski W et al. Morning report: focus and methods over the past three decades. Acad Med 2000; 75(10 Suppl): S1-5 2. Parrino TA. The social transformation of medical morning report. J Gen Intern Med 1997; 12: 352-3 3. Barton LL, Rice SA, Wells SJ et al. Pediatric morning report: an appraisal. Clin Pediatr 1997; 36(10): 581-83 4. Bassiri A, Kassen BO, Mancini GB. Improving the format of morning report. Acad Med 1995; 70: 343-43 5. Carruthers A. General practitioner participation in ‘Morning Report’ at a major teaching hospital. Australian Family Physician 1997; 26 Suppl 2: S96-98 6. D’Alessandro DM. Documenting the educational content of morning report. Arch Pediatr Adolesc Med 1997; 151(11): 1151-56 7. D’Alessandro DM, D’Alessandro MP. Radiologic education of pediatric residents during morning report. Acad Radiol 1997; 4(7): 534-38 8. D’Alessandro DM, Qian F. Do morning report format changes affect educational content? Med Educ 1999; 33(9): 648-54
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9. Durning SJ, Sweet JM, Cation LJ. Morning Report: an analysis of curricular content and comparison to national guidelines. Teach Learn Med 2003; 15(1): 40-4 10. Gerard JM, Friedman AD, Barry RC et al. An analysis of morning report at a pediatric hospital. Clin Pediatr 1997; 36(10): 585-88 11. Hill RF, Tyson EP, Riley HD Jr. The culture of morning report: ethnography of a clinical teaching conference. South Med J 1997; 90(6): 594-600 12. Parrino TA, Villanueva AG. The principles and practice of morning report. JAMA 1986; 256(6): 730-33 13. Reisman AB, Gross CP. Gender differences in the ability to identify a mentor at morning report: a multi-institutional survey. Teach Learn Med 2002; 14(4): 236-39 14. Schwartz A, Hupert J, Elstein AS et al. Evidence-based morning report for inpatient pediatrics rotations. Acad Med 2000; 75(12): 1229 15. Solet DJ, Norvell JM, Rutan GH et al. Lost in translation: challenges and opportunities in physician–to-physician communication during patient handoffs. Acad Med 2005; 80(12): 1094-99 16. Spickard A 3rd, Hales JB, Ellis S. Outpatient morning report: a new educational venue. Acad Med 2000; 75(2): 197 17. Ways M, Kroenke K, Umali J et.al. Morning report: a survey of resident attitudes. Arch Intern Med 1995; 155: 1433-37 18. Welsh CH, Pedot R, Anderson RJ. Use of morning report to enhance adverse event detection. J Gen Intern Medn 1996; 11(8): 454-60 19. Wenderoth S, Pelzman F, Demopoulos B. Ambulatory morning report: can it prepare residents for the American Board of Internal Medicine Examination? Journal of General Internal Medicine 2002; 17(3): 207-9 20. Gross CP, Donnelly GB, Reisman AB et al. Resident expectations of morning report: a multi-institutional study. Arch Intern Med 1999; 159(16): 1910-14 21. Mehler PS, Kaehny WD, Fraser V et al. Clinical effect of morning report. Acad Med 1993; 68: 547 22. Stiles BM, Reece TB, Hedrick TL et al. General surgery morning report: a competency-based conference that enhances patient care and resident education. Curr Surg 2006, 63(6): 385-90 23. Reilly B. Lemon M. Evidence-based morning report: a popular new format in a large teaching hospital. Am J Med 1997; 103(5): 419-26 24. Brancati F. Morning distort. JAMA 1991; 266: 1627 25. McGaghie WC, Engel JD, Wolf K et al. Morning report: a descriptive view from two different settings. Res Med Educ 1985; 24: 157 –62
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26. Elliott SP, Ellis SC. A bitter pill: attempting change in a pediatric morning report. Pediatrics 2004; 113(2): 243-47 27. Barrows HS. A taxonomy of problem based learning methods. Med Educ 1986; 20: 481-86 28. Accreditation Council for Graduate Medical Education. http://www.acgme.org/outcome/comp/ compHome.asp. Accessed 2/7/06 29. Dolmans DHJM, De Grave W, Wolfhagen IHAP et al. Problem based learning: future challenges for educational practice and research. Med Educ 2005; 39: 732-41 30. Gelula M. M. Kolb’s Learning Style Inventory and Experiential Learning Cycle. MPHE: 2003, 502 31. Kolb D. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs: Prentice-Hall, 1984 32. Schon D. The Reective Practitioner. San Francisco, CA: Jossey-Bass, 1983 33. Vygotsky LS. Mind in Society. Cambridge: Harvard University Press, 1978 34. Maslow AH, A theory of human motivation. Psychol Rev 1943. 50: 370-96 35. Bateman W. Open to Question. San Francisco: Jossey-Bass, 1990: 15-16 36. Cotton J. The Theory of Learning Strategies: an Introduction. Philadelphia: Kogan Page, 1995: 19: 113-14 37. Morgan R, Ponticell J, Gordon E. Enhancing Learning in Training and Adult Education. Westport: Praeger, 1998: 15-16 38. Barrow MV. Medical students’ opinions of the house ofcer as a medical educator. Jr Med Educ 1996; 41: 807-10 39. Busari JO, Prince KA, Scherpbier AJ et al. How residents perceive their teaching role in the clinical setting-a qualitative study. Med Teach 2002; 24: 57-61 40. Busari JO, Scherpbier AJ. Why residents should teach: a literature review. J Postgrad Med 2004; 50: 205-10 41. Steward DE, Feltovich PJ. Why residents should teach; the parallel processes teaching and learning. In: Edwards JC, Marier RL, eds. Clinical Teaching for Medical Residents, Roles, Techniques and Programs. New York: Springer-Verlag, 1988: 3-14 42. Remmen R, Denekens J, Scherpbier AJ et al. An evaluation study of the didactic quality of clerkships. Med Educ 200; 34: 460-64 43. Apker J, Eggly S. Communicating professional identity in medical socialization: considering the ideological discourse of morning report. Qual Health Res 2004; 14(3): 411-29 44. Arluke A. Roundmanship: inherent control on a medical teaching ward. Soc Sci Med 1978; 14: 297-302
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45. Gredler M.G. Learning and Instruction. Theory into Practice. Columbus: Pearson Merrill Prentice Hall 2005 46. Anspach RR. The language of the case presentation. In: Conrad P, Kern R eds. The sociology of Health and Illness: Critical Perceptions. 3rd ed. New York St Martins, 1990: 319-38 47. Dent L, Harden R. A Practical Guide for Medical Teachers. Oxford, Elsevier: 2005 48. Svinicki MD, Dixon NM. The Kolb model modied to classroom activity. Coll Teach 35(4): 141-46 49. Kern DE, Thomas PA, Howard DM et al. Step 3: goals and objectives. Curriculum development for Medical Education. A Six-step Approach. John Hopkins University Press. Baltimore, 1998: 29 50. Krych AJ, March CN, Bryan RE et al. Reciprocal peer teaching: students teaching students in the gross anatomy laboratory. Clin Anat 2005; 18: 296-301 51. Litzelman DK, Stratos GA, Marriott DJ, Skeff KM. Factorial validation of a widely disseminated educational framework of evaluating clinical teachers. Acad Med 1998; 73: 688-95 52. Gronlund NE. Assessment of student achievement. Boston: Allyn and Bacon, 1968 53. Guerin RO. Disadvantages to using the oral examination. In: Marcell EL, Bashook PG, eds. Assessing Clinical Reasoning: the Oral Examination and Alternative Methods. Evanston: American Board of Medical Specialties, 1995: 41-8 54. Davis MH. The place of oral examination in today’s assessment systems. Med Teach 2005; 27: 294-97 55. Williams SM. Putting case-based instruction into context: examples from legal and medical education. J Learn Sci 1992; 2(4): 367-427 56. Downing SM. Reliability: on the reproducibility of assessment data. Med Educ 2004; 38: 1006-12 57. Downing SM. Validity: on the meaningful interpretation of assessment data. Med Educ 2003; 37: 30-7 58. Downing SM, Haladyna TM. Validity threats: overcoming interference with proposed interpretations of assessment data. Med Educ 2004; 38: 327-33 59. Crossley J, Davies H, Humphris G et al. Generalisability: a key to unlock professional development. Med Educ 2002; 36: 972-78 60. Stiles B, Reece TB, Hedrick T et al. General surgery morning report: a competency-based conference that enhances patient care and resident education. Curr Surg 2006; 63(6): 385-90
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