Hebert, Randy S. MD, MPH; Wright, Scott M. MD
Purpose: To study medical grand rounds, the cornerstone of a department of medicine's educational programs.
Method: Between April and June 2001, a questionnaire was sent to chairs of departments of medicine at the 389 U.S. hospitals with medicine residency programs accredited by the Accreditation Council for Graduate Medical Education. Data were collected on the objectives and attendance, educational structure, perceived quality, and costs of medical grand rounds.
Results: Three hundred questionnaires were returned (77%). Grand rounds were offered by 97% of departments and accredited for continuing medical education in 96% of hospitals. The most important objectives were to educate, showcase faculty role models, and promote a collegial atmosphere. Patients were present at grand rounds less than 3% of the time. Grand rounds were predominantly lecture based; only 10% were clinical case presentations or interactive workshops/small groups, the formats proven most effective for facilitating adult learning and a humanistic approach to patients. Curricular tenets of needs assessment, program evaluation, and knowledge assessment were performed in only 73%, 59%, and 17% of programs, respectively. University hospitals were less likely to incorporate these principles (p < .01). Although respondents attested to the high quality of grand rounds, many potential attendees missed more than half the sessions. Grand rounds were the most expensive conference in 78% of departments, with the pharmaceutical industry providing the majority of the funding.
Conclusions: Medical grand rounds are costly and often do not take into account learners’ needs. Departments of medicine should reevaluate their commitment to grand rounds.
In the late 19th century, medical grand rounds emerged as a key teaching exercise, originating from the bedside rounds conducted by outstanding clinicians like Sir William Osler. Because attendance outgrew the confines of a patient's room, rounds eventually shifted to an amphitheater with the patient present.1 As recently as 25 years ago, medical grand rounds remained a weekly convocation wherein house officers summarized a patient's history, often with the patient in attendance, followed by discussion of the case by a senior physician. Despite medical educators’ enthusiasm for problem-based, interactive models of medical education,2,3 grand rounds have gradually shifted from a patient-focused conference to a lecture series with limited clinical relevance.4,5 Grand rounds are still viewed as a valuable educational activity, but some have commented that audience apathy, deteriorating decorum, and shrinking attendance have diminished grand rounds’ status as a venerable departmental activity.5–7
Another disturbing trend in the evolution of grand rounds is the reliance on the pharmaceutical industry for funding medical education.8 In 1999, the pharmaceutical industry spent millions of dollars on medical grand rounds.9 Although drug companies are interested in physician education, they are equally concerned with marketing their products and often provide biased information.10
In recent years, there has been demand for a greater accountability of academic medicine's educational programs.11 Given the ubiquity of grand rounds and the resources dedicated to them, the conferences deserve further examination. In this study, we sought to characterize the objectives and attendance of medical grand rounds, determine their educational structure, gather data about perceived quality, and collect information about the costs of the conference.
For the study we developed an eight-page, 47-item questionnaire that covered five areas: objectives, educational structure, quality, attendance, and costs. Responses were multiple-choice, short answer, yes-or-no, and five-point Likert scales. We performed pilot testing to refine the instrument.
Between April and July 2001, we sent the questionnaire with a self-addressed, return envelope to 389 U.S. hospitals that sponsor the 392 medicine residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Three hospitals had two separate residency programs (i.e., primary care and categorical) listed in the 2000–2001 Graduate Medical Education Directory.12 Questionnaires were initially sent to department chairs. If no questionnaire was returned after two mailings, we sent additional questionnaires to the primary organizer of medical grand rounds. We obtained contact information by communicating with departmental representatives using addresses, phone numbers, and e-mail addresses listed in the Graduate Medical Education Directory and the Association of Professors of Medicine 2000–2001-membership directory.13 We used repeat mailings and/or facsimiles to encourage participation.
We summarized responses to questions as means. Both t and chi-square tests were used to compare the responses between university hospitals (defined as the primary teaching affiliate of a medical school that is a member of the Association of American Medical Colleges) and other hospitals. Other hospitals were hospitals that were not the primary teaching affiliates but that had affiliations with a medical school. This group predominantly included community and Veterans Affairs hospitals. Results of analyses comparing university and other hospitals were unchanged when controlling for number of beds (data not shown). We analyzed data using STATA 6.0, a standard statistical software.
Three hundred of 389 questionnaires were returned (77%). Department chairs completed two thirds of the questionnaires. One hundred and eight (36%) respondents were from university hospitals and 192 (64%) were from other hospitals. Medical grand rounds were offered at 291 (97%) of the hospitals. Ninety-six percent of hospitals had continuing medical education (CME) accreditation for the conference.
To educate about clinical and research topics, having faculty role model the importance of life-long learning, and promoting a collegial atmosphere were among the most important objectives of grand rounds. Respondents from university hospitals were more likely to highly rate education about research topics and highlighting expertise in the faculty and less likely to view providing CME as important (see Table 1).
Respondents reported that medical grand rounds were weekly (93%), hour-long (84%) conferences with audience participation limited to a few minutes at the end of the lecture in almost all (96%) departments. Less than 10% of grand rounds were clinical case presentations and 1% were interactive workshops, small groups, or mixed sessions. Patients were rarely present (at 3% of conferences).
The majority (72%) of departments had specific learning objectives and performed needs assessments (73%) to select topic areas to be covered. Attendees evaluated grand rounds speakers at 81% of hospitals. This information was forwarded to the speakers roughly 60% of the time. Only 17% of departments made regular attempts to assess learners’ knowledge and/or clinical performance after grand rounds. University hospitals were less likely to incorporate these core principles of curriculum development (see Figure 1).
Seventy-three percent of respondents rated the quality of their departments’ grand rounds as very good or excellent; only 6% rated them as fair or poor. Furthermore, 93% believed that medical grand rounds held at their institution were of the same or better quality than those they had attended elsewhere. The quality was thought to have improved over the last five years at 51% of hospitals and remained the same at 43%.
Respondents reported that an average of 83 people attended grand rounds, 20 (24%) full-time faculty, 11 (13%) part-time faculty, 36 (44%) graduate medical trainees, ten (12%) medical students, and six (7%) other learners. Many learners, particularly faculty members, missed more than half the sessions (see Table 2).
Respondents reported that grand rounds were the most expensive conference in 78% of departments (69% of university hospitals versus 82% of other hospitals, p = .013). The pharmaceutical industry provided the majority of funding for grand rounds (see Table 3). Forty percent of speakers at university hospitals were from outside the hospital or affiliated medical school compared to 55% at other hospitals (p < .0001). The median honorarium paid to these speakers was $1,000.
Medical grand rounds are expensive, ubiquitous, have large audiences, and are thought to be of high quality. Our findings suggest that medical grand rounds are perceived as a valuable endeavor and continue to have a strong foothold in the medical culture. However, the conferences have multiple deficiencies.
First, although the traditional teacher-dominated lecture is suboptimal for facilitating higher-level adult learning and behavioral change,14–16 or for role-modeling the humanistic dimensions of medicine,17 grand rounds remain a passive lecture series. The combination of a suboptimal teaching method and unmatched educational needs is a recipe for learner dissatisfaction. The high absentee rate at the conferences, despite their reported high quality, likely reflects their low priority for learners with competing demands.
Second, the American Medical Association and Accreditation Council for Continuing Medical Education have determined that before an institution can assign CME credit to a teaching activity, there must be a demonstrable need, clearly stated objectives, appropriate learning methodologies, and thorough evaluation mechanisms.18 These requirements were often not met, putting departments at risk of citation for noncompliance.19
Third, drug company expenditures on physician education have been criticized for influencing physicians in ways detrimental to patients,20 yet, the pharmaceutical industry supplies the bulk of the funding for grand rounds. In addition to the substantial direct expenditures were “hidden” costs. According to our study, roughly 30 faculty physicians per hospital spent more than an hour per week away from their primary work to attend the conferences. Assuming that time spent at the conference could be spent in compensated clinical activity, at US $325 per hour in billing per physician,21 grand rounds are worth $9,750 per conference or almost $400,000 per institution per academic year (assuming 40 sessions per year). This sum does not include the value of clinical care provided by graduate medical trainees. These costs are hard to justify considering that grand rounds are often not structured to accomplish their stated goals.
Why then do medical grand rounds persist in their current format? The answer is probably multifactoral. First, the ubiquity and consistency of grand rounds’ format typifies the inertia that must be overcome in medical education reform.22 Second, education is only one objective of grand rounds. Third, lectures are a relatively easy and efficient method of disseminating information to large groups. Interactive small-group sessions based on learners’ needs, while promoting adult learning, are often less practical.
Our study had a high response rate and was the first study of medical grand rounds in the United States in over ten years. However, several limitations should be considered. First, we relied exclusively on respondents’ reports to characterize grand rounds; some responses were subject to desirability bias. Second, although we collected information on the percent of departments that performed needs assessment and evaluation, we have no data on the adequacy of these measurements. Finally, all institutions surveyed were ACGME-accredited internal medicine programs. Our results may not be applicable to other institutions or to grand rounds in disciplines other than medicine.
The organization and implementation of medical grand rounds needs to be reexamined. Learning objectives must be based on comprehensive needs assessments of targeted learners. Educational strategies should be selected for their ability to promote these objectives. Evaluations should provide feedback to speakers and assess educational impact. Costs and pharmaceutical industry influence should be reduced by using interactive formats such as case presentations, with patients present, facilitated by a department's own faculty. Such reforms are necessary to increase educational effectiveness, enhance role-modeling, and better foster collegial relationships at medical grand rounds.
The authors are indebted to Drs. L. R. Barker, D. Kern, D. Hellmann, D. Levine, R. Levine, and S. Kravet for their assistance.
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