Morning Report Format
Starting June 2007, we will introduce a new format to our
morning reports at both Hermann and LBJ. Philosophically, our goals are (1) to
improve the educational output of this time honored exercise in internal
medicine training; (2) to train our house staff to effectively communicate
clinical data to an audience of medical professionals; and (3) to foster and
perpetuate sound deductive reasoning and decision making skills.
Practically, the sole objective is to train our house staff to present clinical
data in a chronologically clear, germane, and concise narrative from which your
audience can quickly generate a focused differential diagnosis, which in
turn, will form the basis for a discussion centered on clinical decision
making and management. We hope to turn our Morning Report into the
best didactic exercise in the history of our training program.
GENERAL POINTS:
·
At Hermann
we will still have two cases per morning report session on most weekdays. Per
session, we will have one general internal medicine case and one consultation
case, thirty minutes per case. For the general internal medicine case, the
on-call team will present. For the first two months of the new academic year
(July and August), only residents will present. General internal medicine will
present first. Exceptions:
Ø
On the select Cardiology
days that will feature Dr. Oscar Rosales as the faculty discussant, this will
be the sole case of the morning, due to the fact that Dr. Rosales is such a
superb instructor that the entire one hour will be allotted to him and the
presenter.
Ø
On the day of Critical
Care Morning Report, that case will be presented first (see below).
Ø
On two Wednesdays
each month, we will forgo our standard Morning Report. Instead, we will present
an extended, informal slide show in which the Chief Resident will present
physical exam and radiologic images on Power Point® slides with an
accompanying brief verbal clinical vignette, to which audience members may give
their thoughts on the likely problem or diagnosis, not unlike what is
occasionally done by our current Chief Residents before Morning Report.
Occasionally, we will add board-like questions to this session. The purposes of
this exercise are (1) to give our house staff a mid-week break from a formal
morning conference and (2) to give our house staff practical training for their
American Board of Internal Medicine examination. This session will be informal
and casual, yet attendance will remain mandatory.
Ø
On the Wednesdays that we do not schedule a
teaching slide show, there will only be one consultation case.
Starting the second week of July 2007, Dr. Phillip Orlander will facilitate a post-call morning report on Tuesday. Please refer to the bulletin in a separate mailing for further details. At our first Hermann orientation meeting on July 3rd, the Chief Residents will give a full description and address your questions and concerns.
Dr. James T. Willerson will continue his tradition of conducting at least two morning report cases per month on Saturdays at Hermann. There will be one general internal medicine case per session. The post-call resident will present. Please refer to the Hermann conference schedule each month.
·
At LBJ,
there will be several promising changes to both the general and Dr. Fred
post-call morning report format. Please refer to the LBJ conference bulletin in
a separate mailing that will give a comprehensive description. At our first LBJ house staff orientation
meeting on July 2nd, the Chief Residents will give a full description
and address your questions and concerns. A few general points:
Ø
Traditionally, on
Mondays, the Division of Endocrinology has graciously and consistently
committed one of its faculty to facilitate Morning Report. Please, let’s make a
concerted effort to present one of the cases with an endocrinology perspective.
To help accomplish this, the endocrinology case may be derived from an
ambulatory experience or an in-patient experience (either from a general
internal medicine admission or a remote consult).
Ø
Traditionally, on Wednesdays,
the Division of Pulmonology has graciously and consistently committed one of
its faculty to facilitate Morning Report. Please, let’s make a concerted effort
to present one of the cases with a pulmonology perspective. To help accomplish
this, the pulmonology case may be derived from an ambulatory experience or an
in-patient experience (either from a general internal medicine admission or a
remote consult).
Ø
As at Hermann, we will
present an informal teaching slide show, most likely on Fridays.
The interns who are on call will present both cases.
However, as at Hermann, for the first two months of the new academic year (July
and August), only residents will present. On select days, there will be a
bedside Intern Morning Report that will be mediated by Dr. Niraj Mehta;
please refer to the LBJ conference schedule each month.
·
The Chief Resident
will strictly enforce the thirty-minute time limit. The presenter
and discussants should bear this in as the case evolves. In between cases, the Chief
Resident will make announcements for the day.
·
We would like to
establish a new tradition of audience seating that we hope will nurture a more
supportive atmosphere for the case discussion (see below). As much as possible,
we would like our students to be seated in the first and second rows of the
auditorium (or classroom on select days at LBJ); our interns in the second and
third rows; and our residents in the fourth row.
·
To optimize the
learning potential and the efficiency of each case, and time permitting, we ask
that the house staff briefly discuss their case (content, teaching points, etc.)
with the Chief Resident at some point the day before presentation. You’re
welcome to drop by our office in person; flag us down in the corridors; or
simply call. We will always have an open door policy, and we would be delighted
to help prepare your cases. Please, utilize us to help you put forth a
professional and insightful case for your colleagues.
SPECIFICS:
For the consultation cases at Hermann, you
may derive the case from either an ambulatory experience or (more commonly) an
in-patient experience. Each case must begin with two pieces of information: (1)
a specific REASON FOR CONSULTATION or REFERRAL, not
a chief complaint, and (2) the REQUESTING SERVICE (e.g., internal
medicine, PMR, general surgery). The purpose of this exercise is NOT
to rehash the primary team’s (or referring out-patient physician) initial
diagnostic approach per se, but to tell your audience why your specialty
team was asked to see this patient and how the problem was addressed, focusing
more on MANAGEMENT. Often, the reason for a consultation is a
procedure (e.g., coronary angiogram, bronchoscopy, EGD, colonoscopy) or
to help manage a specific clinical syndrome (e.g., acute renal failure,
lupus flare, bacteremia). The reason for consultation or referral must be
stated without any concern for revealing a salient feature of the case or the
underlying diagnosis (if it is already known at the time), because arriving at
the diagnosis is NOT the sole objective of this exercise. MANAGEMENT
of a specific problem is the objective. Of course, if the diagnosis is unknown
at the outset and the request for the consultation is specifically to aid in
the diagnosis (e.g., fever of unknown origin), then naturally, the
reason for this consult at Morning Report is justifiable and appropriate, and
the differential diagnosis will take precedence.
For example, suppose a primary team admits a patient for
hemoptysis and discovers a right upper lobe cavitary lesion on chest x-ray.
Suspecting tuberculosis, the team asks pulmonology to perform a bronchoscopy.
In this case, the reason for consultation should be “BRONCHOSCOPY TO EVALUATE A
RUL CAVITARY LESION”, NOT hemoptysis. Thus, the focus of the
differential diagnosis should be on cavitary lung lesions in the context of
hemoptysis. Another example: if an in-patient develops a nosocomial pneumonia
and the respiratory culture grows out an unfamiliar or virulent organism and
wants infectious disease to help manage, then the reason for the consultation
is “POSITIVE STENOTROPHOMONAS SPUTUM CULTURE”, or perhaps, “POSITIVE SERRATIA
MARSCESENS SPUTUM CULTURE”, NOT pneumonia or dyspnea. Again,
the reason for a consultation must be specific and narrow and
allow both the presenter and audience to focus on a specific problem,
which in turn, sets the stage for a narrow and efficient discussion. Final
example: a “SERUM CALCIUM 14.5” is a more informative and compelling reason for
a consultation, as opposed to “HYPERCALCEMIA”, as the severity of a problem in
itself may have a more limited differential diagnosis.
Why identify the requesting service? Because in so
doing, important insights into the nature of the case may be intuitively
inferred. For example, if the reason for a consultation is “blood pressure
control” and the requesting service is general surgery, then the entire case
may be immediately placed into proper perspective, because we should know that
there are well-known and documented perioperative issues that adversely impact
blood pressure (e.g., pain, nausea, vomiting.). Thus, this
singular piece of datum may help your audience identify, a priori,
salient features of the case. Furthermore, the clinical course will, in most
cases, be instrumental to the discussion. Of course, you will need to give a
brief synopsis of what the primary team discovered during their management. A
commentary on how the patient behaved clinically to the initial management and
on whether certain aspects of the case evolved is invaluable to differential
diagnosis and an assessment of management.
Furthermore, the above changes will effectively and
(appropriately) eliminate the “mystery” case format that has plagued our
Morning Report for years. Far too often and by cruel design, the audience has
had to labor through an obligatory and extensive differential diagnosis, in the
process frustrating (and annoying) the audience and siphoning precious time
from the discussion of the clinical course and management, the audience
discussion, and teaching points. This old approach is philosophically and
fundamentally flawed and is no longer acceptable.
For the general internal medicine cases at
both Hermann and LBJ, the format will remain mostly the same. Each presentation
will begin with a specific chief complaint. However, as with the consult cases,
we want to eliminate the “mystery” case. To this end, we will strongly
discourage and prohibit the practice of concealing relevant and a priori
known historical details (i.e., a recent hospitalization or
diagnostic work-up for the same problem, a known diagnosis) from the case
narrative to purposefully craft a more elusive and interesting case. Exception:
new historical or physical data that is discovered during the in-patient
clinical course may be held at the discretion of the presenter until the
discussion, in order to give the audience a real-time appreciation of the
dynamics of the case. If you are concerned about presenting a case in which the
audience knows the diagnosis and you fear the discussion will not be interesting
or educational, please do not be. Remember, we want our Morning Report to
repetitively underscore the common problems that we will face in internal
medicine so that we become proficient and comfortable at approaching and
managing these problems, especially for our entry-level trainees (students and
interns). If the case involves frank congestive heart failure or community
acquired pneumonia or asthma, for example, then so much the better! On the
contrary, we strongly encourage you to present the
“bread-and-butter” cases, because these cases form the core of our internal
medicine training. At the conclusion of our training, we should be able to
firmly grasp and appreciate the scope, gravity, pitfalls, and management of
these problems. Perhaps such a case was problematic in that the patient did not
respond to conventional treatment. Perhaps some in our audience may have taken
a difficult approach. Please understand that this is the whole point in
changing the format of Morning Report--to LEARN, not to be
confused and stumped.
Next, we will end the customary (and stressful) practice
of appointing a single house staff member discuss the case and generate the
differential diagnosis. Philosophically, our objective here is to involve the
medical students, who have traditionally been non-existent in our Morning
Report. This old philosophy is no longer acceptable, because this
exercise should also be an integral component of our students’ training in
internal medicine. Specifically, we will ask the medical students, as a group,
to initiate the discussion. When the students need help (and they naturally
will), we will ask the interns as a group to assist. When the focused
differential remains incomplete (and it will), we will turn to our more
experienced residents (and faculty) to complete the differential. [Exception:
for our Critical Care Morning Report (see below), the upper level residents
will initiate the discussion]. We strongly believe that the initiation of the
discussion by the entry-level members of our audience (and by committee) and
with assistance from our senior audience members will transform the atmosphere
into one that is more supportive and comfortable, which always lends itself
well to learning.
For our presenters, please present your case with as much
relevant details as necessary (history and review of systems) to create a
chronologic and clear narrative. Please make a concerted effort to include
pertinent clinical data from outside hospitals (if applicable), because such
data is an essential component of the history of the presenting illness.
Furthermore, your audience would appreciate it if you are prepared.
Please have all available laboratory and imaging data ready to divulge, if
needed. We ask that if you wish to present radiologic images, please export the
relevant individual images from Centricity Web® (Hermann) or Epic
Web® (LBJ) in the form of jpeg files and place them on a Power Point®
slide, which is easy to manipulate. For chest x-rays, this task is easy. For CT
scans, we would prefer to see only the clinically relevant cuts. We have all
experienced the frustration of the presenter and chief residents attempting to
scroll down multiple cuts to identify the pathology, often at a painfully slow
or fast pace. If you need help exporting the images files to an external
storage device, we will be happy to assist. If you wish to show EKGs, you can
either photocopy the original so that we can project the photocopy via the ELMO
onto the screen. If you wish to show actual digital photographs of your patient
in lieu of a portion of the physical examination narrative, your
audience would likely be pleased.
For our discussants, in the interest of time, please,
limit the differential diagnosis to what is most likely to explain the clinical
presentation. And please offer a reasonable, common sense,
and focused diagnostic and management approach (i.e., do not recommend a
chemistry panel as your first diagnostic test for a patient who presents with
fever and a productive cough or with a headache and fever). As the framework
for our new philosophical approach for developing sound clinical judgment, we
expect you to be able to justify why a given test will narrow your
differential diagnosis or alter your management, i.e., why do you
want to order a given test and what information do you expect and how
will that information will help you. For example, if you wish to ask the
presenter for the results of a chemistry panel or a chest x-ray, you will
automatically expect the following question from the Chief Resident: Why do
you want this test? And the discussant will be expected to appropriately
answer; otherwise, the Chief Resident will not allow the presenter to present
that information. In so doing, we hope to hold all of our trainees to a much
higher standard of decision making than in the past, a standard that will
require you to justify your reasoning and your actions. The old practice of
house staff requesting diagnostic tests in a random (and sometimes
inappropriate) fashion and without any justification whatsoever in the Morning
Report discussion is fundamentally, philosophically, professionally, and
economically flawed and is no longer acceptable. Remember, when
you eventually enter the real world of practicing medicine, the landscape of
which will be dramatically different from the protected confines of either a
community or university residency training program, you will be required by
insurance companies, and hospital and clinic administrative entities to provide
written justification for every test that you order, or else, you will
not get reimbursed, or worse, your patient will receive an unpleasant bill. We
hope that by training you as a house staff member to justify your actions in a
didactic exercise such as Morning Report, you will become a conscientious and
responsible doctor in the real world. Furthermore, if you seek more relevant
details (e.g., review of systems, physical exam) from the presenter,
please be prepared to justify why you are seeking this information.
Finally, the end-of case Power Point®
presentations will cease. Although past presenters have done an admirable job
in their preparation of these presentations, sadly, they often defeat the
purpose of Morning Report, in that the topic is sometimes completely irrelevant
to the case at hand and often too long, dull, and short in practical relevance.
Instead, we will replace these presentations with “Take Home Points”,
which will consist of a single Power Point® slide with
no more than five teaching points that the presenter wants the audience to
“take home” regarding the case. Alternatively, the presenter may want to offer
verbal talking points or a five point hand out that can be projected through
the ELMO® onto the screen. Keep in mind that we want the audience to
grasp a few salient features that can be instrumental to the approach and
management of similar cases in the future. Furthermore, we would also encourage
our presenters to find a review article or short communication on your case (as
is often done by our house staff), preferably in a PDF format, that you think
would benefit our understanding of the case and will elaborate on your Take
Home Points. The review article will NOT be discussed but only
referenced for the audience. At the conclusion of Morning Report, the Chief
Resident will archive both the Take Home Points and the review article in a
soon-to-be constructed section of our residency program web site so that our
house staff can review them throughout their training.
Finally, starting June 2007 at Hermann only, we will introduce
a Critical Care Morning Report. Our rationale is simple and
clear. Over the years, it has become obvious that the weakest aspect of our
training program is preparation for critical care, especially among our
entry-level trainees. We have repeatedly observed house staff display a weak
grasp of basic critical care concepts and a visible sense of uncertainty and
trepidation during their MICU rotations. Through the addition of a single
monthly morning report in critical care that will focus on common critical care
problems, our objective is to develop competency and foster confidence in our
house staff in this aspect of training.
The format and guidelines will be straightforward. An
upper level internal medicine or medicine-pediatrics resident who is currently
on duty in the MICU and is neither on-call nor post-call, at the end of the
month, will present one case. The timing will allow ample time for the resident
to prepare. This case will be presented first; and at the conclusion of the
presentation, the resident will be excused to join his/her team in the MICU. A
faculty member from the Division of Pulmonology and Critical Care Medicine will
facilitate the case.
The case should be a common problem that is
encountered in the MICU, such as sepsis; volume resuscitation; shock;
pneumonia; mechanisms of hypoxemia; ARDS; etc. Again, the objective of
this exercise is MANAGEMENT. Furthermore, the case will begin not
with a chief complaint, but with a specific REASON FOR ADMISSION—the
problem that necessitated the critical care admission. Examples: “hypoxemic
respiratory failure”; “hypovolemic shock”; “diabetic ketoacidosis”; “bacterial
meningitis”; “suspected septic shock”; “gastrointestinal hemorrhage”; etc.
From month to month, we will present the same types of critical care cases--over
and over again. The case must be pre-authorized in advance by the Chief
Resident. If the feedback from our house staff and faculty is positive, we will
quickly expand this exercise to LBJ.
-- End of document --