Morning reports teach and reinforce clinical reasoning skills for your residents, interns and students. Often occurring between resident and then faculty rounds, these precious 45-60 minutes should be maximized so that your learners get the most from the session.
Purpose of Morning Reports
These sessions allow students and residents to learn and demonstrate clinical reasoning. By listening to the conversation, you can identify deficiencies of learners from every level, which you can then correct. It ensures that proper illness scripts are being learned and knowledge is being reinforced.
Illness scripts are an organized mental summary of an individual’s knowledge of a particular disease, which could be as short as a few lines or as detailed as a book, depending on the disease itself. They usually consist of a disease's pathophysiology, epidemiology, time course, salient symptoms and signs, diagnostics, and treatment. You can understand these working illness scripts which your residents have as they speak through cases.
The participants:
Morning reports often involve a diversity of learners. These learners have varied experience in the medical field and range from students to residents.
Medical students are the lowest level, rarely called on unless they volunteer. Their ability to listen to the thought processes of their mid and upper levels adds value to their presence in the session.
Interns (PGY1) are the middle level, who usually identify abnormal labs, simple symptoms and assess vital parameters. These sessions help them level up faster by acquiring reasoning skills.
Residents (PGY2-PGY3) are referred to as ‘Uppers’. These are the most experienced, hence preferred for questioning. They build long and short-list differentials, interpret results and order labs.
“The purpose of ‘morning report’ is to teach residents how to think, with an emphasis on clinical reasoning, test characteristics, and cognitive bias.” [1]
Getting the basics right
For a morning report session to be successful, participants need to know what is expected of them so that they may come prepared. .
The presenter is the leader of the session, who needs to steer the discussion from beginning to end. Usually, the person presenting a case is an upper, while the faculty plays the role of a facilitator.
If the case or the presenter has not been selected beforehand, participants need to know that they may be called upon to provide content for the morning report.. While it is best to have a routine wherein specific residents know which days they will need to lead a case, having everyone come prepared with a case in mind will also keep them engaged academically while caring for patients on the wards.
Oftentimes, the most challenging part of Morning Report for faculty is in letting the presenting, upper level residents guide the case discussion. However, it is essential for the presenter to solely guide. If you inadvertently lead the learners to the correct diagnosis because you are familiar with the case, you will undermine the purpose of nurturing clinical reasoning. Never facilitate a case you know the answer to. Inevitably, you will alert the learners to your knowledge, leading to a direct discussion, where participant energy and engagement is low. Hence, take up cases where the conclusion is unknown. Remember that there is something new to be discovered for every case, no matter how common it may be.
The scribe should also be presented with ground rules, on how to record the session. Usually interns are tasked with this, as it gives them a chance to learn and process the information as opposed to simply presenting it.
Don’t forget to coach your interns on the proper layout and recording of information as it is discussed. Their goal is to capture spoken information and record it on a whiteboard to prompt systematic thinking. Also, use of digital mediums won’t be helped. Morning reports are designed to be spontaneous, so the entire needs to be fluid - which also means it needs to be simple and reliable. Stick with the whiteboards, but use a systematic layout.
Whiteboarding Morning Report - An Ideal Layout
Coach your morning report scribe to split the white board into large thirds - take up as much space as possible.
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Use the left third to record details of the case: chief complaint, HPI, physical exam, etc.
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Use the right third for differential tracking
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Pro tip: have your scribe rank the differential diagnoses in order of likelihood as provided by the team. Obligating the scribe to rank lists differentials will spark dialogue amongst the rest of the team.
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Use the middle third to capture pearls of wisdom or other tangential but valuable lessons, sometimes referred to as day trips
Even though it shouldn't happen, learners will inevitably be paged out of the discussion or arrive late. Because of this, do not erase any of the board. It will allow latecomers, the distracted, and slower learners catch up as needed.
This layout will help the learners navigate to the correct diagnosis. The physical design of information will progress learners through the HPI, ROS, PE in such a way that they might arrive at the correct diagnosis well before getting information in regard to labs or other studies.
Day Trips - Mini-lessons
Remember when you were a student or resident and your mentor succinctly explained that one particular tricky concept you struggled with? Odds are, it wasn’t improvised.
The best facilitators have quick mini-lessons ready for discussion. They are helpful, brief, and enable students or residents to get a key concept. Often referred to as day trips, these are pieces of clinical reasoning relevant across different diagnoses. At best, they enable you to ‘spontaneously’ teach something valuble to the participants (e.g.: “She’s on Metoprolol”, and then talking about beta blockers or protein gaps.)
Day trips are best used when there is an error in reasoning that needs correction, or, when something interesting croups up from discussion. Do it only once, but jump in andtemporarily pause the case. Review your topic for no more than 2-5 minutes. Don’t force it, but look for the opportunity to sponateously insert short learnings on pre-prepared topics. Position yourself so you seem to have the mastery to coach on any topic at the drop of a hat.
“Differential diagnosis (DDx) is the fun part of medical thinking, and hopefully the lessons learned about the process endure.” [2]
Getting into the process
As the facilitator of a morning report, your key function is to balance the conversation while ensuring the learners navigate through a case in a methodical and timely manner. In short, facilitators ensure that ultimately the hour is productive.
Once you’ve collected the learners, appointed a scribe, and have an identified presenter, here’s how you can best run the session: Use systematic steps to work through the case as below. Use individual learner names, quell the noise, and prompt progression with open-ended questions.
Systematic steps:
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Kick off with the Chief complaint and have residents seek the History of Present Illness
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(leverage the framework used at your institution, or try out FAR COLDER - Frequency, Associated sx, Radiation, Character, Onset, Location, Duration, Exacerbating factors and Relieving factors)
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Prompt your Uppers choose the top 5 differentials
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Rank order the differentials, if the scribe does not ask the upper levels for the order, prompt the discussion - ask why
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Uppers ask ROS questions for a chosen diagnosis
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Update the rank order of differentials given ROS informationIntern interprets the vitals
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Uppers call for specific physical exam maneuvers they would like to assess
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General examination reported out
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Upper levels request laboratory and study findings
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Interns should identify the abnormals
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Uppers should interpret the findings
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Final diagnosis conversation
Use Names:
Using specific names generates substantial participation. Students or residents may be distracted with clinical work still pending completion, feeling tired, or eating food brought with them. Use names to pull learners back into the conversation and engage them directly so they engage in the process. If you ask a question that is not targeted to an individual, chances are that there is no clarity in the ensuing discussion, or worse, silence. As an example, let’s take Jack.
Try “Jack, how does CHF usually present?”. Although others begin to answer while Jack might be initially shocked, ignore the rest and persist, while still giving Jack the space needed. If he knows, it is the time to prove it, and if he doesn’t, it is an opportunity to learn.
Ask open-ended questions:
If conversation is lagging, ask open-ended questions and let your participants know that there is no wrong answer. Every opinion counts. In addition to sparking discussion, open ended questions allow you to assess an individual’s knowledge. Have the scribe record everything spoken onto the board, no matter how simple it sounds. Listening for where your learners start their thought processes will give you perspective into their depth of knowledge.
An example of an open-ended question perfect for a morning report could be “What questions are important for gathering the HPI from pancreatitis patients?”. Once they answer, this can be supplemented with “Why did you say that?”. Answers could range from a simple “The GI told me to” to “Radiation of pain to the back with relief when leaning forward is typical for presentation”. This opens up further discussion opportunities on what could have been done differently.
Quell Everyone Else:
Ensure that Jack is the one who answers. While other learners, who - in their enthusiasm, may try to dominate the conversation, it is essential not to lose control but rather keep an intentional momentum. Do not hesitate but quickly call out such behavior squarely. Interrupt the dominant voices with a - “Hold on, Jack was going to share his thoughts next, but I appreciate it.”. This gets the session back to order, with the ones who aren’t Jack shifting to a listener’s role. As Jack was momentarily out of the limelight, he’s likely to be composed and ready to answer. The learning is able to continue.
Leveled Learning:
It is imperative that the right level of participants are chosen to engage on topics that are appropriate to the amount of training and experience they have had so far. Medical students (M3s and M4s) should be primarily listeners and participate only voluntarily. They are the most inexperienced of everyone else in the room, and therefore lack practical expertise and may feel badly when they fail. The intern learning curve is steep during their first year. Keep in mind that new interns are only a few months from having been M4s, and are therefore less likely to contribute substantially.
Uppers are the best choice for advanced clinical reasoning questions as they:
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Describe symptoms of common diseases easily
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Assess probabilities readily
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Have established robust illness scripts
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Differentiate between positive and negative findings of the process
In conclusion
Morning report time is a valuable pause in clinical responsibilities and activity; it is the only hour where learning is the key and only function. Use the time wisely, empower the learners to practice reasoning, and show your residents not just what to think, but how to think.
References:
- http://www.tulanemedicine.com/programinfo/system.html
- https://www.reddit.com/r/medicine/comments/1j83i3/does_anyone_know_the_acronym_colder/
