Are medical grand rounds dead?

Are medical grand rounds dead?

A little bit of an unusual topic because a lot of what we’re hearing about is bedside teaching and assessment and so forth at the micro level. But I hope you’ll see after this presentation, which I try to make interactive as well, it is an important thing to think about.

So are medical grand rounds dead? And I’ll tell you why I got to that.

So that’s me. I don’t have any disclosures of any kind. This was not generated through ChatGPT because it would have to actually present if it was generated.

At the end of this what I hope is that you’ll understand the origin of grand rounds and its current status—mostly around North America, the way the literature is—understand and use effective teaching methods to improve your grand rounds, use effective teaching techniques to improve attendance at grand rounds and to improve your own presentation if you’re presenting at grand rounds or at rounds like this as well.

I’m going to do this. It was in the app. So I’m the only one, actually, from this educational forum who put an electronic app on to answer questions to have an interactive session. But given the smaller size of this special audience, I would like to do it as a show of hands. There’s nothing personal here anybody has to worry about, about answering accurately. I don’t think anybody will take any offense in any way. So the first question is, does your institution or organization offer a regular grand round? What is it? That’s a question… I’m going to define that for you. But from your perception of what a grand round is and in respirology or hematology even or medicine or neurology. So we had a grand round in neurology every week and we had a grand round in stroke neurology, a separate grand round. Who has the grand rounds at their institution? Okay. Most people, actually at least half, say that they do.

I was charged for many years to organize neuroscience grand rounds. We met with the division head of neurosurgery, myself, neurology, our residency program directors in neurosurgery and neurology. I’m thinking back, we never met with our neuroradiology colleagues who are part of the grand rounds. We developed a very complex schedule, which you can’t read there. I specifically designed it that way. You can’t read what’s on there. But it was a very organized schedule of neurology, neurosurgery, neuroradiology, neuropathology, residents teaching, invited speakers teaching people to get a feel for what the grand rounds are like and probably feel very similar to what you do in your institutions as well for grand rounds.

I was charged with doing that and I found it to be a tremendous amount of work and responsibility: getting the announcements, the venue and making sure everything was correct. Moderating the round myself every week and trying to find somebody who would moderate for me. Those of you who do that kind of stuff know what that means. I found it somewhat frustrating, arranging the speakers and encouraging people to attend and participate in the round. It was kind of disappointing when after a lot of work and effort people would not show up to rounds and the attendance was poor. And I basically said to my successor, after I finished doing this, to the next division director, I said, “I think we should just cancel them. That’s sort of my personal kind of frustrated feeling. And then I get the big feedback saying, “No, no, no, you can’t cancel them. We have to have grand rounds.”

So where did all this come from? Where did the grand rounds come from? They started at the bedside with William Osler there on the top left. For those of you who don’t know, William Osler actually is from Dundas/Hamilton/McMaster. He spent his internship year at the Hamilton General Hospital at McMaster before he moved on to Johns Hopkins University, where he introduced experience from being in Europe and all kinds of different medical centers, experience of actually teaching at the bedside. Medical practitioners before that trained with books and then went and took care of patients. So he brought students to the bedside and he was the person who invented that. That has sort of changed and we’re back to EPAs again, assessment at the bedside, which is probably an important thing to do. And the whole idea behind what we do and what he did was to improve clinical performance and improve patient outcomes. That’s the bottom line for all our work, is that itself.

So small bedside teaching. That’s the Hamilton General when William Osler was teaching there on the left bottom. And that’s where we now have neuroscience grand rounds at the Popular House Research Institute, completely out of the hospital, with an auditorium. It’s an auditorium… that’s the McMaster Internal Medicine Review course in Hamilton, held every year, the 15th iteration, with 500 attendees. That’s a big grand round.

What happened is that the origin is it started at the bedside. The attendance outgrew the ward. They went to an amphitheater, and originally there were the amphitheater and the patient and the amphitheater. And then it became sort of a lecture-based approach. That’s sort of the natural history of evolution, the historical event.

What is the status of grand rounds? When doing big major surveys in multiple academic centers in North America, virtually all academic centers hold a forum of a grand rounds. That’ll be a lecture-based series, mostly where it’ll be held on a weekly basis, commonly weekly, commonly a duration of one hour, organized by the department chair or organized by a faculty leader, organized by the residency program director or organized by the chief medical resident. And it’s half of the matter first thing in the morning, the other half in the afternoon.

What’s the main purpose of this grand round? Let’s do a little bit of hands up kind of thing. So let me just run through these: provide a clinical update on a specific topic, provide an update and latest research on a topic, educate medical students, residents or faculty, showcase faculty, the department and new recruits, to provide a means of obtaining education and credits, which we all need to do in many centers, and provide a forum for collegiality to meet your colleagues and so forth.

So provide a clinical update. Who thinks clinical update? Provide an update on the latest research on the topic. One more clinical update. Educate medical students and residents. So many more hands for that. Showcase faculty, the department and new potential recruits. One. One. Provide a means of obtaining educational credits. No hands are up. I think we get educational credits from many other venues as opposed to grand rounds. Provide a forum for collegiality. Actually a fair number of hands. I can meet my colleagues at rounds.

So overall, from multiple surveys, just like this, the biggest, the top answer always is provide a clinical update. The second answer is an update on research. The third answer is to provide CME credits. And the fourth answer, the most common, is to educate residents, students and faculty. But other people do… The other thing is that it’s a way to role model lifelong learning for our learners, for us to show how we are learning by presenting at grand rounds and our learners can learn from us. We can actually highlight who’s in our faculty and the expertise. And collegiality and social interaction has always been up there is on the list.

Do you attend grand rounds? Almost always, if you have grand rounds. Two. Okay. Three. Sometimes. About the same number of people. Infrequently. Depends on the topic. Depends on the speaker. No hands for either. So it’s looks like people either attend all the time or sometimes.

The attendance at grand rounds of doing big surveys of a hundred medical centers and grand rounds and who’s attending, is that among those who missed 50% of medical grand rounds, of full-time faculty, it’s about 45%. So half of them missed half of the rounds. Of part-time faculty, nonacademic part-time faculty missed more. Students and trainees go often. So actually our learners are often at rounds, at medical grand rounds. The same can be said for neuroscience grand rounds—my interest—in that more than half the faculty, more part-time faculty aren’t attending. So my faculty members, that’s one of the big frustrations for me always was about my faculty members attending and showing themselves to our residents and students [and they were] less likely to attend than the residents and students. So we are always telling you have to attend, to the point of trying to marking who’s there and saying that you have to be there 80% of the time or you won’t graduate. And so all that type of stuff.

So the question is, this grand round—which happens almost everywhere, attended by only half the people, if faculty-wise, more residents and students—what’s the educational value of grand rounds? Is it actually… I said, let’s just cancel it. I’m just having all these frustrations with it. The ultimate answer for grand rounds is it needs to improve clinician performance and improve patient outcomes.

One of the things is that there’s no question and this is why we’re here actually, at this educational forum, is that continuing medical education is effective. These are some landmark papers looking at way back to 1992. David Davis and Brian Haynes from McMaster looked at the first assessment of trials in looking at CME back in 1992. And there’s no question that CME does work. It does work. Its effect size on physician knowledge is moderate, not high. So we do learn stuff. We learn stuff. The effect size and physician performance based on research is small, and the effect size on changing patient outcomes is small. This is the overall CME.

And what seems to work? The question is, what seems to work? Thinking back, I’m always thinking about what do I need to do in grand rounds to make them a better medical education event. What does work is that if they’re interactive. What does work if they’re using multiple methods and exposures, if it’s focused on outcomes deemed important for physicians. So whenever you attend, it should be important for you. And it’s designed for more of a small group as opposed to a large group. So those things work better than the opposite of those things.

One of the ways to develop grand rounds—this has been looking at the literature again—you need to do a needs assessment: why do we have grand rounds? So the division heads, residency heads match and we’re trying to develop a needs assessment, what we need for our programs. We should have some kind of multifaceted interventional strategy during the rounds, like question-answer periods, or patients there, or examinations or things related to this interaction. A sequence in such a way that the sequence of the round makes sense, not just random things. That seems to make better educational value. More interaction and the commitment to change.

When you look at what programs do, about half of them do a performance of needs [assessment]. Only half of them do. Learning objectives are more commonly done, but evaluate speakers. That’s such a common thing that sort of came up. But to evaluate the program itself and to evaluate the overall objective assessment of the program and the outcomes is rarely done. So what we’re doing and spending time on is rarely assessed. The same thing can go for neurological grand rounds. This is 98 neurological centers across the U.S. Same thing. Needs assessment—yes, but overall objectives at the end and outcomes of physicians and patients are rarely assessed that way.

And one thing is that these rounds are actually… I’ve just remembered, they’re very expensive. What do you mean by expensive? We have over 300 members in the Department of Medicine at McMaster. Approximately 40 grand rounds just for the Department of Medicine, we’re not talking about subspecialty rounds. If every physician has a net economical loss of $100 and the department has an economical loss of $100 for every time they attend grand rounds for an hour, that’s $1.2 million that we spend on those physicians to attend grand rounds. It’s not about money, but it’s just sort of to put into perspective, the cost.

Now, those of you who don’t attend grand rounds more often, it’s because why? The sessions are usually not relevant to me. Hands up. The sessions are often of poor quality or boring. But there’s one… some… a few. Sessions are poorly organized. So that goes back to my job. Yes, a few hands up for that. The sessions are not convenient for my schedule due to timing or location. Lot of hands for that. And I’ll talk a little bit about that, how that’s changed. The sessions interfere with my clinical duties. A lot of hands up for that. And again, it’s that cost. It has to pay, not financially but some way for me, correct? And so the thing about the rounds is that… in neurology I was quite surprised that that the audience participation happened a lot in neurology rounds, and thinking back it used to and not now, when I sort of over my training, we used to have patients often coming to rounds like the amphitheater, examining them and getting people to examine, and residents will present the case and the faculty would discuss with more like the sessions this morning, which was very interactive and very engaging. And they’ve changed much more so.

One of the things that you heard with virtual care as well is that what about these patients and patients don’t want to be seeing students or residents or that. Charles Warlow from Scotland, the senior author here, they did a study of looking at patients and physicians and patients like being at rounds. Patients find the experience useful. They don’t find the experience intimidating. Neither do the physicians when they’re assessed about them. So there’s no excuse for not potentially having a patient come to grounds done properly. The other way… there’s food out here outside. And it’s been shown very clearly that if you feed people, they’re going to come. Even the coffee in the morning, get your cup of coffee. They will come on time because they don’t want the coffee to run out or the pizza to run out and it improves, including this session here. It’s a funny kind of thing.

The other thing that clearly has changed, maybe one of the few things that the pandemic has made better is I’ve been talking about going back to in-person grand rounds and there is a pushback. People like virtual rounds and those people who are online now, there’s an example. You can be online anywhere. You don’t have to travel, park or anything like that. But as this slideshow in this paper goes over as well, there’s a huge responsibility to making it work properly. There’s technology, good moderation, good audio, video and so forth. You can do questions and things online and that. This has really become a good way to enhance and improve grand rounds.

Here’s a slide which I will go over out of Medical Teacher in 2022. There’s many components to grand rounds you need to think about as an organizer. I’m glad I didn’t know this when I was the one in charge because I find it too overwhelming. It’s about the time, the parking, but the food and the interaction and so forth. It’s very, very important.

The other thing about grand rounds. Here’s something very important that you can use grand rounds for. I would like to introduce… So Professor Jaeschke would introduce me and say Professor Oczkowski here is going to be talking. And then his boss in Hamilton, he’d say, I’d like to ask Madeleine here to come up and give us a presentation. Male physicians tend to introduce male and female physicians by their titles more so, female physicians introduced by title. But male physicians will tend to introduce female professors by their first name and so forth significantly more. So guys know they’re all professionals. You can use that as a role model example in grand rounds about your faculty.

I enjoy presenting at grand rounds. I’m almost done. Enjoy presenting at grand rounds and find it a positive personal educational experience. I strongly agree. Nobody strongly agrees about presenting and positive personal experience. Somewhat agree that I enjoy presenting this. A few hands up? Yes. Neutral. Neutral. More hands up. Somewhat disagree. Don’t be shy. And strongly disagree.

This is another very good reference for you to look at. This has been my mantra. The presenter learns the most in grand rounds. So getting ready, organizing, reviewing the literature, trying to make it interactive, putting it together in that nugget. I learned the most about this. And I actually was… unfortunately, I didn’t delve into this when I first started organizing and preparing for organizing my own grand rounds, because I would have been much better. But these are some examples of what you can do. Those of you who want to present at grand rounds, this is a beautiful article about the steps you should take for presenting at grand rounds and so forth.

So are medical grand rounds dead? No, but they may need some resuscitation if you look at the literature about what to do. I think it’s very important for the organizers. Anybody here organizes grand rounds? Yes, a couple of people. It’s important for the organizers to then go back and look what the needs are, to make sure they’re interactive, to get the best speakers, to make the educational value as high as possible and to evaluate at the end not just the speakers, but the participants and, if possible, the outcomes. And it’s very important for the presenters to be interactive, engaging and to provide the highest educational value that you can at rounds themselves as well, because it costs a lot of money. You’re spending somebody’s valuable hour when they could be doing something else. You want them to be there. Thank you very much.