Background: Morning report is a core educational conference in internal medicine training programs. A recent national survey found that the duration and content of expert clinician commentary influences residents’ perceptions of morning report quality, yet no prior study describes comments made by internal medicine attendings in this core conference.
Methods: We conducted a multicenter prospective observational study describing the content, frequency, and duration of comments made by attending physicians during morning report at 13 different Veterans Affairs academic medical centers. Investigators at each participating site observed a series of morning reports and recorded a range of variables including number of attending comments, field of practice of commenter, duration of comment, and whether the comment contained teaching. Teaching and non-teaching comments were categorized by type of content. Sites also collected data on number of learners, report format, and whether report was scripted (facilitator has advance knowledge of the case) or unscripted. A negative binomial regression model was developed to describe variables associated with the number of attending comments per report.
Results: A total of 2,344 attending comments during 250 conferences were observed. The mean number of attending comments per report was 9.4, with a range of 3.9 to 16.8 comments per report at different sites. After excluding chat box comments, 33% of comments were longer than one minute, with a range between 12% and 68% across sites. The median number of attendings present at morning report was 3 (IQR, 2 – 5), most of whom were hospitalists (median 2, IQR, 1 – 3). Approximately equal proportions of comments were made by hospitalists (36%), general internists (30%), and internal medicine subspecialists (33%). Similar numbers of in-person (889) and virtual audio/video (847) comments were observed, while virtual chat box comments (597) were observed less often. 73% percent of all comments were categorized as educational by observers with the top teaching topics being differential diagnosis (21%), management (14%), and testing (10%). The most common categories of non-teaching comments were non-clinical questions (50%), jokes (14%), and past clinical experiences (9%). On multivariate analysis, in-person reports were associated with 57% more attending comments [aIRR 1.57 (1.23, 2.01); p=0.0003], while scripted reports were associated with 28% fewer attending comments [aIRR 0.72 (0.58, 0.91); p=0.005]. Each additional non-hospitalist general internist present was associated with 26% increased comments [aIRR 1.26 (1.09, 1.46); p=0.002].
Conclusions: Attending comments were predominantly teaching-oriented and emphasized differential diagnosis, management, and testing. There were substantial differences between programs in the number of comments and their duration which likely affects the local learning environment. Programs that are interested in increasing attending involvement in morning report should consider encouraging in-person and unscripted reports. Programs that are interested in decreased attending involvement should consider virtual formats and scripted reports.
