Development of Resident Led Outpatient Morning Report As An Educational Model to Improve Resident Lectures Hobart Lee, MD Academic Fellow Clinical Lecturer Brian Bluhm Chief Resident 2009-2010 Tom O’Neil Chief Resident 2010-2011 Department of Family Medicine University of Michigan

Goals & Objectives Literature Review Methods Results Discussion & Conclusions

Literature Review … “The [residency] program must possess a well-organized and effective curriculum, both academic and clinical” (ACGME RRC) Primary focus on education, fewer cases better, proceed in stepwise fashion (Gross 1999) Unusual or rare diagnoses, management issues, remarkable imaging studies (Ramratnam 1997) Evaluation of resident performance and quality of clinical care (Parrino 1986)

… Literature Review 2 teams competing against each other (Huffman 2010) FM: 4-5x/week for 30 minutes, pre-prepared cases, < 50% outpatient 75% have no goals & objectives 77% did not track educational outcomes (Drifmeyer, 2008)

Methods Initial survey using surveymonkey regarding resident lecture conferences (no interns surveyed) Two 30 minute cases presented each month 25 minute case presentation + 5 minute “expert” debrief Varied response format Repeat survey in 9 months

Rank diagnosis after each section Clinical reasoning Rank diagnosis after each section Diagnosis History Physical Labs/Rad Final arrhythmia 1     5 4   aortic stenosis 2   1 MI  3   2  orthostatic hypotension  medication reaction autonomic insufficiency 

Results

Case Diagnoses Ovarian mass Pediatric pneumonia Post-strep arthritis Acute lymphoblastic leukemia CVA Diabetes myositis Grave’s disease Hypersensitivity pneumonitis Myopericarditis Molluscum contagiosum Neck cellulitis Ovarian mass Pediatric pneumonia Post-strep arthritis Secondary adrenocortical insufficiency Serum sickness Syncope Trigeminal Neuralgia

Pre-survey 13/20 residents Post-survey 8/20 residents Survey Results Pre-survey 13/20 residents Post-survey 8/20 residents

Year of Training

Percent of conferences attended

Lecture types 16 different types of resident lectures ranked by educational content: #1 Case presentation conference (presented by attending) #2 Morbidity & mortality conference #3 Grand rounds (outside speakers) … #14 Professional skills #15 Resident wellness #16 Ethics

Specialty cases Out of 22 specialties, residents requested lectures on: #1 Pediatrics #2 Infectious disease #3 Dermatology #4 Cardiology … #20 Hematology-Oncology #21 Dentistry #22 Anesthesia

Results How would you rate the overall educational quality of Wednesday morning lectures? (Likert scale 1-7) 4.2 vs. 5.8, p= 0.003 To what extent do you agree/disagree that a outpatient "morning report" case presentation would be (has been) a valuable addition to the conference schedule? (Likert scale 1-7) 6.5 vs. 6.1, p= 0.3

Number of cases to present in 1 hour

Length of “expert teaching”

Differential Diagnosis Discussion 50% as one big group 0% as two groups competing against each other 50% small groups (3-5 people)

Residents’ Comments “Case based lectures are the best” “I like everyone shouting out different things and getting the whole differential on the board including ‘zebras’ so we can hear all of the different ideas rather than only the most likely.” “I would like to see more practical lectures on topics encountered clinically and I think that the case presentations were a good step in that direction.”

Limitations: Limited residents response in surveys Recall bias Self perceived educational benefit does not always equal education

Conclusion: Based on resident perceptions, outpatient morning report could provide a preferred alternative model for conveying outpatient specific medical knowledge and enhance real time problem solving.

Acknowledgements Stephanie Kay, MD (Chief resident 2009-2010) Tammy Chang, MD (Chief resident 2009-2010) Brian Bluhm, MD (Chief resident 2009-2010) Tom O’Neil, MD (Chief resident 2010-2011) Department of Family Medicine, University of Michigan

Questions?