Reverse Morning Report: A Case-Based, Fellow-Lead, Curriculum for Internal Medicine Residents Rotating on the Inpatient Malignant Hematology Service

Introduction

Malignant hematology inpatient services are increasingly busy and often staffed by internal medicine residents (IMR) and hematology fellows (HF). Despite time constraints, institutions must prioritize efficient means of educating these learners about a complex patient population. “Morning report” is a time-honored tradition in IM residency and involves the prospective presentation of data to facilitate discussion on diagnosis and management. However, residents rotating on inpatient malignant hematology services often care for inpatients where the diagnostic and management plans are already established, making the traditional morning report a less effective learning format. To address this educational gap, we created a case-based curriculum called “Reverse Morning Report” to facilitate resident learning about the diagnostic process, management, and recognition of emergencies in patients with hematologic malignancies.

Methods

The curriculum involved biweekly, thirty-minute discussions led by the HF rotating on the malignant hematology service at the James P. Wilmot Cancer Institute during the 2023-2024 academic year. On a weekly basis, the HF identified a patient with a hematologic malignancy or complication including acute myeloid leukemia, non-Hodgkin’s lymphoma, multiple myeloma, febrile neutropenia and tumor lysis syndrome; with the objective of addressing these four key topic areas on a rotating basis. Using the patient case, the IMR retrospectively reviewed the initial presentation, diagnosis, and management with provided discussion questions that were designed under a conceptual framework described for teaching cases (Kim et al, Medical Education 2006). The first session of each week focused on relevant hematopathology including flow cytometry or cytogenetics, and the second session focused on treatment decisions at the level of expected knowledge for an IMR.

Immediately following the teaching sessions, IMR were asked to complete an electronic, 5 question survey based on the concept of ecological momentary assessment, to allow respondents to provide real-time, repeated feedback about each session and to increase survey responses. IMR were asked to provide their impressions about the format of the sessions and the impact of the learning sessions on their clinical practice. Qualitative comments about the curriculum were collected from IMR rotation evaluations. HF were also surveyed to assess their impressions of the curriculum.

Results

Seventy-six IMR surveys were completed; data failed to accurately capture how many sessions were completed over the course of the academic year. All IMR responses indicated that they “learned something relevant to patient care” (99% “yes definitely” [YD], 1% “yes, somewhat” [YS]), “would recommend these sessions to a colleague” (92% YD, 8% YS), and that “the structure of the session was helpful in learning the content” (92% YD, 8% YS). 97% felt the session would impact their clinical practice (87%YD, 11%YS). Several end-of-rotation evaluations specifically commented on these sessions as a valuable addition to the rotation. Some representative comments include “very thorough, yet simplified explanation of teaching material...easy to follow and I learned a lot” and “overall informative session, will help guide management of my in/outpatient panels.”

Eight of twelve (67%) HF completed the survey. 88% reported being able to complete the biweekly sessions “most of the time” or “always.” 88% enjoyed leading the sessions “a lot,” with 14% answering “not at all.” When asked if leading the sessions was burdensome, 50% responded “not at all” and 50% responded “somewhat.” 86% were at least somewhat interested in continuing to lead the sessions the following year.

Conclusions

This novel curriculum for teaching malignant hematology was a feasible and impactful intervention that IMR felt was a helpful structure likely to impact their practice and learning. It allowed for the use of current inpatients to teach diagnosis and management. Completion of the sessions by HF was achievable and enjoyable, though modifications to improve the consistency of post-session survey completion are being explored in the current academic year. Reverse Morning Report could be practically and feasibly disseminated at other institutions in need of a method of teaching malignant hematology on busy inpatient services.