Khaja H. Mujtaba Quadri  ( Shifa College of Medicine, Islamabad. )
Tara Jaffery  ( Shifa College of Medicine, Islamabad. )
Ali Yawar Alam  ( Shifa College of Medicine, Islamabad. )
Faisal Rahim  ( Shifa College of Medicine, Islamabad. )

To determine the impact of multimedia and up-to-date on internal medicine resident learning in morning report (MR), we converted our traditional medicine morning report to 'Up-to-date' programme incorporated and multimedia supported format which includes computer, multimedia projector and up-to-date CD ROM. A questionnaire was administered three months after the change and rated on a Likert scale. Preliminary experience demonstrated of a favourable overall resident and faculty perception and acceptance of the change. 

Medicine has lately taken a learner centered twist in  higher education. Most house staff considers the primary function of morning report (MR) to be educational.1  Attending physicians with limited knowledge are often viewed  as the major obstacle to effective teaching in morning reports.2 Morning reports can be used effectively to address nontraditional or rarely discussed topics that are important to the overall professional development of  residents.3
Outpatient morning reports have also found a niche in several leading academic centers to meet the needs of increasing numbers of residents and medical students rotating  through ambulatory settings.4
The purpose of morning report has been predominantly cited as education, evaluation of residents and quality of services, detection and reporting of adverse events, discussion  of non-medical issues and social interaction.5 In this information technology age, one challenge is to create an educational system which is better able to respond to changes in the outside world than has been the case to date.6
Medicine morning report has been a time honored learning tradition but it appears to have been trapped in its evolutionary trajectory by forces of stagnation.
In an effort to create a renewed interest in this prime academic activity, a change in format, content and attractiveness of presentations has become imperative. In addition, evidence  'at hand' is replacing  unchallenged  "opinion based" expertise of faculty. At Shifa College of Medicine and Shifa International Hospitals we attempted to change this status quo and our preliminary experience is reported here.

At our institution comprising of a blend of North America,United Kingdom and Pakistani trained faculty, we had for the previous six years adopted a traditional morning report format consisting of presentation of interesting  cases by residents with the aid of overhead projectors,transparencies,a white board and an X-ray illuminator box. Consultants, residents and elective students were participants in the process. The expert opinion was predominantly "opinion" based. In an effort to move to a more 'evidence based' setting, a new pilot project was introduced  in 2004-2005  incorporating a computer, multimedia projector and the popular CD Rom reference library, 'UptoDate'.
This format involved case presentations made in 'power point' and projected by a multimedia projector, followed by a targeted topic presentation. Provision of  online internet access and Up-to-Date CD Rom  was ensured. This 4 monthly updated reference library is edited by Dr.Burton Rose at Harvard University, Boston,USA.
A survey of 40 participants was sought three months after the pilot project was initiated, whereas 15 participants were excluded having attended only the new morning report format.
Statistical software SPSS Version10.0 was used for data entry and analysis. Data analysis was based on exposure to previous format of morning report in comparison with the new format on the same respondents. The study participants were asked to rate their experience of the two formats of morning report (as Better or Not Better) in terms of the various explanatory variables, which were ' Use of audiovisual aids', 'scientific information', 'learning,', 'Use of Up-to-Date' and 'whether they would recommend any one format of morning report to others'.  Chi-Square test was applied to see the association between the outcome of interest and each of the explanatory variables. Fisher's Exact test was used where the expected cell count was less than five. The level of  statistical significance was p<0.05.
 Table 1 depicts the results of the survey. It was observed that 92% of the respondents thought that the new format of morning report involved better usage of audiovisual aids, as compared to 4% respondents in favor of the old morning report (p <0.001). Of all, 68% of the respondents considered the new morning report better as compared to 24% who thought that old morning report was better in terms of scientific information (p= 0.004). Sixty four percent respondents opined that Use of Up-to-Date CD Rom reference library improved the new morning report format, while 5% liked  the old morning report format   (p=0.004). There was no perceived difference in learning amongst respondents exposed to the two formats of morning report (p=1.000).
Sixty percent respondents said that they would recommend the new morning report format to others, 24% were in favour of the old morning report format, while 16% were still undecided.

Table 1. Comparison of the two formats of Morning Report.

 

	Previous	New Morning
Variables	Morning Report Better		Report Better	P value
	(n=25)		(n=25)
Audiovisual aids	1 (4)	23	(92)	<0.001
Scientific information	6 (24)	17	(68)	0.004
Learning	10 (40)	10	(40)	1.000
Use of 'Up-to-Date' CD
Rom Reference Library	5 (20)	16	(64)	0.004

Our experience of the pilot project with a new innovative morning report format was an interesting one. An analysis of our results based on a questionnaire administered to a mixed group of faculty, medical residents in CPSP approved Internal Medicine Residency program and Medical officers, reveals that Audiovisual aids, incorporation of Up-to-Date and quality of dissemination of scientific information were perceived to have made the newer morning report format better. In addition most respondents would recommend this format to other learners.

We made an attempt to break away with tradition in conducting our prime educational activity, the Medicine morning report, by incorporating a more evidence based culture and modern audiovisual aids such as UptoDate and use of multimedia presentations. Despite small numbers, our initial experience demonstrated a significant change in consultants and residents perception for the better. However we were unable to demonstrate objectively any improvement in overall learning at this preliminary stage. Subsequent data may demonstrate a long term impact of this change.

We gratefully acknowledge,  Dr.Marie Diener-West, Professor of Biostatistics, Johns Hopkins Bloomberg School of Public Health (U.S.A), for her guidance with the statistical analysis.

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2. Ways M, Kroenke K, Umali J, Buchwald D. Morning report: A survey of resident attitudes, J, Arch Intern Med,1995;155:1433-7.
3. D`Alessandro DM. Documenting the educational content of morning report, Arch Pediatr Adolesc Med 1997;151:1151-6.
4. Spickard A 3rd, Ellis S. Outpatient Morning report: A New Educational Venue, Academic Medicine 2000, 75:197.
5. Amin Z, Guajardo J, Wisniewski W, Gordage G, Tekian A, Niedeum LG. Morning Report: Focus and methods over the past three decades, Academic Medicine 2000, 75:S1-5.
6. Towle A. Changes in Health care and Medical Education for the 21st Century, Br Med J 1998, 316:301-4.