What internal medicine attendings talk about at morning report: a multicenter study | BMC Medical Education
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We observed 250 morning reports from 13 residency programs. An overview of the locations is shown in Table 1. Most sites observed at least 20 reports. Three locations held the majority of the conferences in person. The rest of the sites contained mostly virtual reports. Unscripted reports were the predominant format at five sites. Four sites contained only scripted reports, and the remaining sites contained a mix of unscripted and scripted reports.
Description of the morning reports
Personal reports accounted for 26% of the conferences observed. The remaining reports were roughly equally divided between single-site virtual (21%), multi-site virtual (22%), or a hybrid conference with virtual and in-person participants (30%). Most conferences were attended by residents (97%), interns (87%) and medical students (72%). The conferences were predominantly case-related (83%), with a small number of magazine club (9%), lecture-related (2%) and game-related (2%) reports. The conferences were mainly chaired by chief physicians (81%), the remainder by treating physicians (10%) or second- or third-year residents (9%). At the case discussion, clinical information was often provided by a resident (70%) and less frequently by a senior physician (20%) or resident (6%). Most conferences were scripted (65%) and the median length of the morning report was 50 minutes (IQR, 42-60).
The mean number of participants present at the morning call was 3 (IQR, 2.0-5.0), most of whom were hospital doctors (median 2, IQR, 1.0-3.0). A program director or deputy/deputy program director was present at 59% of the conferences. The mean number of learners was 15 (IQR, 7.0 – 26.0). For conferences with virtual learners, a median of 3 virtual groups participated (IQR, 0–6.0).
Description of accompanying comments
The average number of comments per report was 9.4, with a range from 3.9 to 16.8 comments per report across different websites. After chat was excluded, 33% of comments were longer than a minute, with a range of 12% to 68% across all sites. Both the number of comments per report (p< 0.001) and proportion greater than one minute (p< 0.001) were statistically significantly different between sites. Roughly equal proportions of comments were made by hospital physicians, general internists, and internal medicine specialists (Table 2). A similar number of in-person (38%, 889/2,333) and virtual audio/video comments (36%, 847/2,333) were observed, while comments in virtual chat boxes (26%, 597/2,333) were observed less frequently. Most comments were short, and without virtual chat, 66% were shorter than a minute. Forty-one percent of the comments led to further discussion among the trainees. Twenty-one percent of the comments were prompted by the moderator. For conferences moderated by treating physicians, the rate of solicited comments was fifteen percent. Observers rated 73% of all comments as instructive, with the most important teaching topics being differential diagnosis (21%), management (14%) and testing (10%). The most common categories of comments outside of class were questions (50%), jokes (14%) and previous clinical experiences (9%).
Variables associated with the number of comments
In univariate analysis, personal reports, report duration, number of visits, number of general internists, and report supervisors present were all associated with an increased number of comments (Table 3). An increased number of learners, the presence of a program director or deputy/deputy program directors, and written reports were all associated with fewer comments in attendance. In the multivariate analysis, personal reports, report duration, and number of general internists were all associated with increased comments, while written reports remained associated with significantly fewer comments. Personal reports were associated with 57% more comments, while written reports were associated with 28% fewer comments. Each additional non-hospital GP present was associated with 26% more comments. The number of treatments was not included in the fitted model as it was collinear with the number of general practice treatments.
The most common categories of instructional comments are listed in Table 4 and include differential diagnosis, management, and testing. The most common differential diagnostic syndromes discussed by the treating physicians were delirium, polyarthritis, and rash. The most common specific diagnoses discussed by the participants were tuberculosis, endocarditis, histoplasmosis, adrenal insufficiency and lymphoma. The most common treatment categories were drugs, diagnostic approach, and surgical indications, while the most common specific diseases treated were hyponatremia, hepatic encephalopathy, and COVID-19. The three main categories of commentary on diagnostic tests included imaging, biopsy, and serum chemistry studies. The most commonly discussed specific tests were d-dimer, IFN-Ò¯ release assay, chest computed tomography, urinalysis, and arterial blood gas analysis.
