INTRODUCTION

Educational conferences are a staple of internal medicine (IM) residency programs, dating back to the beginning of residency training in the USA.1 Most institutions offer a variety of conference types, including case-based discussions led by chief residents (e.g., “morning report”), didactic lectures about core internal medicine topics, morbidity and mortality conference, and skills workshops.2,3,4,5,6 The Accreditation Council for Graduate Medical Education (ACGME) mandates that training programs sponsor a broad range of structured didactic activities, but gives little guidance on content or delivery method.7

Social distancing requirements during the COVID-19 pandemic caused many programs to pivot from primarily in-person conferences based at each clinical site to virtual conferences. This shift brought both benefits and drawbacks.8 Rather than coordinating several individual conferences, multi-site training programs can now host a single virtual conference. Conversely, the digital format can limit engagement from participants, hinder community building among attendees, and facilitate distractions by clinical work.8 As COVID restrictions ease, residency programs are faced with balancing these tradeoffs and yet again deciding how to update their educational conferences.

Our class of chief residents comprised the last class to begin residency prior to the COVID-19 pandemic and shift to virtual conferences. Thus, we began this year ready to reinvigorate our conference curriculum before institutional memory forgot the benefit of in-person gatherings. Although we have enjoyed being in-person again, we continue to struggle with low in-person attendance and a lack of engagement during digital sessions. Anecdotally, many of our colleagues at peer institutions face similar challenges. We’ve posited many theories to explain these current difficulties: fatigue related to the COVID-19 pandemic, high hospital census, and even the inherent characteristics of Generation Z (e.g., preferring self-directed over structured learning).9 While many of these factors may be contributing, we also recognize that these concerns about conferences are not new. Studies across multiple eras of resident education have shown that resident attendance at educational conferences varies between only 34 and 63% of residents who are on inpatient rotations.6, 10, 11 This historical perspective raises the question: should we go back to the way it was?

Rather than just returning to the pre-COVID format, this transition out of COVID is an opportunity to fully re-evaluate the role of inpatient conferences within IM resident education. We should question whether didactic lectures are effective means of teaching residents during a busy workday12,13,14. We should recognize the value of expertise in education as we develop curricula. And we should demand that our conference offerings prepare residents to understand and dismantle the structural racism and inequity embedded in our healthcare system.

Given the variation in residency program size, structure, and resources, it would be unrealistic to expect that a single educational model can universally advance inpatient educational conferences. As we have undertaken reforming our own conference curriculum over the course of this academic year, we have embraced a set of guiding principles. These principles are grounded in a mix of educational theory, institutional memory, and our lived experiences as residents and educators. We have also included a list of previously published curricula that we feel exemplify the principles for which we advocate (Table 1). We share these reflections in the hopes that they guide other programs to effect change in their educational programing.

Table 1 Previously Published Curricular Interventions
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PRIORITIZE ACTIVE LEARNING AND EDUCATIONAL EXPERTISE

Sound curriculum design begins with writing clear objectives.15 Bloom’s Taxonomy is one tool to help understand how educational objectives and outcomes align (Table 2).16 Lower levels of the taxonomy focus on recalling facts and understanding concepts. These outcomes are well suited to didactic lectures, which in part explains why didactic lectures are often used in pre-clinical medical education. In contrast, residents need to leave conferences ready to use newly acquired knowledge in the clinical environment. Achieving this goal requires components from higher levels of Bloom’s Taxonomy, where learners apply, analyze, and evaluate knowledge.

Table 2 Bloom’s Taxonomy Applied to Inpatient Conferences
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After crafting objectives, educators should align their objectives with appropriate educational strategies.15 Achieving these higher-level outcomes requires educational strategies that embrace active engagement rather than passive lectures.1 Moving towards active learning can take on many forms, from low-activation changes like incorporating poll questions to more comprehensive redesigns eliminating slide-based formats and instead focusing on case-based discussions. For example, team-based learning (TBL) is a small-group educational approach that prioritizes active learning by providing learners opportunities to apply conceptual knowledge to authentic problems both individually and within teams with immediate feedback.17, 18

Another long-standing tradition of medical education is inviting preeminent experts to teach trainees about their area of focus. However, excellence in research and clinical care may not always translate to excellence in teaching; in fact, many content experts may not have the educational background to feel comfortable facilitating active learning experiences.19 A prior study demonstrated that residents value learning core knowledge during noon conferences, as opposed to in-depth discussions of cutting-edge topics, in order to aid their clinical practice as well as board exam preparation.19, 20 Effectively teaching this desired content does not require subspecialty expertise. One approach to maximize the use of institutional resources could be pairing content area experts (i.e., subspecialty faculty) with educational experts (i.e., chief residents, residency program core faculty) as co-facilitators.

PARTNER WITH LEARNERS TO DEVELOP CURRICULUM

It is easy to overlook residents’ expertise and perspective on their own learning experiences. Yet, today’s residents have had a significantly different experience than many in leadership; any changes to conference curricula should include, at minimum, an effort to understand residents’ experiences of inpatient conferences. Consider a residency program contemplating integrating TBL into their conferences. For residency leaders, this could be their first time interacting with the format. But, as many medical schools have embraced TBL as a component of pre-clinical education, most residents would bring their own experiences and attitudes to the sessions. Residents may bring experience that helps design effective sessions and avoid common pitfalls. Conversely, prior negative experiences make residents reluctant to join any session labeled “TBL.”

Beyond simply surveying current residents or reviewing prior evaluation data, programs should embrace a model of “co-production” between residents and residency leadership. Co-production recognizes that all services involve participation from both consumers and creators.21 In the context of medical education, this means that residents and students always play a role in creating their education, regardless of whether teachers recognize it.22 During the early phases of the COVID-19 pandemic, one medical school successfully embraced a co-production model to increase partnerships amidst rapidly changing distancing requirements. Medical students participated in key decisions around curricular adjustments alongside administrators, and this resulted in a flexible curriculum adapted to learners’ and teachers’ evolving needs.23, 24 Co-production between residents and faculty was also key to successfully implementing new Canadian competency–based medical education standards.25 Programs should ensure that residents receive credit for their contributions to curriculum design. This credit could include aligning projects with residents’ career goals, allowing curriculum design projects to fulfill scholarship requirements, and designating mentorship to help residents transform their work into scholarship (conference abstracts and/or publications). Breaking down barriers between leadership and residents can ultimately improve the conference quality and process of improving conferences.

INCORPORATE HEALTH EQUITY AND STRUCTURAL COMPETENCY

The ACGME states that part of an internist’s role is to: “promote health and health equity,” but gives little guidance as to how programs should train their residents to do so.7 Learners have long advocated for increased attention to health equity in medical school in residency curricula. These demands were finally met with urgency over the past few years, as police violence against communities of color gained national attention and the COVID pandemic highlighted existing health disparities.26, 27 Still, a recent survey of IM residencies found that only 39.6% had dedicated equity curricula, and that the presence of an equity curriculum did not increase residents’ perception that they received quality education on health disparities.28 Across GME, residency programs have strived to implement equity curricula with limited outcomes data thus far.29

Prior effective interventions in this area have included longitudinal, leadership-centered approaches, and problem-based learning.30,31,32 We see inpatient conferences as another opportunity to embed equity content into residency curricula. Rather than limiting these topics to isolated lectures throughout the year, we strive to include content related to health equity in every teaching session. For example, while there may be rotations and talks specifically focused on people experiencing homelessness, a session on heart failure could also include a brief activity to navigate barriers to taking guideline-directed medical therapy for a patient with heart failure. Recognizing and responding to implicit bias is another key topic that, while worthy of individualized sessions, should also be threaded throughout other sessions.33 This thread of equity within all teaching should be complemented by dedicated sessions to unpack more complex equity topics including responding to microaggressions in the clinical learning environment, high-value care delivery in resource-limited settings, and the racist legacy of research practices in the USA.

Adding this content will require additional expertise. This could be another opportunity for content experts to partner with experts on health equity, or to provide educators with equity-based continuing education opportunities. Speakers should also be given basic standards of structural competency prior to teaching, with the opportunity for peer review. For example, cases should appropriately distinguish between sex and gender, use diverse patient images, and avoid stereotypical language. Implementing durable, comprehensive equity curricula requires significant institutional investment and commitment by residency leadership.

FOCUS ON ATTENDANCE AS AN OUTCOME, NOT A GOAL

Because conferences are only one part of residents’ entire educational experience, discerning the impact of conferences on residents’ knowledge or even clinical outcomes is challenging. Attendance is the primary outcome of most prior inpatient conference assessments, likely because it is easy to measure and compare year to year.6, 10, 34, 35 Though an imperfect measure of efficacy, we suggest continuing to focus on attendance as the primary outcome of conference, but with a shift in perspective.

Prior interventions to improve conference attendance—focused on food, timing, and offloading other resident responsibilities—have not resulted in meaningful changes.6, 34, 36 Despite being a mainstay of some institutions’ noon conference (sometimes called lunch conference as a result), offering meals has been shown to have a variable impact on attendance.6, 34 Timing adjustments, making conferences mandatory, and setting consequences for poor attendance have all failed to increase attendance.6, 36 These well-intentioned interventions fail to address the major underlying barrier to conference attendance.

When considering conference attendance, residents are weighing the relative benefit of attending a teaching session against the time lost completing other tasks, and potentially extending an already stretched workday. The best incentive for conference attendance is not pizza, or coffee, or threats of professionalism violations. Our experience as chief residents has shown us that residents will make time in their day for high-impact conferences that can immediately improve their clinical practice, regardless of their ultimate career goals. Conversely, they resent being required to attend sessions they perceive as being a poor use of their time. And though this embrace of resident autonomy may be a shift away from the historically hierarchical nature of resident education, self-directed learning is a key component of residents’ development.37

RE-FRAME COMMUNITY AS AN OUTCOME

Burnout among trainees has been a rising issue for the past decade, exacerbated by the COVID-19 pandemic38, 39. However, the impact of the pandemic on our community extends beyond trainees; medical educators and residency program directors have also reported higher levels of burnout amidst the pandemic.40,41,42 Although burnout is a complex phenomenon with multiple drivers, one key component is a lack of connection and community.43

Social interaction has long been part of conference attendance. Breakout rooms, lively chat box discussions, and groups meeting to watch virtual conferences together have all been attempted to curtail the impact of virtual conferences on socializing, but these efforts pale in comparison to in-person interaction.8 We aspire to make community building a core objective rather than simply a byproduct of conferences. Teachers should start conferences by setting aside time for introductions and brief icebreakers. The use of interactive cases creates time for participants to interact not only with the cases and facilitators, but with each other as well. We envision an ideal noon conference as a “town square” for residents where all participants have a sense of belonging. Overcoming burnout will take more than returning to in-person conferences. But, cultivating opportunities for community and connection is a vital piece of the complex puzzle, both for learners and educators.

CONCLUSION

Resident education comes in many forms, including real-time teaching on the wards, asynchronous learning, and just-in-time training. We believe inpatient conferences should continue to represent an important part of residents’ education. However, residents’ educational needs have changed significantly over the past century, and the format of most inpatient conferences has remained stagnant. It’s likely the next century will bring new technology, program requirements, and possibly even new pandemics that will continue to affect the educational environment. We hope these principles can serve as a guide for a continuous evolution of noon conferences so that our educational offerings are best suited to train future generations of residents.