Residency weekly conferences and morning report

[OneoftheGuptas]

I'm going to resurrect this thread in hopes to gain some insight into how to improve morning report (MR) and academic half day (AHD) attendance. We currently have 1 hour of MR Monday through Friday and 4 hours of AHD on Wednesday afternoons. ICU, night float, and certain away rotations are exempt. Though we have informed everyone that there is a 70% attendance requirement, attendance is dwindling day by day, and there is decreased interest in presenting due to poor turnout. Guest lecturers have also refused to present, based on the same reasoning. Those who do attend are often 10 minutes late. Part of the problem is that our attendings do not always complete rounds in time, so a team may still be rounding. Another problem is that we keep our pagers available during these sessions, so the time is not exactly protected. Those reasonings aside, the main issue is that we are lazy and there is no consistent punitive action for poor attendance.

Does anyone have thoughts on how to improve attendance? Do your programs have any corrective actions taken for poor attendance? How do you provide "protected time" without affecting patient care in the hospital?

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[BoardingDoc]

I'm going to resurrect this thread in hopes to gain some insight into how to improve morning report (MR) and academic half day (AHD) attendance. We currently have 1 hour of MR Monday through Friday and 4 hours of AHD on Wednesday afternoons. ICU, night float, and certain away rotations are exempt. Though we have informed everyone that there is a 70% attendance requirement, attendance is dwindling day by day, and there is decreased interest in presenting due to poor turnout. Guest lecturers have also refused to present, based on the same reasoning. Those who do attend are often 10 minutes late. Part of the problem is that our attendings do not always complete rounds in time, so a team may still be rounding. Another problem is that we keep our pagers available during these sessions, so the time is not exactly protected. Those reasonings aside, the main issue is that we are lazy and there is no consistent punitive action for poor attendance.

Does anyone have thoughts on how to improve attendance? Do your programs have any corrective actions taken for poor attendance? How do you provide "protected time" without affecting patient care in the hospital?

I assume from your post that you're in IM. You're asking a bunch of EM docs about problems with rounding. We don't round. I'd move this thread to the IM forum.

As to getting your attendance to 70%, that's easy. At least 1 chief needs to be at each AHD and take attendance. Anyone below 70% conference attendance gets a required meeting with the PD / Chiefs to explain why they're absent which if persistent will lead to them being on probation / not graduating. That may sound overbearing/childish, but if your residents aren't acting like responsible adults, don't treat them like adults.

 

[OneoftheGuptas]

I assume from your post that you're in IM. You're asking a bunch of EM docs about problems with rounding. We don't round. I'd move this thread to the IM forum.

Oh my lord, I didn't even see which forum the thread was located in. I apologize. I searched for what appeared to be an appropriate thread and just posted. Thank you for your response!

I agree that it may be time for tough love. The incoming chiefs all have made it a point to ensure that there will be a chief present at each MR, and we will definitely be more proactive in discussions with delinquent residents.

 

[rokshana]

Oh my lord, I didn't even see which forum the thread was located in. I apologize. I searched for what appeared to be an appropriate thread and just posted. Thank you for your response!

I agree that it may be time for tough love. The incoming chiefs all have made it a point to ensure that there will be a chief present at each MR, and we will definitely be more proactive in discussions with delinquent residents.

if your chiefs aren't even present, then why would the residents think it is important...ALL your chiefs should be present.

The academic half day...how is that set up? everyone for the same time? I know at tulane they revamped the way MR and noon conferences were done many years ago to basically do away with them and have certain topics be handle as online modules that needed to be done to get core knowledge done (these repeated on an 18 moth cycle or something like that) and then the half days were split..interns in the AM and residents in the PM...and when the interns were in the residents took all pages and when the residents were in the ATTENDINGS took the their role (so obviously you have to a HUGE commitment form the Attending...and voila! protected time for everyone.

or you could have breakfast and lunch available...amazing what people will do for free and quickly available food...

 

[Psai]

Tell the nurses that they need to stop paging between 12 and 1. There is almost nothing that I've been called about during those hours that couldn't wait.

Have great food.

Tell the attendings to finish rounding on time.

Make the sessions actually relevant. I don't want to hear theoretical nonsense, I want to hear "you should order this lab if you see this because this" not lambda567delta gene on chromosome 16 blah blah blah

 

[Gastrapathy]

Carrot: food
Stick: extra call. Low attenders get the holidays.

 

[QualityProcess]

Tell the nurses that they need to stop paging between 12 and 1. There is almost nothing that I've been called about during those hours that couldn't wait.

Have great food.

its bad enough that they take all the food and good seats at grand rounds, and now you want them doing it at morning report too?

 

[OneoftheGuptas]

Rokshana, your program setup for protected time sounds fascinating!! Our attendings also see patients in other locations, so I don't think it would be a possibility for them to cover our pagers. Rounding times are erratic because of their other responsibilities. We could potentially work out a way to have only the on call team covering the pagers (we have 3 teams, each rotates a call day) during academic half days.
Currently, we have morning reports Mon-Fri from 8:00AM to 9:00AM. Academic half day is from 12:00PM to 3:00 or 4:00PM on Wednesdays. Wednesdays get really long, we're trying to do away with some of those lectures.

Psai, to be honest, our lectures are not of the highest quality. They used to be good, with very enthusiastic attendings/specialists presenting. When attendance dwindled and tardiness increased, they didn't feel the love, and started refusing to come. In turn, the residents started presenting, and the quality of reports went down...which, of course, led to less people showing up. We're trying to get attendance back up so that we can get quality lecturers again.

Gastrapathy, Holiday back up calls sound great. I'm not sure how to give actual calls without another person ending up with less calls in return, which will lead to petty arguments.

About the food, we tried that. People grab food and leave. Somehow, the discipline of our program has dwindled, and we have lots of residents that think the rules don't apply to them, which doesn't work in the real world. The general consensus, I believe, is extra presentations, extra calls, discussions with the PD, and finally corrective action plans.

 

[rokshana]

Rokshana, your program setup for protected time sounds fascinating!! Our attendings also see patients in other locations, so I don't think it would be a possibility for them to cover our pagers. Rounding times are erratic because of their other responsibilities. We could potentially work out a way to have only the on call team covering the pagers (we have 3 teams, each rotates a call day) during academic half days.
Currently, we have morning reports Mon-Fri from 8:00AM to 9:00AM. Academic half day is from 12:00PM to 3:00 or 4:00PM on Wednesdays. Wednesdays get really long, we're trying to do away with some of those lectures.

Psai, to be honest, our lectures are not of the highest quality. They used to be good, with very enthusiastic attendings/specialists presenting. When attendance dwindled and tardiness increased, they didn't feel the love, and started refusing to come. In turn, the residents started presenting, and the quality of reports went down...which, of course, led to less people showing up. We're trying to get attendance back up so that we can get quality lecturers again.

Gastrapathy, Holiday back up calls sound great. I'm not sure how to give actual calls without another person ending up with less calls in return, which will lead to petty arguments.

About the food, we tried that. People grab food and leave. Somehow, the discipline of our program has dwindled, and we have lots of residents that think the rules don't apply to them, which doesn't work in the real world. The general consensus, I believe, is extra presentations, extra calls, discussions with the PD, and finally corrective action plans.

for the call that are the consequence of missing round, the balance issue shouldn't be there...if they don't want more calls than others, well, they shouldn't miss rounds.

put the food up front and when the lectures starts you don't get foot...don't make it something easy to grab and go...

also make sure the attendance sheet can only be signed (i.e. send it around) in the latter half of conference...

and i can't take credit for the protected time idea...the PD at Tulane is the innovator with that.

 

[cestlavie]

Honestly I don't go to morning report when its useless and, more importantly, incorrect. People are not motivated during morning report in my residency. Sometimes they are hostile with questions, like 'why didn't you order x? Or do y?' and that's usually because x and y are either not applicable to the dx or appropriate for the timing in its course. We also have residents leading ours and its like the blind leading the blind sometimes. I prefer attending lead lectures to resident lead morning report or attending lead morning report. I think they take more time to explain physiology where indicated and they just sound like they know what they're saying as opposed to reading from slides or papers.

There is also a debate of how useful these lecture and didactic times are. I've heard there are programs that make it self-study time and in some ways that is sensible because it allows the resident to focus on their weaknesses in a non-threatening environment. Whereas, in didactic type settings, they may be more reserved or less likely to pursue improving their knowledge base because they're too scared that they'll be thought of as dumb by their peers if they ask questions. You know, the questions we technically already know the answers to because we all learned it in school but at that time you can't exactly recall.

 

[OneoftheGuptas]

ALL good ideas. Our new policy will dictate 70% attendance requirements. Delinquent interns get an extra MR presentation and extra back-up on weekends and holidays. Residents get an extra MR and extra ICU calls during their elective months. We've received some pushback, but I believe 70% is reasonable. With 5 morning reports per week, you could technically one presentation per week.

Rokshana, love the food in front idea!! Our food funds are currently in limbo; if we start regularly getting breakfast in MR, I will rearrange the room to accommodate this.

Cestlavie, I completely understand where you're coming from. Our morning reports are led by residents, but usually the environment is collaborative and encouraging rather than hostile. Also, we don't use powerpoints at all, we're told to be as interactive as possible (which I agree with). However... our relaxed, discussion-based sessions lead to people preparing for MR at the last minute and not taking it as seriously. So... what would you do differently? Our attendings wouldn't be able to come every day, we are a private hospital, and most attendings have patients aside from those on the teaching service. Our program will also not allow for self-study.

 

[Gastrapathy]

I don't love the decision to use the stick without the carrot. Push management to support the program and pony up a few bucks for chow.

 

[ABatOutofHeck]

I'm speaking from my n=1 experience, but attendance at our teaching conferences is excellent and here's why:

1) Quality - our morning reports are terrific and high yield. This actually doesn't require that much; the chiefs do a prepared 5-10min bit every report (usually a MKSAP question followed by 2-3 slides on teaching points). A resident then presents a case, usually with no prep. The chief guides the case, using socratic method to spur collegial discussion. Some of our program leadership (program director or aPD) always attend and add their teaching points.

2) We also have dedicated academic days but these are strictly protected time. The interns are excused for one half day a month, and their resident covers their work/pager during this time. The upper levels have multiple half days per week during ambulatory rotations and have no conflicting clinical duties during that time. Attendance is mandatory at these. They are usually great, clinically relevant lectures, and separate half days for interns and senior residents are also great because the teaching is at your level.

3) Noon conference attendance is also pretty good (though variable based on quality of speaker). There is the expectation that attendings prioritize resident learning so if rounds are still going on, teams will break for noon conference and resume afterwards. Food is always provided.

Notably, our program has no punitive measures for not attending morning report and noon conference. As an intern and first call, I often found it hard to attend but as a senior, I usually make 80 - 90% of conferences. But the biggest pull for that is that the conferences are great and worth my while.

 

[tantacles]

I'm speaking from my n=1 experience, but attendance at our teaching conferences is excellent and here's why:

1) Quality - our morning reports are terrific and high yield. This actually doesn't require that much; the chiefs do a prepared 5-10min bit every report (usually a MKSAP question followed by 2-3 slides on teaching points). A resident then presents a case, usually with no prep. The chief guides the case, using socratic method to spur collegial discussion. Some of our program leadership (program director or aPD) always attend and add their teaching points.

2) We also have dedicated academic days but these are strictly protected time. The interns are excused for one half day a month, and their resident covers their work/pager during this time. The upper levels have multiple half days per week during ambulatory rotations and have no conflicting clinical duties during that time. Attendance is mandatory at these. They are usually great, clinically relevant lectures, and separate half days for interns and senior residents are also great because the teaching is at your level.

3) Noon conference attendance is also pretty good (though variable based on quality of speaker). There is the expectation that attendings prioritize resident learning so if rounds are still going on, teams will break for noon conference and resume afterwards. Food is always provided.

Notably, our program has no punitive measures for not attending morning report and noon conference. As an intern and first call, I often found it hard to attend but as a senior, I usually make 80 - 90% of conferences. But the biggest pull for that is that the conferences are great and worth my while.

Our program, similarly, is not at all punitive about not attending.

For our intern morning reports, which happen twice per week and are in addition to daily noon conference, the chair of medicine is always at one of them per week and adds great quality to the presentation, which is usually led by a chief resident.


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