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Three people partake in a Morning Report session.

Residents, research, and rhabdomyolysis

'Morning Report' takes the library to the doctor

By Lucy Vilankulu

From eNews, December 1, 2005

If you've ever gone online to try and diagnose an itchy rash or a disquieting lump, you already know the dizzying amount of information a typical search engine will return. Luckily for just about everyone involved, residents and medical students at the University's Medical School are getting help narrowing it down.

When surveys of residents and medical students showed that they were largely unaware of the Web-based health information databases available through the U's Bio-Medical Library, associate librarian Cindy Gruwell and Medicine-Pediatric Residency Program director Bradley Benson teamed up to renovate Morning Report (a program in practice-based learning) to combine evidence-based medicine with the skills of effective research.

In each week's class session, students are presented with the symptoms from a real-life case at the University hospital, and they try to guess at the diagnosis within the hour allotted by asking questions about the case. It is a kind of medical "20 Questions" about a real patient at the hospital. As the students ask questions and consider the evidence before them, Gruwell does research on a laptop in the corner, accessing resources like Ovid Medline, PubMed, drug databases, and journals available only through the University.

How it works
It's Monday morning at the weekly Morning Report session. Shortly before the students arrive, chief resident Dimitri Drekonja greets Gruwell with the diagnosis of the day--rhabdomyolysis--and a short list of prescriptions: simvastatin, gemifibrozil, and cyclosporin.

The participants arrange themselves to reflect an unspoken hierarchy: residents at the conference table, medical students ranged along the walls. The "clues" appear on the white board as one of the residents reads the case file: 58-year-old male suffering from weakness, which seems vague enough.

"It's a place where we can model clinical reasoning, clinical judgment, and more and more access to the best evidence to answer questions," says Benson.

After a brief speculative silence, the residents start peppering the case reader with questions. Is the weakness in any specific muscle group? Has the patient suffered any falls? Does he have problems getting up out of a chair? Out of bed? Getting only negatives, the residents change the focus of the questions. Does he live alone? Is he depressed? How many alcoholic drinks does he consume per day?

"Think more diversely," urged Dr. Jonathan Ravdin, who leads the sessions. "What else might you think of?"

Their attention turns to the prescriptions-the patient is taking a daunting number of medications including statin drugs and sleeping pills. By the time one of the residents ventures to mention the word "rhabdomyolysis," Gruwell has cross-referenced the drugs simvastatin and gemifibrovil and determined that together they can cause the condition. At the end of the session she shares the steps of her search with the rest of the group. This would seem to support the idea that the real usefulness of Morning Report is in the on-the-scene, on-the-fly discussion.

Benson stresses the importance of the critical thinking skills that Morning Report promotes. "One of the things that is so critical in medicine is reflection. You build in reflection on people you've cared for, looking critically at what could we have done better, what would we do next time, what went well. When you're dealing with real lives, it's so different than an abstract discussion or a lecture. It's reflection on real practice."

Residents seem to enjoy Morning Report, and Benson's surveys have revealed that they are pleasantly surprised by how many tips and tricks they pick up during the sessions. Michael Kim, chief resident in pediatrics, adds that there is an important social component to Morning Report. "Residency is demanding and it is easy to feel isolated," he says. "By having an interactive time (as opposed to being lectured to) with other residents, we create a sense of community and share our burdens."

Gruwell, who admits to using Google when appropriate, maintains that the inclusion of library researchers in Morning Report encourages information literacy in students. "Libraries offer much more directed searching [than Google]," she says. "With the rate of information and the pace of technologies there are a lot of things you can do, but knowing how to do it saves a lot of time."

Benson agrees. "The problem with Google is information overload. What we teach them is search strategies that not only make sure that you maintain the highest quality of evidence that you retrieve, but also eliminate the garbage. You want the highest level of evidence."

Edited from the original story in Continuum, fall 2005, a publication of the University of Minnesota Libraries.