Morning Report Goes Virtual: Learner Experiences in a Virtual, Case-Based Diagnostic Reasoning Conference

Background: Participation in case-based diagnostic reasoning (DR) conferences has previously been limited to those who can attend in-person. Technological advances have enabled these conferences to migrate to virtual platforms, creating an opportunity to improve access and learner participation. We describe the design and evaluation of virtual morning report (VMR), a novel case-based DR conference. Methods: VMR took place on a videoconferencing platform. Participants included health professions students, post-graduate trainees, and practitioners. In designing VMR, we adapted concepts from experience-based learning theory to design opportunities for learner participation. Teaching strategies were informed by information-processing and situativity theories. We evaluated learner experiences in VMR using a survey with open and closed-ended questions. Survey items focused on accessing case-based teaching conferences outside of VMR, participant perceptions of the educational value of VMR, and VMR’s impact on participants’ con�dence in performing DR. We used qualitative content analysis to manually code open-ended responses and identify themes. Results: 203 participants (30.2%) completed the survey. 141 respondents (69.5%) did not otherwise have access to a DR conference. The majority of participants reported increased con�dence performing DR. Respondents highlighted that VMR supplemented their education, created a supportive learning environment, and offered a sense of community. Conclusions: VMR can expand access to DR education, create new opportunities for learner participation, and improve learner con�dence in performing DR.


Introduction
Case-based teaching conferences are consistently the highest rated curricular element of graduate medical training in internal medicine and are an important vehicle for teaching diagnostic reasoning (DR) to trainees. (1-3) However, there is limited evidence on the optimal design of and teaching strategies in these conferences, and participation has been limited to only those who can attend in-person. (1)(2)(3) Physical constraints to attendance are relevant because access to effective DR education continues to be a barrier to teaching this important clinical skill. (3) Recent studies of resident experiences in face-to-face morning reports highlighted impediments to learner attendance and participation, including the location of morning report, discomfort with contributing to case discussions by talking aloud, and not feeling knowledgeable enough to participate. (2) Technological advances have enabled medical education to transition from physical to online spaces, (4,5) and case-based conferences have migrated to virtual platforms. (6-9) This has created an opportunity to redesign and expand participation with the hope of improving DR education. In March 2020, The Clinical Problem Solvers (CPSolvers), a multimedia organization focused on teaching and learning DR, designed the rst multi-institutional, virtual, case-based DR conference, known as virtual morning report (VMR). With virtual learning platforms playing an increasing role in medical education, educators need an understanding of how the design of and teaching during these conferences impacts learners. In this research report, we describe the design, implementation, and evaluation of VMR.

Aims
The aims of VMR were to expand access to case-based DR conferences, leverage a virtual platform to create new opportunities for learner participation, and improve learner con dence in performing DR.
Setting & Participants VMR took place on a videoconferencing platform (Zoom Video Communications Inc., San Jose, CA, USA) and was hosted by CPSolvers. Participants included health professions students, post graduate trainees, and practitioners who asked to attend VMR.

Program Design
In developing VMR, we focused on three distinct elements of its design: conference structure, opportunities for learner participation, and facilitator teaching strategies. These three elements were the most likely to support the achievement of our aims.

Conference Structure
The structure of VMR ( Fig. 1) is similar to morning reports in United States-based internal medicine residency programs (1, 2, 10-13) and draws on evidence supporting the bene ts of peer-assisted learning while also ensuring the involvement of experts in DR teaching. (14)(15)(16) In VMR, a participant volunteers to present a patient case and two health professions students or postgraduate trainees volunteer to discuss the case alongside two clinician-educators, who serve as facilitators. At the start of VMR, discussants and case presenters introduce themselves, their training level, and their location. Case presentations include sequential aliquots of clinical information followed by the nal diagnosis. Discussant-facilitator pairs alternate sharing their DR aloud after each aliquot. In addition, an unlimited number of participants discuss the case using the video conferencing platform's chat function. In real time, two CPSolvers team members transcribe case details and teaching points on a virtual whiteboard. (17) VMRs are recorded and posted online for asynchronous viewing. To prioritize explicit teaching of DR, VMR is an unscripted case conference. (12) Facilitators, discussants, and participants are unaware of the case details, including the nal diagnosis. We, as others have previously written, believe this structure offers the best opportunity to explicitly teach DR by allowing all participants to think through the case in real-time, similar to how DR occurs in a clinical environment. (12) Opportunities for Learner Participation We designed opportunities for learner participation in VMR by adapting concepts from experience-based learning theory, which views supported participation as fundamental to learning. (18) Applying these concepts to DR education in case-based teaching conferences, learning DR does not come from a facilitator reciting information to a learner. Rather, it happens when learners engage in the practice of performing DR through varied levels of participation that range from observation to direct contribution.
(18) Speci c opportunities for learner participation in VMR include Passive participation: watching VMR without contributing to the discussion Chat-based participation: watching VMR and actively contributing to the discussion via the videoconferencing platform's chat function Presentation-based participation: preparing and presenting a case Active participation: sharing one's thinking aloud by discussing alongside a facilitator These opportunities for supported participation create varied levels of engagement that accommodate a variety of learners who may have varied DR skills, educational priorities, and comfort with the traditional form of participation that involves being called-on by facilitators. (2) Teaching Strategies: We used teaching strategies informed by two theoretical frameworks that play an important role in teaching and learning DR: information-processing theories and situativity theories. (19)(20)(21)(22) The former emphasize the importance of knowledge organization, while the latter highlight the role of contextual factors in learning and practicing DR. (19)(20)(21)(22) Speci c teaching strategies comprised previously described tactics, including connecting case discussions back to core tenets of DR, such as diagnostic schemas, illness scripts, and Bayesian reasoning, and giving feedback to trainee discussants that expands and re nes their knowledge structures and decision making. (20)(21)(22)(23)(24)(25) For example, in articulating their reasoning aloud, facilitators often explicitly discussed a diagnostic schema, highlighted illness scripts of diagnoses under consideration, and integrated probabilistic reasoning into their teaching. Additionally, to help decrease the cognitive load for learners, facilitators asked learners to focus on one speci c piece of data that they perceived to carry important diagnostic information. (26) Facilitators also incorporated teaching related to the role of contextual factors in DR. This included asking learners to consider how their thought processes might differ if certain contextual details of the case changed (e.g., if patient communication was limited because of acute encephalopathy or if the patient presented to clinic rather than the hospital). (19)(20)(21)(22) Finally, at the end of a case, trainee discussants had the opportunity to re ect aloud on their reasoning under the guidance of facilitators. (27,28) Program Evaluation We evaluated our program using a survey that included both open and closed-ended questions. (29) We followed guidelines for survey development to address content and construct validity. (30) We created and administered the survey using Qualtrics. We also collected data from VMR sessions, including total attendees and the number of chat-based participants. Descriptive statistics were performed (mean, standard deviations) using Microsoft Excel.
Individuals who attended VMR were eligible to take the survey. Participants received a link to the survey via email. Data collection occurred between June 9th, 2020 and July 29th, 2020. To maximize the response rate, we sent weekly reminders to the email list for three weeks. No nancial incentives were offered. Participants responded anonymously. The Institutional Review Board at the University of California, San Francisco reviewed the study and deemed it exempt.
Survey items (Additional File 1) focused on accessing case-based teaching conferences outside of VMR, participant perceptions of the educational value of VMR, and VMR's impact on participants' con dence in performing DR. Survey items related to the construct of DR were informed by information processing theories, such as cognitive load and script theory, and situativity theories, such as situated cognition. We piloted survey items with eight CPSolvers team members. One team member trained in cognitive interviewing (S.L.) used previously published guidelines to perform one-on-one cognitive interviews with ve VMR participants who provided verbal feedback. (30) Pilots and cognitive interviews led to changes in item wording and removal of two questions that confused participants.
Two coders (J.C.P & L.C.S.) used qualitative content analysis to manually code data and identify themes.
(31) Coders actively generated themes by categorizing codes. The two coders coded transcripts line-byline using a constant comparative process to organize responses into codes and themes. They discussed and resolved con icts of codes and themes with a third person (S.N.).

Results
The mean average attendance at VMR was 80.7 participants (SD: 22.5), with a mean of 44.5% (SD: 11.0%) of participants contributing to the platform's chat function each session. Two-hundred-three participants (30.2%; 203/672) completed the survey. Demographic information of survey participants is included in Table 1. Active participants and case presenters joined VMR from 24 countries (Table 1). Onehundred forty-one (69.5%) respondents did not have access to another case-based DR teaching conference beyond VMR. One-hundred ninety-two (94.5%) respondents described VMR as very educational or educational. The majority of participants reported increased con dence with elements of DR, such as creating a problem representation (72.4%), developing and using a diagnostic schema (71.9% and 74.9%, respectively), developing and using an illness script (61.6% and 61.6%, respectively), and articulating DR aloud (63.1%) ( Table 1). • Clinical Fellow: 6 (3.0%) • Allied Health Professions Student: 6 (3.0%) • Allied Health Professional: 2 (1.0%) • Declined to answer: 6 (3.0%) • USA Strengths of VMR included that it supplemented their education, was an engaging and supportive learning environment, and offered a sense of community (Table 2). Potential improvements to VMR included developing ways to include multimedia pieces of clinical data (e.g., radiology images). videoconferencing software to not only expand access to off-site participants, including those outside their institution, but also support varied methods of participation that accommodate a variety of learner preferences and styles.
Speci c facilitator teaching strategies informed by theoretical frameworks related to DR supported improved learner con dence with core DR concepts. Cognitive approaches to DR posit that one can improve their reasoning by synthesizing information into organized knowledge structures for storage in long-term memory. (22, 32, 33) Theoretical frameworks that move beyond the cognitive approaches and focus on the in uence of contextual factors, such as situated cognition, emphasize the importance of integrating or re ecting on the complex interactions that occur between clinicians, patients, and the physical environment. (19)(20)(21) By explicitly discussing diagnostic schemas and illness scripts and connecting these knowledge structures to real-life clinical scenarios, facilitators may support learners' increased con dence in organizing and applying knowledge. Furthermore, the use of reasoning terms-"schema," "illness script," "pretest probability," etc.-can equip learners with a vocabulary that serves as a linguistic scaffolding upon which they can incorporate new knowledge and direct future learning. (25) We encourage facilitators to employ these strategies as a means of explicitly promoting DR education during case conferences.
Limitations to this study include a low response rate, which may have been driven in part by distribution of the survey on an email list that included individuals who had expressed interest in VMR but never participated. The subjective responses also limit our ability to objectively assess DR skill development. Areas for further research include examining whether virtual DR case conferences can improve the performance of DR using pre-and post-assessments and further exploring strategies for case-based DR teaching.

Conclusions
VMR is a viable model that can expand access to DR education, create new opportunities for learner participation in case-based conferences, and improve learner con dence in performing DR. While VMR focuses primarily on internal medicine cases, this model is easily transferable to other clinical specialties.

Declarations
Ethics approval and consent to participate The Institutional Review Board at the University of California, San Francisco reviewed the study and deemed it exempt.

Consent for publication
Not applicable

Competing interests
All authors are volunteer members of the Clinical Problem Solvers Team. They receive no nancial bene ts from this organization.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Funding
None Authors' contributions JCP was the lead investigator and participated in the study design, data analysis, manuscript drafting, and manuscript revisions. SL participated in the study design, data analysis, and manuscript revisions.
LCS participated in the study design, data analysis, and manuscript revisions. HMM participated in the study design, data analysis, and manuscript revisions. DJM participated in the study design, data analysis, and manuscript revisions. SN was the senior investigator and participated in the study design, data analysis, manuscript drafting, and manuscript revisions.