Computer access of morning report/ Harrison Club PowerPoint presentations to the medicine residents has improved their confidence in management and in preparation for the monthly exams and for the American Board of Internal Medicine: an innovative education quality improvement project at Harlem Hospital center.

Background: Morning report is an important conventional teaching activity of residency programs worldwide.
Objectives: We aimed at creating a shared digital folder of the morning report/Harrison Club presentations for the training year of 2018-2019. Our primary objective was to assess the residents' satisfaction regarding its accessibility, as well as to estimate the percentage of residents who felt improvement in confidence levels in their management skills and their preparation for the monthly exams and for the American Board of Internal Medicine (ABIM).
Methods: This study is a cross-sectional study comparing the three different Post-Graduate Year residents. An anonymous questionnaire was distributed to 44 participating residents, and a multivariate analysis test was conducted.
Results: Most of the residents thought the morning report/Harrison Club folder was easily accessible. 86.7%, 82.4% and 83.3% found it valuable to improve their confidence in management; 80%, 70.6% and 83.3% found it valuable to improve their confidence in preparation for the monthly exams; and 86.7%, 82.4% and 83.3% found it valuable to improve their confidence in preparing for the ABIM among the PGY1, PGY2, and PGY3 residents, respectively.
Conclusion: Almost all the residents agreed that they would recommend adoption of a similar digital tool in other residency programs.

Introduction

Morning report is an important traditional and conventional educational tool for training of residents in residency training programs worldwide and across the USA [1]. McNeill et al. performed a literature review of morning report researches in residency training programs and found that the outcome of their research was difficult to measure since morning report had variable purposes and structures in different residency programs and concluded that programs should tailor its structure to its specific training goals [2]. Many residency programs have developed their own better version of morning report framework [3]. Daniels and Goldstein implemented a change in morning report framework and found the residents and the teaching faculty felt the change they made was important [4]. Morning report at Harlem hospital medicine department is unique in being structurally composed of two separate sections: ‘a Harrison club’ presentation during which a junior resident presents a 20-min PowerPoint educational lecture to the residents using different sources like Harrison textbook, UpTodate online reference and other different medicine board preparation references; and a 40-min clinical case presented by another resident of an interesting, rare or important case scenario they have encountered during their training. The subjects chosen for morning report focused on all the important medical topics in each medicine field that the residents would likely to encounter as medical cases in their future career; and were not pertaining to the monthly exams. Through this well-structured educational session that the medicine residency department has developed; and continued to improve throughout the years; the residents manage to improve their critical thinking, as well as their diagnostic and management skills.

A new development was implemented in July of the training year 2018–2019, in order to create an easy and handy computer access to the residents; the morning report/Harrison Club PowerPoint presentations of the year 2018–2019 were saved on a daily basis after the presentation in a shared department digital folder that was accessible to all the medicine residents. The residents did not know before creating the digital folder that they would be sent a survey later to assess the change of their confidence levels in the intended tested parameters.

The primary objective of our research project was to assess the residents’ satisfaction regarding the availability of the newly developed digital folder comprised of the residents’ Harrison club PowerPoint presentations, and to assess its importance in improving their confidence levels in preparation for their monthly exams and for the American Board of Internal Medicine (ABIM). A secondary objective was to assess the residents’ comfort level in recommending its adoption in other educational residency programs and educational institutions across the nation.

Materials and methods

Since our quality improvement research project used subjective data and did not include human subject research, no Institutional Review Board submission or approval was needed. Our department of medicine approved the research project and was supportive of the creation of the digital folder of the residents’ PowerPoint presentations to be accessible to all the residents.

Since all the residents in the program were granted access to the Harrison club/Morning report folder in July 2018, and hence no control group from the previous years of training was feasible for the study, the study we ran was a comparative analysis study, assessing the dependent variables in the three different compared Post-Graduate Year (PGY) levels of training.

This study was a cross-sectional study comparing the different groups of residents according to their PGY level of training, conducted in February 2019 on two consecutive days, assessing the primary and secondary objectives of the study. The number of saved morning report presentations from the beginning of the year to the time of study was 54.

An anonymous questionnaire was distributed to a group of participating residents from the different years of training in form of a Likert scale in order to find out the percentage of residents who found the ‘Harrison Club’ digital folder easily accessible, as well as to calculate the percentage of residents who felt their confidence level improved regarding their preparation for the monthly exams and for the ABIM.

Data collected from 44 PGY residents were analyzed using SPSS software (Statistical Package for Social Sciences software) version 23 where descriptive statistics and chi-square test were conducted. Descriptive statistics were conducted to determine the distribution of the data where frequencies and percentages were calculated. A multivariate analysis test was conducted to determine the significant difference between the independent variables and several dependent variables. Data analysis was conducted to assess the residents’ satisfaction regarding the availability of this tool as an accessible tool, and to evaluate its importance in improving their confidence levels in their management of patients and in their preparation for the monthly exams and for the ABIM certification per PGY level.

Results

Demographic variables

All of the PGY1 residents were aged between 25 and 30 years (53.8%, n = 7) and 30 and 35 years (46.2%, n = 6), whereas the majority of PGY2 residents were aged between 30 and 35 years (75%, n = 12). Fifty percent of the PGY3 residents were aged between 30 and 35 years (50%, n = 6). Two residents from the PGY1 class and one resident from the PGY2 class did not indicate their age group in the survey. Female respondents were the majority in PGY1 and PGY2 residents with 53.3% (n = 8) and 58.8% (n = 10), respectively, whereas male respondents accounted for 58.3% (n = 7) among PGY3 residents. Most of the residents had 3 or more years of clinical experience before residency with 46.7%, 58.8% and 83.3% among PGY1, PGY2 and PGY3 residents respectively, as shown in Table 1. Multivariate analysis indicated that there was a significant difference between age of the residents in the three different PGY levels with the p-value < 0.001. The age of the residents increased as the level of PGY increased from 1 to 3 as shown in Table 1.

Table 1.

Demographic variables (n = 44).

		PGY1 (n = 15)		PGY2 (n = 17)		PGY3 (n = 12)
		Frequency	Percent	Frequency	Percent	Frequency	Percent	P-value
Age	25-30 years	7	53.8	2	12.5	0	0.0	.000
	30-35 years	6	46.2	12	75.0	6	50.0
	35-40 years	0	0.0	2	12.5	3	25.0
	Above 40 years	0	0.0	0	0.0	3	25.0
Gender	Male	7	46.7	7	41.2	7	58.3	.508
	Female	8	53.3	10	58.8	5	41.7
How many years of clinical experience before residency	None	2	13.3	1	5.9	2	16.7	.222
	1 year	4	26.7	2	11.8	0	0.0
	2 years	2	13.3	4	23.5	0	0.0
	3 years or more	7	46.7	10	58.8	10	83.3
	Total	15	100.0	17	100.0	12	100.0

Most of the residents found the Harrison club/morning report folder an easily accessible tool with 86.7% (n = 13), 58.8% (n = 10), and 91.7% (n = 11) among PGY1, PGY2, and PGY3 residents, respectively. The residents’ use of the digital folder varied across the PGY levels. Majority of the PGY1 and PGY2 residents used Harrison club/morning report digital folder at least once constituting 57.1% (n = 8) and 35.3% (n = 6), respectively, whereas majority of the PGY3 residents constituting 41.7% (n = 5) have never used Harrison club/morning report digital folder. On the other side, 7.1% (n = 1) of the PGY1 residents, 17.6% (n = 1) of the PGY2 residents and 25% (n = 3) of the PGY3 residents used Harrison club/morning report digital folder more than three times.

Approximately, 86.7% (n = 13), 82.4% (n = 14) and 83.3% (n = 10) found it valuable to improve their confidence in management among PGY1, PGY2, and PGY3 residents, respectively.

Majority of the residents which constituted 80% (n = 12), 70.6% (n = 12) and 83.3% (n = 10) of the residents found it valuable to improve their confidence level in preparation for the monthly exams among PGY1, PGY2, and PGY3 residents, respectively.

Approximately, 86.7% (n = 13), 82.4% (n = 14) and 83.3% (n = 10) found it valuable to improve their confidence level in preparing for the American Board of Internal Medicine among PGY1, PGY2, and PGY3 residents, respectively.

Almost all residents from the different levels (apart from 1 resident in each group) agreed that they would recommend its adoption in other educational residency programs with 93.3% (n = 14), 94.1% (n = 16) and 91.7% (n = 11) among PGY1, PGY2 and PGY3 residents as shown in Table 2.

Table 2.

Residents' satisfaction.

		PGY1		PGY2		PGY3
		Frequency	Percent	Frequency	Percent	Frequency	Percent	p-Value
Do you find the Harrison club/morning report folder an easily accessible tool?	No	2	13.3	7	41.2	1	8.3	.065
	Yes	13	86.7	10	58.8	11	91.7
How often did you use Harrison club/morning report digital folder?	Never	4	28.6	4	23.5	5	41.7	.452
	1 time	8	57.1	6	35.3	1	8.3
	2 times	1	7.1	4	23.5	3	25.0
	3 times or more	1	7.1	3	17.6	3	25.0
Do you find it valuable to improve your confidence in management?	No	2	13.3	3	17.6	2	16.7	.973
	Yes	13	86.7	14	82.4	10	83.3
Do you find it valuable to improve your confidence in monthly exams?	No	3	20.0	5	29.4	2	16.7	.685
	Yes	12	80.0	12	70.6	10	83.3
Do you find it valuable to improve your confidence in preparing for the medical board?	No	2	13.3	3	17.6	2	16.7	.973
	Yes	13	86.7	14	82.4	10	83.3
Do you recommend its adoption in other educational residency programs?	No	1	6.7	1	5.9	1	8.3	.978
	Yes	14	93.3	16	94.1	11	91.7
	Total	15	100.0	17	100.0	12	100.0

Moreover, when multivariate regression analysis was conducted, we found that there was no significant difference between the residents' PGY levels and their level of satisfaction among the above variables with p value > 0.05.

Discussion

Most of the residents in our study found the Harrison club/morning report digital folder an easily accessible tool among the three different PGY levels although their use of this innovative tool varied substantially amongst the residents. This great variability is possibly related to the availability and variability of other conventional educational tools, or due to its novelty which brings with it unfamiliarity of use to some of the residents. Despite that, the majority of the residents felt their confidence in management and in preparation for the exams increased substantially when they used the morning report/Harrison club new digital folder. This is similar to Daniels and Goldstein research who implemented a change in morning report framework and found the residents and the teaching faculty felt the change they made was important [4]. This suggests that residency programs should continuously aim at changing their morning report structure and format to meet its educational goals.

Majority of the residents in all the different PGY levels stated that they found it valuable to improve their confidence in preparation for the monthly exams and for the ABIM. This is an important finding from this study although more research is needed to support it since a significant number of those residents mentioned they had never used it, or had used only one or two times, with only a small percentage of them who stated they had used it three times or more across the different PGY classes.

Almost all the residents from the different residency training years agreed that they would recommend its adoption in other educational institutions and residency training programs. This shared opinion indicates that the residents had similar views when it came to their satisfaction regarding the availability of Harrison club/morning report digital folder and its importance in improving their confidence levels in management of their patients and in preparation for the monthly exams and for the ABIM.