Morning report: how to do it.

Morning report is an important clinical learning activity in many neurological institutions. A long experience of these meetings allows identification of several components to enhance its success. Meetings are best if brief (one or two cases) and held regularly, preferably daily and early in the working day, with full in-person team engagement. A senior clinician should lead the meeting and commit to a single interpretation, without fear of being wrong. Although the environment is relaxed (refreshments typically provided), it is a working meeting and with the essential focus on the patient rather than the learners. The rich learning experience is greatly enhanced by a subsequent confidential email summary and interpretation of the case(s) sent to all participants.

The active feedback program: bringing medical students out of the shadows.

Despite many advances in medical education, medical students continue to mostly shadow on inpatient rotations like Neurology. They seldom receive face-to-face feedback or mentorship from attending physicians. This results from not training attending physicians how to integrate medical students into clinical activities in a way that does not detract from patient rounds. The 'active feedback program' is a framework for inpatient rotations that immerses medical students in clinical activities with the attending physician providing mentorship and feedback that emphasizes brevity. Expectations are laid out early. Students pick up 2-3 patients, performing daily oral reports and focused neurological exams with immediate feedback. Feedback includes items to not only correct the treatment plan, but also improve the student's oral presentation and neurological exam skills. Students also receive formal individual feedback twice during the rotation that includes constructive criticism and specific task-oriented praise. The active feedback program awaits formal testing, but seems to result in medical students learning at an accelerated rate. Neurology residents also appear to benefit by learning from critiques of the medical students and taking on higher level responsibilities. Patient rounds move quickly, leaving time for the attending physician to keep up with other obligations. As academic Neurologists we have a duty to transfer our skills to the next generation of physicians. If proven in future studies, wide adoption of the active feedback program will allow us to finally move medical students out of the shadows and come closer to achieving this noble goal.

Building upon the foundational science curriculum with physiology-based grand rounds: a multi-institutional program evaluation.

Introduction: Vertically integrating physiology into patient care has the potential to improve clinical reasoning. Clinical Physiology Grand Rounds (CPGR) is a case-based teaching method that brings together students from all years of medical school to focus on linking clinical presentations to core basic science concepts including anatomy, physiology, and pathophysiology. In this study, we describe the implementation of CPGR at two different institutions in the United States and assess student-reported outcomes.Methods: We survey students who participated in CPGR at Columbia University College of Physicians & Surgeons (P&S) and Medical University of South Carolina (MUSC). Subjects were queried across three domains: the benefits of attending, the impact of concept maps, and the impact of the mixed-learner environment.Results: Despite differences in session leadership and the underlying medical school curricula, conference attendees reported similar benefits at the two schools included in this study. Students overwhelmingly (92.9%) reported that remembering clinical presentations was easier when they understood the underlying physiology. They also reported gaining a true understanding of concepts that were previously memorized (87.5%). Both clinical (92.5%) and preclinical students (93.1%) valued the mixed-learner environment as a component of the conference.Discussion: By assuring a mixed-learner environment with near-peer interactions, using concept maps as a teaching tool, and rigorously linking clinical presentation and management to physiological concepts, we found that the key benefits of CPGR were replicable across different institutions, despite several local differences in how CPGR was implemented, led, and conducted.

Teleconferencing for Virtual Visiting Professors and Virtual Grand Rounds.

SUMMARY: The 2020 global pandemic related to the coronavirus has led to unprecedented interruptions in typical patient care and resident education. Teleconferencing software was deployed by many institutions to comply with quarantine and social-distancing regulations. To supplement the loss of clinical experience for trainees, the authors implemented a novel virtual-educational programming using virtual visiting professors and virtual grand rounds. The authors describe the two different formats and advantages such as access to multiple speakers on diverse, innovative topics and decreased financial burdens to the host program. However, the authors do acknowledge some disadvantages from lack of face-to-face social interaction/networking and the need to consider time-zone differences. Both new programs were embraced by trainees at the authors' own institution and residents/medical students across the United States and Canada and around the world. The authors believe teleconferencing should be permanently incorporated into future educational opportunities for plastic surgeons, as it provides easy access to high-quality information.

Implementation status of morbidity and mortality conferences in Austrian hospitals-A cross-sectional national survey study.

INTRODUCTION: Morbidity and mortality conferences (M&MCs) are an instrument for learning from past complications, unexpected follow-ups and deaths in hospitals and are important for improving patient safety. However, there are currently no quantitative data on the implementation of M&MCs in Austria. The aim of the study was to determine the status quo of the M&MCs in Austria. MATERIALS AND METHODS: A national cross-sectional study was conducted by means of a survey of 982 chief physicians of surgical disciplines, internal medicine, anesthesiology, intensive care, gynecology/obstetrics and pediatrics. The questionnaire focused on overall goals, structure and procedures of hospital M&MCs. RESULTS: Of the 982 contacted chief physicians, 314 (32.0%) completed the survey. Almost two thirds of the respondents, i.e. 203 (64.7%), had already implemented M&MCs. Of the 111 chief physicians who had not yet introduced M&MCs, 62 (55.9%) were interested in introducing such conferences in the future. Of the 203 respondents that had implemented M&MCs, 100 stated that their M&MC could be improved. They reported issues with "shame and blame" culture, hierarchical structures, too little knowledge about the capability of M&MC and, in particular, time constraints. Overall, the participating chief physicians showed that they are striving to improve their existing M&MCs. DISCUSSION/CONCLUSION: While we found a relatively high number of already implemented M&MCs we also identified a large heterogeneity in the format of the M&MCs. A highly structured M&MC including guidelines, checklists or templates does not only considerably improve its outcome but can also alleviate the main limiting factor which is the lack of time.

Bedside teaching without bedside - an introduction to clinical reasoning in COVID-19 times.

Introduction: The Corona virus pandemic rendered most live education this spring term impossible. Many classes were converted into e-learning formats. Teaching at the bedside (BST) seemed unfeasible under the circumstances. BST and clinical reasoning as its major outcome is introduced at the beginning of semester 5, henceforth all BST refers to this first presentation. Project outline: To ensure proficiency of current 5th semester students in future BST sessions, the introduction could not be cancelled albeit teaching with patients was. Knowing that the practical learning objectives of bedside teaching cannot be mirrored in online formats, a compensating module to teach the concept of BST and clinical reasoning had to be designed. Summary of work: To facilitate an understanding of the concept of bedside teaching with a focus on clinical reasoning we developed paper cases and a survey in Microsoft Forms following the history and examination path used in live BST with the addendum of clinical reasoning tables. For the first paper case, a personal feedback was provided for the clinical reasoning tables. A sample solution was provided later for self-feedback on the whole case. The first case was completed by 87, the second by 40 of 336 students. Response to individual feedback was positive. Students still missed hands-on training in history taking and examination with patients. Discussion: Paper cases cannot fully substitute BST. However, given the prime directive during the pandemic to protect our patients, this module engaged around one third of the cohort. The review of uploaded clinical reasoning tables gave proof to the sufficient students' grasp of clinical reasoning. Conclusion: Albeit not an exhaustive substitute for BST, this online module seems a feasible way to convey clinical reasoning strategies to students.

Colaboración interprofesional en las sesiones clínicas conjuntas en una Unidad de Cuidados Intensivos: percepciones de enfermeras y médicos / Interprofessional collaboration in joint clinical sessions in an intensive care unit: Perceptions of nurses and physicians

INTRODUCCIÓN: La práctica colaborativa es un proceso interpersonal en el que interactúan diferentes disciplinas profesionales que comparten objetivos, participan en la toma de decisiones y proporcionan una atención integral y de calidad. Las sesiones clínicas conjuntas ofrecen la oportunidad de interactuar y mejorar la comunicación entre profesionales y optimizar los resultados en la práctica. OBJETIVOS: Explorar las percepciones de enfermeras y médicos sobre la práctica colaborativa en las sesiones clínicas conjuntas en Unidad de Cuidados Intensivos. MÉTODO: Estudio de análisis crítico del discurso, a través de entrevistas semiestructuradas y diarios de campo, usando como referencial teórico los conceptos de Campus, Capital y Habitus planteados por Pierre Bourdieu. PARTICIPANTES: enfermeras y médicos de una Unidad de Cuidados Intensivos, reclutados mediante muestreo intencional. Las entrevistas fueron codificadas por todos los investigadores, posteriormente se hizo una puesta en común y se interpretaron los datos en el contexto en el que fueron recogidos. RESULTADOS: Emergieron 5 categorías: 1) Concepto: integración e implicación de un equipo con aportaciones colectivas y objetivos compartidos, 2) importancia: aumenta la seguridad del paciente, mejora la satisfacción de los profesionales y la calidad de atención, 3) factores: la ausencia de cultura de organizaciones dificulta la práctica colaborativa, 4) rol: la enfermera percibió que tiene un rol pasivo (oyente) durante las sesiones clínicas y el médico un papel activo (comunicador), y 5) estrategias de mejora: establecer horario y conciliación de tareas interprofesionales. CONCLUSIONES: Existe una necesidad de empoderamiento en la participación activa por parte de las enfermeras en las sesiones clínicas conjuntas. El colectivo médico debe tener más en cuenta las percepciones humanísticas que pueden aportar otros profesionales. Fomentar la escucha activa en los médicos, mejorar la comunicación real por parte de las enfermeras y generar un espacio donde impere el respeto y la confianza, favorecerán la dinámica de trabajo interprofesional

INTRODUCTION: Collaborative practice is an interpersonal process in which different professional disciplines that share objectives interact, participate in decision-making and provide comprehensive and quality care. The joint clinical sessions offer the opportunity to interact and improve communication between professionals and optimise results in practice. AIM: To explore perceptions of nurses and physicians about collaborative practice in joint Intensive Care Unit clinical sessions. METHOD: Critical discourse analysis, through semi-structured interviews and field journals, using as theoretical reference the concepts of Campus, Capital and Habitus by Pierre Bourdieu. PARTICIPANTS: nurses and physicians of the Intensive Care Unit, who were recruited by intentional sampling. Semi-structured interviews were conducted and a discourse analysis was then performed. The interviews were coded by all the researchers, then shared and the data were interpreted in the context in which they were collected. RESULTS: Five categories emerged: 1) Concept: integration and involvement of a team with collective contributions and shared objectives, 2) importance: it increases patient safety, improves professional satisfaction and quality of care, 3) factors: the absence of culture organisations make collaborative practice difficult, 4) role: the nurse perceived that she plays a passive role (listener) during the clinical rounds and the physician an active role (communicator) and, 5) improvement strategies: to establish a schedule and balance interprofessional tasks. CONCLUSIONS: There is a need for empowerment in active participation by nursing staff in joint clinical sessions. The medical group should be more aware of the humanistic perceptions that other professionals can bring. Encouraging active listening in physicians, improving real communication by nursing staff and generating a space where respect and confidence prevail, will favour interprofessional work dynamics

Virtual Rotations During COVID-19: An Opportunity for Enhancing Diversity.

The COVID-19 pandemic has presented unique challenges to medical education. With the lack of in-person away rotations for the 2020-2021 residency application cycle, virtual rotations have surfaced as an alternative. The virtual rotations that the authors participated in allowed for active participation in various resident educational activities such as journal club, grand rounds, and morning conferences. One critical aspect of virtual rotations was the one-on-one meetings with the program leadership. In addition to a virtual tour of the hospital and campus, many programs offered virtual social hours with the residents to converse about the program, the city, and the match process. A few programs even allowed applicants to attend virtually live-streamed surgeries. These rotations offer students, especially those without a corresponding home program, an invaluable opportunity to express their interest in a particular program and gain foundational knowledge about the specialty. Virtual rotations also provide underrepresented minorities and international medical graduates with clinical exposure, mentorship, and networking opportunities, mitigating some of the challenges presented by COVID-19.

Exploring interdisciplinary teamwork to support effective ward rounds.

PURPOSE: This paper aims to explore if health professionals share understanding of teamwork that supports collaborative ward rounds. DESIGN/METHODOLOGY/APPROACH: A purpose-designed survey was conducted in two acute medical and two rehabilitation wards from a metropolitan teaching hospital. Medical officers, nurses and allied health professionals participated. To understand characteristics that support collaborative ward rounds, questions developed from literature and industry experience asked: what are the enablers and challenges to teamwork; and what are clinicians' experiences of positive teamwork? Descriptive and thematic analyses were applied to the dimensions of effective teamwork as a framework for deductive coding. FINDINGS: Seventy-seven clinicians participated (93% response rate). Findings aligned with dimensions of teamwork framework. There was no meaningful difference between clinicians or specialty. Enablers to teamwork were: effective communication, shared understanding of patient goals, and colleague's roles. Challenges were ineffective communication, individual personalities, lack of understanding about roles and responsibilities, and organisational structure. Additional challenges included: time; uncoordinated treatment planning; and leadership. Positive teamwork was influenced by leadership and team dynamics. PRACTICAL IMPLICATIONS: Ward rounds benefit from a foundation of collaborative teamwork. Different dimensions of teamwork present during ward rounds support clinicians' shared understanding of roles, expectations and communication. ORIGINALITY/VALUE: Rounds such as structured rounding, aim to improve teamwork. Inverting this concept to first develop effective collaboration will support team adaptability and resilience. This enables teams to transition between the multiple rounding processes undertaken in a single ward. The emphasis becomes high-quality teamwork rather than a single rounding process.

Creating and Implementing a Resident Emotional Wellness Initiative in an Acute Care Setting: The Role of the Palliative Care Social Worker.

Caring for dying patients is often a new experience for ICU residents. End-of-life and palliative training in medical schools is lacking. Many residents experience troublesome emotions during residency. Literature establishes that residents show lower well-being scores than similar populations. To make emotional wellness a priority for residents, monthly mandatory Palliative Care Rounds (PCR) were established in the ICU. The role of the Palliative Care Social Worker (PCSW) is central in planning and implementing PCR. Social workers have unique skills well-suited to this type of activity in an acute care setting. Residents present cases and the PCSW facilitates discussion to explore complex emotions helping residents process their feelings. Forty-five residents responded to a seven-item questionnaire, out of 70 potential resident respondents (64% response rate). Only 60% said they learned about end-of-life and its emotional aspects in medical school. Ninety-eight percent reported the PCR helped them be more aware of their feelings, and would recommend it to colleagues. Ninety-five percent said PCR are important for interns and residents to help them grow professionally and become better clinicians. Through the process of dissecting their emotions, PCR allows for personal and professional growth that improves residents' ability to become empathic providers.

[Assessment of a newly-implemented blended teaching of intensive care and emergency medicine at Paris-Diderot University]. / Évaluation d'un enseignement multimodal intégrant du e-learning dans l'apprentissage de la réanimation et de la médecine d'urgence au cours du second cycle des études médicales.

INTRODUCTION: Blended-learning methods could be a response to student nonattendance. Non-compulsory teaching combining e-learning/interactive face-to-face sessions has been implemented at Paris-Diderot Medical School for the teaching of intensive care and emergency medicine during the 2018/2019 university period. The aim of the study was to assess this newly-implemented blended teaching. METHODS: Questionnaire submitted to the 388 DFASM3 medical students present at the faculty exam of intensive care/emergency medicine. Attendance at a teaching modality was defined by the follow-up of more than half of this teaching modality. Correlations between attendance at e-learning and/or interactive face-to-face sessions, and grade were performed. RESULTS: A total of 358/388 (92%) students participated in this survey. A quarter of the students (88/321 - 25%) reported they usually attended at traditional lectures. Regarding blended-learning, 210/317 (67%) students reported having attended at e-learning courses and 84/321 (27%) attended at interactive face-to-face sessions. The distribution of students according to their attendance at e-learning and/or interactive face-to-face sessions was significantly different (P<0.01). There was a significant correlation (P<0.001) between attendance at e-learning and grade obtained at the faculty exam. Nevertheless, this correlation was also found for these students in another course taught traditionally. Overall, 309/315 (98%) students were satisfied with the blended teaching, 297/318 (93%) wanted its extent to the whole medical school's curriculum. CONCLUSION: The use of combined learning methods reached more students than traditional teachings and allowed the University to focus on its role of knowledge transfer.

Goal-Directed Achievement Through Geographic Location (GAGL) Reduces Patient Length of Stay and Adverse Events.

This prospective cohort study aimed to improve hospital outcomes through geographic location of hospitalist patients and conducting daily multidisciplinary team rounds-Goal-directed Achievements through Geographic Location (GAGL). Patients were admitted to a geographic (GAGL) study unit where daily multidisciplinary rounds took place among nursing, case management, a hospitalist, pharmacy, physical and occupational therapy, respiratory therapy, and nutrition services. A total of 985 (56.4%) patients were admitted to the GAGL study unit and 760 patients (43.6%) were admitted to non-GAGL units. Patients admitted to the GAGL study unit had a shorter average length of stay (3.64 days vs 4.35 days, P = .0001) and a lower number of risk events (91 [9.2%] vs 93 [12.2%], P = .038). There was no significant difference in 30-day readmissions, avoidable day events, or code blue team activations. GAGL provides a framework for hospital organizations to improve provider communication, hospital efficiency, and patient safety.

Improving Efficiency and Meeting Expectations Without Compromising Care on Trauma Surgical Rounds.

BACKGROUND: Care teams on complex surgical services face a growing list of competing expectations. Approaches to quality improvement must use minimal resources and address both system and human requirements to meet expectations without compromising care. The purpose of this study was to demonstrate that iterative prototyping, combined with a rigorous quantitative evaluation approach, can effectively improve system and stakeholder efficiency on daily trauma surgical rounds at an academic safety-net hospital and level 1 trauma center. MATERIALS AND METHODS: This study occurred between May 2017 and October 2017 at the Zuckerberg San Francisco General Hospital and Trauma Center. Care team members rounding on the trauma service included attending trauma surgeons, fellows, residents, interns, nurse practitioners, pharmacists, and medical students. We used human-centered design to develop and test solutions to improve the surgical rounding process. Each prototype was evaluated using qualitative design research methods, which informed the next iteration. Time observations of rounding activities were adopted from the Lean methodology and tracked before and after implementation. Intern work hours, on-time operative starts, and discharge order times were also tracked before and after implementation. RESULTS: Four prototypes were designed and iteratively implemented, producing care team satisfaction by the end of the implementation period. Discharge order times decreased by a median of 58 min, intern work hours were decreased by 97 min/d, and first operative case on-time starts increased from 40% to 63% (P < 0.05). The time spent on clarifications decreased by 4.7% (P < 0.05), allowing for more time to discuss care plans with the patients themselves. CONCLUSIONS: Iterative prototyping as part of a human-centered design methodology is a powerful tool to address complex systems with diverse interests and competing priorities. Rapid, in-context prototyping is feasible on a complex trauma surgical service and can result in improved workflows and efficiency for the system and its stakeholders.