Morning Report: Can an Established Medical Education Tradition Be Validated?

Morning report may be the most visible educational feature of residents' teaching. Although residents consistently rank it as the most important educational activity,1–4 its value is unclear. In this era of cost management and work hour restrictions, no facet of resident education should escape critical assessment. Does morning report have an evidenced-based impact on residents' learning or is it a ritual that could be abandoned? The objective of this narrative review is to examine the evidence for the value and effectiveness of morning report in graduate medical education.

We searched PubMed, Ovid, and the Cochrane Library for studies published in the English language between January 1, 1966, and October 31, 2011. Three authors independently performed the search (I.A.M., S.K.A., M.M.) under the direction of the librarian in Brooke Army Medical Center. We searched for key words and Medical Subject Heading terms related to medical education, methods, attitudes, and outcomes in regard to morning report. Search terms included morning report, teaching rounds, graduate medical education, academic medicine, and clinical competence. We limited our review to English-language articles. All journals and types of articles, including original articles, surveys, opinions, reviews, brief reports, editorials, and letters to the editor, were included. The References section of each article was reviewed and articles not previously identified were included for review.

After screening abstracts, pertinent articles underwent a full-text review by 3 of the authors to identify the study method, purpose of study, type of training program from which the study originated, interventions performed, outcomes measured, quality of the study, and risk of bias.5 Disagreements were resolved through discussion among all authors.

We identified 1921 articles. Only 90 articles were found to be related to our topic; of these, 19 were duplicates. Therefore, 71 articles were finally included in this report. Of the identified articles, 63 (89%) originated from the United States, 56 (79%) originated from internal medicine residency programs, and 6 (8%) focused on ambulatory morning report. Forty articles were original studies, and 31 articles provided no original data (reviews, brief reports, editorials, or letters to the editor). These latter articles often provided anecdotal reports and are included to complement the research articles. tables 1 and 2 summarize design, methodology, and results of original studies that originated from the United States and Canada.

The identified studies were heterogeneous in objectives, methods, and outcome measures. Most of the reports are unique; typically, each with a different goal and a different intervention to attain the goal. Therefore, they are not suitable for meta-analysis. Main outcome measures were resident satisfaction, faculty satisfaction, preparation for American Board of Internal Medicine examination, implementation of a curriculum by case selection, use of evidence-based medicine, effect on patient care outcomes, and adverse event detection.

Morning report traditionally describes a case-based conference where learners and teachers interact and discuss patient care, allowing learners to develop their professional identities.6 Our review revealed a lack of a formal definition of morning report, the most effective formats, or the optimal approach to assess its educational or clinical value. This may be explained by the fact that morning report did not begin as an educational initiative for residents. It was instituted as a meeting to monitor daily patient care and evaluate medical students and residents.1,7 Over time, this became a traditional way to monitor patients in teaching hospitals.8 

The structure of morning report may be classified into 3 components: (1) a prelude, which reviews outcomes of patients previously presented, answers research questions from previous sessions, or reviews admissions within the last 24 hours; (2) a detailed case discussion, usually focusing on 1 patient in internal medicine2,9,10 and multiple patients in pediatrics and surgical residencies11–13; and (3) a conclusion that may include a recap of “teaching moments” and formulation of questions for further research.2,9,10,14,15 Individual residency programs may add their own “flavor” to this core structure or use innovative approaches to attract new residents.16 For example, an internal medicine residency program may invite a pathologist to discuss a postmortem examination,10 or a librarian to provide in-depth literature review.17,18 Internal medicine programs may start morning report with a review of the Medical Knowledge Self-Assessment Program questions14,17,18 or use a quiz and mini-lecture format or describe “pearls” to optimize learning.19 Other programs may present a mini-journal club, in which articles of significance,20 and/or teachable moments regarding research design and statistical analysis are discussed,17 or they may discuss cost effectiveness and discharge planning.15 Some internal medicine programs reinforced learning points by distributing e-mails to attendees with a summary of the case presented or evidence-based answers to related questions.18,21 Formats of morning report range from a formal approach that divides the session into timed components and incorporates adult learning theory to a nonformal approach. Since 1997, morning report models have tried to incorporate evidence-based medicine and modern adult learning theories by stimulating residents' self-directed learning, conducting an interactive group discussion in the “search mode,” defining questions suitable for evidence-based searches, and identifying clinical uncertainties whose exploration benefit patient care and hence foster more deliberate learning principles.22 Others incorporated the PICO method (patient, intervention, comparison, outcome) in answering clinical questions.17 Some internal medicine programs offered formal training (resident-as-teacher educational intervention) for senior residents to be more effective presenters.23 

There is no standard frequency of morning report. In the past, sessions were held daily, including weekends.24,25 Recent reports indicate a decrease in frequency to 3 to 5 times weekly.2,11,12 There also is no standard length of the sessions. Traditionally, morning report lasted for an hour,2,8,9,12,22,26 although surgical and pediatrics residency programs limited the session to 30 minutes.4,7,11,16 A 30-minute resident-led morning report in a surgical program was perceived to increase medical knowledge and address issues relevant to patient care.27 In 1 study, the most frequent suggestion for improving morning report in a pediatrics residency program was to shorten it from 1 hour to 30 or 45 minutes, and to eliminate it on weekends.8 

Although case presentations with an ensuing discussion are the foundation of morning report, this element has become a point of criticism and debate. Since case presentations depend on residents' presentations and clinical skills, diagnoses discussed frequently differ from the final diagnosis, and several reports have suggested that this is a major limitation.2,4,11,16 In a study, 73% of cases presented at a pediatric morning report had a final diagnosis that differed from the initial diagnosis.11 Some studies found that morning report covered most of the internal medicine curriculum16,28; others commented on narrow coverage of clinical topics26 or criticized it for considering cases with unusual diagnoses at the expense of common illnesses.2 In 1 study, internal medicine residents did not present cases involving 4 of the 7 most common diagnoses, which may limit the educational benefits of discussing common diagnoses.2 Another study found that 14% of cases discussed were cardiovascular related, in contrast to only 5% for general internal medicine.16 In contrast, ambulatory morning report in internal medicine offered more diversity in the resident educational experience.29 It was well received by the residents29 and had valuable and unique contents.28,29 It also allowed some programs to discontinue lecture-based conferences held before the afternoon clinic.30 

A survey of family medicine program directors found that 77% of respondents had written goals for morning report, yet only 33% gave verbal or written feedback to residents.4 

Residents' perception of morning report has varied across the years. In a cross-sectional survey of internal medicine residents, respondents ranked the diagnosis and pathophysiology of diseases as the most important aspects of morning report, while medical ethics, cost, and research methods were considered less important.31 Surprisingly, some studies reported that bedside teaching as a part of internal medicine morning report was not favorably looked upon.24,32 Additionally, residents indicated that morning report should mainly be educational and not a venue for knowledge evaluation or faculty judgment.31 Cases selected by residents for discussion in morning report were more likely to be diagnostically difficult or rare.1 In 2 studies from internal medicine and pediatrics programs, residents preferred cases that were associated with remarkable imaging studies or cases in which residents disagreed with their attending physicians.2,11 Residents were less likely to select patients with chronic disease with a known diagnosis or cases in which the diagnosis was uncertain.2,12 

Most internal medicine residency programs preferred an equal mix of general internists and subspecialists as guest staff during morning report.32 In 1 survey of internal medicine residents, respondents agreed that morning report should be held at protected times and attended solely by second- and third-year residents, possibly owing to the time constraints on interns.32 Residents preferred attending physicians with a generous fund of general medicine knowledge and clinical wisdom, extensive interpretation skills, and an ability to ask stimulating questions to lead the discussion. Residents also identified attending physicians' limited knowledge and narrow focus as the most significant obstacles to effective teaching.32 Residents considered an interactive session with a question-and-answer format as the best format, followed by discussion of cases primarily by residents and lectures by attending physicians with little resident input. Most residents and faculty members preferred cases to be discussed after the history and physical examination had been presented, following the disclosure of all investigations.32,33 The optimal interactive balance was thought to be two-thirds Socratic discussion (moderator asks, residents answer) and one-third didactic discussion (moderator speaks, residents listen).32 Another report compared internal medicine residents' evaluations of 2 models for morning report; the first entailed separate sessions for interns and residents, and in the second model interns, residents, and students all attended the same morning report. Senior medical residents were responsible for selecting cases, faculty was present to share teaching pearls, and the chief residents acted as facilitators.25 Residents rated the second model of morning report as “good” or “very good” when asked about content, discussion, quality, and usefulness.

Residents are commonly responsible for organizing and delivering morning report, yet they typically receive no formal instruction on making effective presentations. A study that tested the effect of training internal medicine residents to deliver morning report entailed (1) a workshop where residents were counseled on how to improve teaching; (2) a 3-hour workshop on how to deliver morning report; and (3) reinforcing interventions where residents received informal short feedback, producing a modest increase in residents' favorable opinion of morning report.23 At the same time, senior residents who received the mentoring intervention reported greater difficulty in engaging the audience and were less confident.23 

Older reports from faculty likened morning report to “a rapid-fire exchange of information,”34 and criticized its educational value by placing learners in a “sponge mode” that did not encourage inquiry or foster research.34 In 1983, a survey of internal medicine residency programs found that morning report was used as a tool to evaluate medical care, yet also indicated changes in the culture with fewer presented cases with less rigorous discussion, and an increase in presentation of didactic information.24 In 1997, another report indicated that most pediatrics faculty members voiced negative views on the educational value of morning report and its impact on patient care.8 In a more recent survey of family medicine program directors, top-ranked purposes of morning report included resident education (100% of respondents), resident evaluation (75% of respondents), and evaluation of quality of patient care (33% of respondents).4 Respondents did not list reporting adverse events, discussing ethical issues, or socializing as purposes of morning report.

Faculty members, particularly subspecialty faculty, feel that morning report can be embarrassing when they miss diagnoses or know little about the subject being discussed.33,35 One study offered an analytic approach to minimize stress for faculty, including identifying the 10 findings that best summarize the case and use of a matrix to place different aspects of a case in a visible format.35 

Several new approaches to morning report have been described, including the use of morning report as a sign-out meeting after implementation of a night float system in a surgery residency.27 The intervention mitigated 2 of the unintended consequences of resident work hour limitations—the fear of disrupted continuity of care and the concern that the night float residents would have substantially limited interaction with faculty members.27 

In another innovative approach, cases presented used blinded, scripted presentations taken from published medical journals.36 Residents competed for the diagnosis, with bits of information given at specific times to allow for discussion, and the first group who answered correctly won. The new format resulted in a 30% to 40% increased attendance with this method.36 

Some internal medicine residency programs held morning report at noon (oral communication with program directors). Users of this approach report that a “noon report” allows for uninterrupted early morning rounds, which ensures timely patient care and earlier discharge times.

One study has evaluated the impact of incorporating evidence-based medicine in morning report on clinical outcome of patients.18 It compared the clinical outcome of 55 internal medicine cases that were presented at morning report to 136 matched controls. Discussion of cases was augmented by a literature search (aided by a librarian) to address questions of care and this information was immediately disseminated to the clinicians, resulting in a reduced length of stay and lower median hospital charges for cases discussed during morning report.18 

There has been a gradual shift in the format of morning report to de-emphasize the authority figures of the department chairs and program directors3,8 in favor of a focus on learner-centered approaches and the principles of reflective learning.1,7,8,15 Other changes in the culture of morning report include moving away from scrutinizing residents3,37 to resident education, nurturing, and encouraging participation.1,7,36 In the past, morning report was used to monitor clinical services and performances3,8,20,24; more recently, the emphasis has been on condensing learning into take-home points.14 The third shift has been a change from a focus on the short-term care of newly hospitalized patients24 to the general principles of patient care, critical thinking, evidence-based decision making, as well as improvement of residents' skills and confidence.4,7,15,18,22,36 

In 2000, a report noted deficiencies in our knowledge about morning report in 3 areas: types and characteristics of learning and teaching, factors affecting participant satisfaction, and effects on residents' knowledge; it also commented on a need for multi-institutional research on the effectiveness of new strategies for morning report.1 Since then, little has been added to our knowledge. A summary of the challenges associated with critically evaluating morning report commented on the impossibility of designing randomized blinded trials and the challenges of standardizing testing and scoring.7 This summary also commented on confounders, such as the personal attributes of residents and faculty, and on the difficulty of isolating the effect of an intervention from previous knowledge or educational offerings such as noon conference.7 Such difficulties were summarized in a recent editorial.38 

The lack of studies to document the effectiveness of morning report does not denote a lack of effectiveness. Morning report is conducted in other countries,33,39–42 using a format similar to that in the United States, and incorporating a learner-centered evidence-based approach.39,42 The continued existence and use of morning report for several decades in different nations and health care settings indicates that it remains a valuable tool.

By interacting with peers and role models, residents and students learn the culture of medicine and develop their professional identities.6 This is shown by a study that explored how medical ideology and physician professional identity are socially constructed by analyzing transcripts from 20 internal medicine morning reports.6 The investigators noted that “although medical residents deviate from traditional ideology by articulating the voice of the life world, faculty physicians counter these moves by asserting the voice of medicine.”6 Recent theories of the acquisition of professional skills also have focused on the importance of deliberate practice.43,44 Deliberate practice is defined as activities that are designed to improve the level of performance, with immediate informative feedback and knowledge of results of the performance.43 

If morning report is to remain a relevant component in resident education, it should be viewed as an educational tool to foster self-directed scholarly inquiry.22 It should de-emphasize passive learning and encourage a learner-centered approach to medicine, and should also serve to improve patient care while emphasizing real-life costs and efficiencies. Finally, morning report should serve as a forum for residents to practice skills in teaching and leadership, with faculty as supporters of resident teaching and inquiry (table 3).

The lack of a standardized format for morning report allows residency programs to tailor it to their own unique needs and challenges. For example, under limits on resident work hours, morning report may be used as an effective way for ensuring continuity of patient care. A program that wishes to increase its residents' board certification pass rate may incorporate relevant questions into morning report, and a center that lacks patients with complex medical problems may use cases derived from published case reports. With this understanding, morning report can be a powerful educational tool to be used by program directors to remedy the weaknesses of their program.

Despite the lack of a clear definition in the literature, morning report represents a scientific formal meeting in which residents and faculty educators interact and exchange case-based clinically oriented information. In a time that calls for innovation and attention to time and financial costs, programs should tailor morning report to their specific needs. Frequent scrutiny is necessary to ensure that it meets the academic and nonacademic goals of our new generation of residents.