While only 1 or 2 cases were presented at each morning report, the curriculum covered all major categories listed in the standard text, mimicked remarkably well the proportions represented by the ABIM exam, and some additional topics as well. Prior survey data indicate that residents prefer to discuss a few cases in depth, and other authors who have found declining case number in their morning reports attribute this trend to increased didactic content.1,6,8
If fewer cases are to be discussed each day, the variety must necessarily increase. It is an impressive feature of the general medicine clinic to be able to supply such a variety of cases capable of bridging information from so many subspecialty domains. We are unaware of any other studies that catalog the subspecialty content of a general medicine clinic's morning report.
The senior resident's use of a logbook appeared to effectively prevent redundancy of cases and over-selection of esoteric ones. Within Endocrinology alone, we covered aspects of diabetes and thyroid disease twice as often as all other endocrine diseases combined, reflecting the frequency seen in outpatient practice. This is relevant because 45% of residents surveyed in university-based training programs indicated that they planned to pursue a generalist career.8
While residents say they prefer discussing common medical conditions, 1 study reported that 4 of the 7 most common clinical diagnoses were never presented at morning report.1,5
The 12.5% of cases labeled “miscellaneous” reflects an expanded curriculum including alternative medicine, newly released medications, and geographic-specific topics that escape standard textbooks, such as West Nile Virus and the new Lyme Disease vaccine.
Our study has a number of limitations. Cross-content areas of the tabulated data can not be addressed well. The “pulmonary” category appeared to be covered far less often than required by the ABIM examination, but this was a function of the case assignment method. Most cases in this topic area focused on pneumonia, bronchitis, and tuberculosis and were thus categorized as “infectious disease.” The hematology/oncology areas were also under-represented. This may reflect the fact that malignancy diagnosis and management remains fairly uncommon in most general medicine clinics and is emphasized heavily during the inpatient experience at our institution.3
Further, we used, for convenience, the most common ambulatory text in our clinic to aid in categorizing cross-content areas, but this is an unvalidated tool. Additionally, our data spans 2 years of morning reports while each resident only has 6 to 12 months of ambulatory exposure over a 3-year period. We do not have prospective data on individual residents' topic exposures; we assume individual exposures would roughly approximate our tabulated cumulative data. While we have amassed prior survey data validating our teaching format, the current study assesses only the breadth of case selection and compares it to the content of the ABIM exam. We do not report on ABIM passage rates because many inpatient rotations clearly affect these rates, and the ambulatory morning report constitutes only a small portion of the cumulative education during residency.
Our teaching residents did not intentionally pick cases to mimic the ABIM exam content; the close correlation between the exam's content and our morning report format was only realized when the data were examined retrospectively. We conclude that an urban general medicine clinic may serve as a valuable resource for exposing residents to numerous subspecialty domains and that the use of dedicated ambulatory teaching residents is an appropriate mechanism to facilitate such broad case selection in a morning report curriculum. Training programs could use a breakdown of ABIM questions as a template for choosing cases to discuss in morning report, and our data suggest that a general medicine clinic would lend itself ideally to such a strategy.