Metamorphosis of "Traditional Grand Rounds" to "Virtual Grand Rounds" Amidst the COVID-19 Pandemic: A Cross-Sectional Survey among the Dermatology Postgraduates.

Sir,

Grand rounds (GRs) are considered to be a time-honored tradition conducted as a weekly educational activity in many teaching institutions.[1] “Traditional” (face-to-face) GRs has been the backbone of medical education for more than a century, allowing clinicians to learn from interesting cases presented by their colleagues.[2] Before the pandemic, GR was conducted in the bedside of ward routinely as a once-weekly session in our department. However, during the COVID-19 pandemic, most of the beds in our institution have been converted into COVID isolation wards. This unprecedented scenario has led to a standstill in regular inpatient flow. Most of the dermatological ailments are managed in the outpatient clinic or via tele-conferencing. Though certain dermatological emergencies are admitted in the ward, the current social distancing norms restrict the ability of all residents and consultants to gather around the patient and discuss the case. This warranted us to introduce the virtual grand rounds (VGRs), and we would like to share our experience of it in this article.

The maintenance of inpatient records in the Medical Records Department (MRD) enables easy retrieval of old case records for academic purposes. In our department, it is customary to take serial clinical photographs of the admitted patients every day to monitor their clinical status. Care is taken to conceal the patients’ identity, and the photographs are stored in a designated folder in our department database with password restrictions providing access only to faculties and residents.

In VGR, a senior faculty member handpicked the cases to be discussed during the VGR for next 3 months from the MRD, ensuring accordance to the prescribed curriculum for postgraduate education. The residents were given the roster well in advance. We have conducted VGR for a total of 24 once-weekly sessions. One case was discussed in every session. The residents and the faculties assembled in a well-ventilated demonstration hall following the social distancing norms. The VGRs were divided into many small segments, with due time allotment for each, thereby all clinical aspects were covered. One member of the faculty was assigned as a moderator for each session. The resident presented the case history in detail from the selected old case record and the corresponding clinical images of the patient during their course of stay were displayed on a projector screen. The differential diagnoses, clinical and laboratorial approach to the case, and therapeutic options were discussed in detail.

With the first year postgraduates, discussions were primarily about history taking, clinical examination, and bedside procedures. The second year residents were trained to enhance their knowledge in clinical features and differential diagnosis of the disease. Final year students were tested primarily for their disease management skills. During the VGR, faculty members shared some fine nuances of clinical diagnosis, their valuable experiences of managing similar cases, and cleared the participants’ doubts. Feedback was received from the residents and faculty at the end of meeting.

A cross-sectional survey was conducted with a self-administered feedback questionnaire among the 12 postgraduates. It included 11 questions, and the responses were recorded using a 3-point Likert scale. The questionnaire had a good reliability (Cronbach’s alpha - 0.722). The data was entered into the Statistical Package for the Social Sciences (SPSS) version 23.0 (SPSS Inc., Chicago, Illinois, USA). The results were expressed as percentage responses.

All the residents who had attended the GRs session completed the questionnaire (response rate – 100%). The mean attendance recorded over the 24 sessions was 91%. The details of the response from students are tabulated in Table 1. The students gave high mean score for many of the attributes of VGR, including ease of presentation, opportunity to provide variety of cases, and adequacy of time for discussion.

Table 1

Perceptions of postgraduates about VGRs (n=12)

Attributes	Disagree n (%)	Neutral n (%)	Agree n (%)	Mean±SD
Do you think VGR is a reliable tool for facilitating virtual learning?	-	3 (25)	9 (75)	2.75±0.45
Is the ease of presentation good in VGR?	-	5 (42)	7 (58)	2.58±0.51
Do you find more variety of cases in VGR as compared to traditional grand rounds?	-	2 (17)	10 (83)	2.83±0.39
Does it provide adequate opportunity for engagement with faculty?	-	5 (42)	7 (58)	2.59±0.51
Are you satisfied with the faculty responses to your queries?	-	4 (33)	8 (67)	2.67±0.49
Do you feel the VGR helps you to prepare yourself for university practical viva voce?	-	5 (42)	7 (58)	2.58±0.51
Would you prefer VGR over traditional grand rounds in future?	4 (33)	5 (42)	3 (25)	1.92±0.79
Does the VGR highlight your areas of weakness?	2 (17)	7 (58)	3 (25)	2.08±0.67
Do you feel VGR is less stressful than traditional grand rounds?	-	5 (42)	7 (58)	2.58±0.51
Do you feel VGR conducted away from wards improve your academic performance?	1 (8)	7 (58)	4 (33)	2.25±0.62
Did VGR have adequate time for discussion?	-	2 (17)	10 (83)	2.83±0.39

VGR=virtual grand round

According to National Medical Commission, postgraduate curricula consist of two types of ward rounds, namely, service rounds and teaching rounds. Service rounds involve providing daily care to the patients. Teaching rounds are considered as “GRs” conducted for teaching the postgraduate residents. The details of these rounds are to be entered and maintained in a log book.[3] The differences between the ward rounds and GRs are shown in Table 2.[456]

Table 2

Difference between traditional ward rounds and virtual grand rounds

Traditional ward rounds	Virtual grand rounds
Visiting inpatients is a daily routine	Occasional activity
Only the concerned faculty and residents are present	Entire medical unit team is present
Conducted for all the patients in the ward	Conducted only with selective patients
Patient’s needs are primary	Student’s needs are primary
Main focus is on comprehensive inpatient care	Main focus is on teaching activity
Only minimal sharing of faculty experience to residents happens	More conducive for sharing the experiences of faculty to students

The benefit of GRs has been extensively demonstrated, and they remain a vital tool for imparting medical knowledge.[27] GRs educate the trainees of all levels; provide recent updates in diagnosis, treatment, and research; promote collegiality among various specialties; and provide a chance to acquire new knowledge and skills. However, there is even a threat that GRs may be at risk of completely vanishing in the future.[8]

In our survey, we received welcoming feedbacks to the major attributes of the VGR. The limitations of the survey include this being a single-center experience, small sample size and potential information bias of the residents as they are unlikely to rate it poor even if anonymized. Shifting from “traditional bedside GR” to this “VGR,” making use of the older case records and images without the real patients, was something new for our students and faculty. However, in spite of many logistic issues, the general response to this new experience in our institution was encouraging and positive.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.