Ambulatory rounds: a venue for evidence-based medicine

The format of inpatient morning reports and ward rounds is infrequently applied in ambulatory medical education. Published reports, however, suggest that this format provides for learner-centered, case-based discussions rather than topic-based lectures in the ambulatory setting.(1) We developed an ambulatory morning report with the specific objective of enhancing evidence-based medical inquiry among our pediatrics housestaff.

We developed a pediatric encounter form (PEF) by adapting and modifying an instrument described by Paccione et al.(2) The PEF was to be used by residents to document pertinent information and unanswered questions about patients seen during each ambulatory clinic session. Prompts were provided for documenting the patient's primary complaints, the patient's disposition, and questions that the resident needed answered. The PEF was piloted among a group of residents and faculty. The final version incorporated both resident and faculty input. Each resident was asked to complete a PEF for a maximum of two patients per clinic session. We did not direct residents as to what types of questions to formulate. All completed forms were maintained in a central folder. Next, we instituted a one-hour "Ambulatory Rounds" seminar once a week at lunch-time. During these seminars, faculty selected PEF cases from the previous week for discussion. Residents presented the cases and discussed the reasons behind the formulation of their questions. Faculty facilitated and guided residents toward resources for answering their questions. Faculty also helped residents to reformulate their questions to reflect an evidence-based medicine approach. At the end of each seminar, residents elected to research specific questions and present brief reports at the next seminar. To test the hypothesis that residents will formulate a higher proportion of evidence-based medicine (EBM) questions over time, we collected and analyzed 445 questions asked by 12 residents between July 2000 and August 2001. We categorized questions into EBM and non-EBM questions based on faculty assessment. We performed a trend analysis using chi-square to compare questions from July 2000 (as reference value) with the six-month periods of August 2000 to January 2001 and February to August 2001. By the end of the observation period, the proportion of EBM questions had significantly increased from 13% in July 2000 to 28% in the first six-month period and 59% in the second six-month period (p < 0.001).

We describe a new application of outpatient morning reports. This format has been very well received. Housestaff gave the ambulatory rounds an average rating of 4.3 (out of 5) on a Likert scale. Our experience suggests that this format not only provides a forum for case-based learning but can be successfully used to enhance the principles of evidence-based medicine among residents.