Keywords
grand rounds - resident education - clinical relevance
Grand rounds (GR) is a medical education tradition dating back to bedside teaching
of the late 19th century. Popularized by clinicians like Sir William Osler long before
the advent of PowerPoint presentations, GR was a patient-centered conference, and
as attendance outgrew the patient's own room, the “rounds” were held in an amphitheater
with the patient as invited guest.[1]
GR means different things in different fields and at different learning centers. Medical
grand rounds (MGR) is well described in the literature. A 2006 Mayo Clinic survey
of the departments of medicine in U.S. medical schools by Mueller et al, based in
part on a similar 1988 survey by Parrino and White, characterized MGR as a weekly
(per 96% of respondents) hour-long (98%) didactic lecture (95%) on a single topic
(98%), typically chosen by the presenter (67%) and based around a case presentation
less than half the time (58%). GR is offered by 97% of academic medical departments,
with patients present less than 3% of the time. Top priorities of MGR were reported
to be providing updates in diagnosis and treatment, providing updates in medical research,
educating internal medicine house staff, and educating faculty.[2]
Ophthalmology grand rounds (OGR), on the other hand, is sparsely explored. At our
institution, Tulane University in New Orleans, Louisiana, OGR is a weekly 2-hour conference
in which three cases are presented. One first-year and one second-year resident each
present a PowerPoint-based didactic lecture structured around a clinical case. The
case is expected to frame discussion of presentation, diagnosis, workup, and management,
with varying integration of basic sciences. Residents are encouraged but not required
to engage the resident and faculty audience throughout the case. One third-year resident
presents a surgical video, discussing challenges and techniques involved in the surgery.
After each presentation, the department chairman presides over the assembled faculty
questioning the presenter and discussing the case. Resident presenters are responsible
for their topic selection, without reference to a needs assessment or a list of assigned
topics.
As GR is often considered the “most important” departmental conference, its quality
has a direct impact on the quality of trainee education.[2] It has been suggested that, in the general case of MGR, topic selection based upon
needs assessment would positively impact training.[3] To our knowledge, the current work represents the first analysis of the topics and
scope of OGR across a resident cohort. Besides breadth of topics presented, we also
analyze and discuss the impact of the diseases discussed.
Methods
From July 2009 to June 2012, the tenure of the ophthalmology residency class of 2012,
all presenting residents at our institution were asked to save their GR videos and
PowerPoint presentations to a designated archive (meditred.com). Two hundred and eighty-four
presentations in all were archived, and all were included in this retrospective review.
As the present study evaluated anonymous, previously collected data, it was determined
to be exempt from Institutional Review Board (IRB) review per the standards of the
Tulane University IRB after appropriate evaluation. For each presentation, the primary
topic of discussion, typically a disease process, was noted. Two ophthalmologists—one
senior resident (EDS) and one attending physician (RAS)—categorized each presentation
by subspecialty topic, by prevalence of the disease process discussed, and by impact
of that disease process. Each grader analyzed the data independently, and any discrepancy
between their scores was resolved by reference to clinical textbooks and medical literature.
Prevalence was graded “common,” “uncommon,” or “rare” based on the frequency of an
ophthalmology resident examining a patient with the disease in a comprehensive ophthalmology
clinic setting in or around New Orleans, Louisiana. Diseases labeled “common” were
estimated to be seen by a resident approximately once per week or more, “uncommon”
at least once per three months, and “rare” once to twice per year or less. Examples
of “common” diseases discussed in the evaluated GR presentations are dry eye syndrome,
cataract, and macular degeneration. Examples of “uncommon” diseases are corneal graft
rejection, neovascular glaucoma, and pseudotumor cerebri. Examples of “rare” diseases
are aniridia, neurofibromatosis, and orbital aspergillosis. For the purposes of statistical
analysis, this scale was recorded as a value between 1 and 3, with 1 being “common”
and 3 being “rare.”
Impact was graded “minimal/academic interest,” “vision-threatening,” or “life-threatening”
based on the natural history of the disease process. An impact of “minimal” or “academic
interest” was assigned if the missing, mismanaging, or delaying diagnosis of the disease
would have little long-term impact on outcomes. An impact of “vision-threatening”
was assigned if the disease could lead to permanent visual sequelae. Finally, an impact
of “life-threatening” was assigned if the disease could lead to serious systemic complications.
Examples of “minimal/academic interest” diseases discussed in the evaluated GR presentations
are epithelial inclusion cyst, conjunctival nevus, and multiple evanescent white dot
syndrome. Examples of “vision-threatening” diseases are macular edema, herpetic stromal
keratitis, and nonarteritic anterior ischemic optic neuropathy. Examples of “life-threatening”
diseases are new bilateral visual field deficits, neonatal gonococcal conjunctivitis,
and cavernous sinus thrombosis. For the purposes of statistical analysis, this scale
was recorded as a value between 1 and 3, with 1 being “minimal” and 3 being “life-threatening.”
Statistical analysis was performed in Microsoft Excel.
Results
A total of 284 presentations from 3 years of GR presentations were analyzed, corresponding
with a cycle of one class of residents through the program. During that time, an average
of 102 presentations per year were given, for a total of 306 presentations. Twenty-two
presentations were not available to be included in analysis because the presenter
did not store their talk or video in the designated archive. Overall, 92.8% of presentations
were available for analysis.
Inter-rater agreement for topic and category was 100%. Inter-rater agreement for impact
was 100%. Initial inter-rater agreement for prevalence was 95.8% (n = 12 disagreements; Cohen κ = 0.933, consistent with excellent agreement). All disagreements on prevalence were
settled to the satisfaction of both raters after reference to the literature.
Ophthalmology is commonly divided into 10 clinical subspecialties (cornea and external
disease, glaucoma, pediatric ophthalmology and strabismus, lens and cataract, neuro-ophthalmology,
orbit and oculoplastics, refractive surgery, retina and vitreous, and uveitis) plus
ophthalmic pathology. Retina, glaucoma, cornea and external disease, and neuro-ophthalmology
each comprised approximately one-sixth (17%) of topics discussed. Cataract and oculoplastics
each comprised 9%, with the remaining cases distributed among strabismus, uveitis,
and refractive surgery ([Fig. 1]). Sixty-five percent of diagnoses discussed represented rare diseases, while 19%
were uncommon and 15% were common ([Fig. 2]). Thirty percent of all disease processes, if missed or mismanaged, could be life
threatening, and 48% would be vision threatening. In total, 78% of all diagnoses had
impact on life or vision. While diseases with minimal impact were distributed fairly
evenly across prevalence categories, 64% of vision-threatening and 79% of life-threatening
diseases were rare ([Fig. 3]).
Fig. 1 Tulane grand rounds (GR) presentations categorization. Results of the categorization
of GR presentations. Retina (18%), corneal and external disease (17%), glaucoma (17%),
and neuro-ophthalmology (15%) were the most commonly represented topics. N = 284.
Fig. 2 Prevalence and impact of grand rounds (GR) presentations. GR presentations were predominately
on “rare” (65%) diseases. Diseases labeled “common” are seen approximately once per
week, “uncommon” one to three times per month, and “rare” one to two times per year
or less in New Orleans.
Fig. 3 Impact and prevalence of grand rounds (GR) topics. GR presentations placed a heavy
emphasis on life-threatening (30%) and vision-threatening (48%) diseases.
Discussion
The main purpose of GR is to discuss a clinical case in sufficient detail and analyze
its management in an academic learning environment (in the presence of all residents
and faculty). The resident presenter typically has participated in the actual patient
care, spent time reviewing the chart, collected and analyzed all the diagnostics tests
and management, and read the up-to-date literature on the topic. It is expected that
the presenter is able to present the case summary and relevant literature in 10 to
15 minutes. When done properly, GR can satisfy several of the core competency requirements
by the ACGME, including patient care, medical knowledge, practice-based learning,
systems-based practice, and interpersonal skills and communications. Systematic analysis
of GR from a given program might give an insight as to the contribution of GR to resident
education.
The choice of GR topic is a key factor in their relevance. Needs assessment and assigned
topics are used in 44 and 33%, respectively, of MGR.[4] In the Tulane OGR, resident selection alone determined the topics. The cohort of
residents at Tulane spontaneously divided their topics across most subjects within
ophthalmology relatively evenly, although some underrepresentation occurred in optics,
strabismus, uveitis, and refractive surgery. This suggests that assignment may not
be necessary in all cases.
Rare diseases comprised a majority of the GR discussions, so the typical GR session
did not address diagnoses likely to be seen in an average clinic. These rare diseases,
however, were much more likely to be vision- or life-threatening in nature. Thus,
these diagnoses, while perhaps encountered only a few times in the typical clinician's
practice, represent diagnoses of critical importance. GR could well be the only exposure
residents have to the clinical presentation of these rare diseases before encountering
them in practice.
Resident fascination with rare cases is a well-known issue in academic circles. It
is not uncommon for even medical students to lean toward presenting the unusual case
compared with the common diseases that are seen every day in the clinic. The impact
of this understandable fascination on the evolution of these young residents' clinical
knowledge and on their future clinical practices needs further studies.
The predominance of unusual diseases presented in GR is not inherently misguided.
Indeed, one of the purposes of GR is to expose residents to a spectrum of cases they
are unlikely to see on their own in clinic, and therefore prepare them to accurately
diagnose unusual vision- or life-threatening diseases in their future practice. Yet
GR should also serve as a didactic device for the most common topics in ophthalmology,
to ensure resident exposure and mastery of the subtler details of typical diseases
and surgeries in clinical practice. Encouraging a greater emphasis on common and uncommon
diseases could provide greater day-to-day clinical relevance for resident education,
but care must be taken to continue discussion of rare diseases that are vision- or
life-threatening in nature.
Residency programs could ensure an appropriate variety of GR case presentations by
tracking and categorizing the presentations by prevalence and impact following a similar
method to ours. Of course, simply presenting a topic does not ensure that successful
education has occurred. Future research could assess whether GR ophthalmology case
presentations are an optimal teaching method for the adult learners in residency programs.
