#14 Mastering the Art of Morning Report

August 17, 2022 | By Era Kryzhanovskaya

With Dr. Tony Breu and Dr. Ryan Bonner

This week, we discuss the best hour(ish) of the week– morning report– with our two guests, Dr. Tony Breu @tony_breu of the Curious Clinicians  and Dr. Ryan Bonner @RWBonner91.  We discuss the history of morning report, best practices for advancing education, and ways to spark engagement for your learners to ensure everyone is benefiting from report!

Website | Instagram | Twitter | Subscribe | Swag! | Top Picks | thecurbsidersteach@gmail.com | Free CME!

Credits

• Writers/hosts/producers: Era Kryzhanovskaya MD, Molly Heublein MD, Andrew DeLaat
• Infographic/Cover Art: Andrew DeLaat 
• Editor: Clair Morgan of Nodderly (audio)
• Guests: Tony Breu MD,  Ryan Bonner MD

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner/ Best piece of advice
• Picks of the Week
• Kashlak Case 1- chief resident perspective
• Definition and types of Morning Report
• Choosing a case and approach
• Tips for successful morning report
• Ways to encourage audience participation
• Kashlak Case 2- attending faculty perspective
• What to do when you’re not familiar with a case
• Giving feedback
• Take home points
• Outro

Morning Report Teaching Pearls

1. Keep the audience engaged and interactive by choosing a variety of cases and approaches- use both scripted and unscripted morning reports, focus on diagnostic and management reasoning, make sure you are covering a variety of topics.  
2. Use learners names and encourage involvement with good questions to keep the discussion going.   Ask open ended questions: have some fall back questions that anyone can answer “what are you thinking now?”   Do not ask questions with a specifically correct or incorrect answer, this can shut down participation.  Consider Scaffolding your questions-“Molly R1, I’m going to ask you to explain your approach here, and then, Ryan R3, I want you to add on”
3. Attendings should recognize their position and limit comments, focusing on supporting the chief if they need it, sharing their uncertainties if this is a case they are less familiar with, and explaining their techniques for answering uncertainties- ie what resources would you go for?
4. A supervising attendings main role is to share feedback with the chief resident facilitator.  We can only improve with a culture of ongoing feedback and improvement.  Focus on feedback around pedagogy rather than around clinical specifics.

Morning Report Show Notes

Definition: What is Morning Report?

Morning report was first engineered for the chief of medicine as a time when they could oversee the house staff in the care of patients.  Now it serves as a teaching conference and as an opportunity to discuss a topic or particular case.   Varieties of morning reports can involve new unprepared cases or more-scripted reports which can have a specific focus or framework within a broader topic. 

Morning reports should be given in a case-based format to benefit learners and deliver information in a way they expect (Lessing 2022).  

Choosing a Case:

Aim for a variety of cases- assess what has been discussed in the program previously and branch out.  To cover both diagnostic and management reasoning, consider splitting the case discussion into two-morning reports (diagnosis day 1 and management day 2).

Cases can be a fresh case unprepared with a whiteboard “unscripted”  or prepped ahead of time with a powerpoint “scripted”.  Dr Bonner prefers scripted cases to allow for thoughtful teaching points, but either approach can be great and mixing it up can keep morning report entertaining and interesting (Lessing 2019).

Zebras vs Horses?  Dr. Breu points out that when discussing zebras (rare diagnoses) you can utilize the case to frame the discussion about larger common problems.  For example, in the case of the “zebra” Paroxysmal Nocturnal Hemoglobinuria, you can spend the majority of the discussion on a differential and evaluation of hemolysis, and only a few minutes at the end on PNH.  Choosing common topics can help cover high yield topics.

Timing of Morning Report

Dr Breu recommends morning report be 45 minutes long, and if you can end early that’s great!  It does not need to be in the morning. 

 Start on time! Establishing a culture where reports start on time and punctual attendance is expected will maximize the time and benefit of morning reports.  Do not go over time! It is always better to end early and leave time for comments, questions, and feedback from the audience.

Facilitating a Successful Morning Report: 

Establish an environment and culture where learners feel safe to be wrong or to give incorrect answers as a way to better facilitate learning. 

Set up the presentation using the 3 Arch Approach (3 parts to the story) and use this to help guide your time management.

1. Initial Diagnosis 
2. Complication 
3. Treatment 

Focus on the learner’s growth points– don’t spend 15 minutes taking a history in a morning report of primarily residents, instead focus on differential and management.

Appreciate that there are other teachers in the room– one of your team might have their PhD in the topic, one may have seen a few patients in this, one may be a specialist.  Don’t feel like you need to know everything.  If you do invite specialists to be discussants on the case, explain your goals for their presence in advance.

Use evidence-based medicine and interpret statistics- don’t just state the likelihood ratio, interpret what this means for the test or treatment.

Keep your teaching points short.  Dr. Breu suggests preparing and then cut it in half.   Aim for 2-3 learning points.  

Synthesize take-home points and ensure that learners can access the essential information easily via handouts, blogs, emails, etc. 

Look to change things up and try new aspects of the morning report to encourage being comfortably uncomfortably to help keep yourself and the audience engaged. (Radhakrishnan 2013)

Tips to Increase Audience Participation

Cold calling listeners can be useful if it involves open-ended questions, inviting a more open discussion without the pressure of being right vs wrong.    Asking an open-ended question like “What are you thinking right now?” can get people starting to talk.  If someone shares a question, asking “why do you ask that?” can help flush out the diagnostic reasoning.

Try to use learners’ names to help them feel included and engaged.

Using pair-share groups as a way to provide opportunities for learners to discuss ideas that they might not have offered in the traditional presentation style.  It also gives learners time to think critically about the case and avoid the stress of on-the-spot answering. 

Scaffold questions– start with a basic question for a medical student for example, “have you ever seen a case of hemolytic anemia?” and then move on to a more advanced learner, asking the resident for example, “what labs might you see in hemolytic anemia”.

When a learner shares an incorrect or unclear response, seek to understand their thought process to help determine the level of correction needed.   Have them explain or help delineate when their answer may be correct, and in what settings it may not apply.  Acknowledge the difficulty of the topics and that we are all learning together to support psychological safety.  (Burgess 2020) 

Role of the Supervising Attending

The supervising attending’s role is to support the chief resident/facilitator and advance the learning for the house staff and medical students in the room.  Bite your tongue and don’t share more than you need.  Help move things along and transition while the facilitator might be feeling overwhelmed.

Support all learners attending morning report.  If a learner isn’t attending, explore why.  Many things can impact a learner’s ability to attend morning report- balancing responsibilities at home with family coordination, feeling overwhelmed, or not feeling like morning report is a valued or valuable part of learning due to institutional culture.  

How to approach a case you don’t know much about

Take it back to a broad differential and make use of the group.   Get used to getting uncomfortable,  and be ok with taking a moment to look things up (like during a pair share) or asking a group member to research a question.  Acknowledge the difficulty of a case, and  provide your learners with how you approach something outside your comfort zone and the tools you will utilize to solve the problem. 

Feedback from Facilitators

Our chief residents do an amazing job facilitating morning report, but they cannot improve without feedback!  Focus on 1-2 action points that are related to pedagogy, rather than clinical specifics.   This can be a  quick 5-10 minute conversation, focusing on what went well and what you might try next time.  Faculty feedback and mentoring can improve resident skill and confidence in leading morning report (Frey-Vogel 2020).  An ideal approach, from Dr Breu’s expert opinion, is that all chiefs attend all morning reports and participate in eachother’s feedback to optimize reports.

Take home points:

Dr. Bonner: Any case can make a great morning report if you can create a great learning environment, get practical learning objectives, and appreciate that everyone in the room has something to teach.

Dr. Breu: Morning report is amazing!  It should never go away!  It’s awesome!

Links

1. Tony’s Pick:  The Count of Monte Cristo 
2. Andy Duke Book – Thinking Bets Making Smarter Decisions
3. Era’s Pick of the Week: Sneakerella  
4. Molly’s pick of the week: Workin’ Moms 
5. Andrew’s pick of the week: Forest 
6. Ryan’s suggestion for resources to learn about morning report: Lessing JN, Wheeler DJ, Beaman J, Diaz MJ, Dhaliwal G. How to facilitate an unscripted morning report case conference. Clin Teach. 2020 Aug;17(4):360-365. doi: 10.1111/tct.13111. Epub 2019 Nov 20. PMID: 31749299.
7. Facilitators Guide to Morning Report Wheeler, Diaz, Lessing, Beaman

Goal

Listeners will learn innovative ways to improve their morning reports to engage learners in constructive conversations around clinically relevant topics. 

Learning objectives

After listening to this episode listeners will…  

1. Distinguish the key components of a successful morning report 
2. Employ new strategies to engage morning report attendees, specifically to encourage active discussion and facilitate feedback conversations during each report
3. Recognize ways to support learners at every developmental level during morning reports.

Disclosures

Dr. Tony Breu and Dr. Ryan Bonner report no relevant financial disclosures. The Curbsiders Teach report no relevant financial disclosures. 

Citation

Bonner R, Breu A, DeLaat A, Heublein M, Kryzhanovskaya E. #14 Mastering the Art of Morning Report”. The Curbsiders Teach Podcast. http://thecurbsiders.com/teach.  August 16, 2022.