A hospital’s grand rounds is the way that most physicians receive their continuing medical education (CME). Traditionally, grand rounds was a weekly live event, held in a hospital auditorium. The time has come to offer all grand rounds on-line.
Grand rounds originated with Dr. William Osler at Johns Hopkins in 1889. Initially, it was a patient-centered presentation, where a senior physician would bring out a patient and then discuss that patient’s clinical findings and treatment.
Over the past 50 years, grand rounds has evolved into more of a lecture format to update the medical staff about the latest developments in the medical field. As state medical boards began to require a minimum number hours of CME to maintain medical licensure, hospital grand rounds became accredited for CME and physicians increasingly turned to grand rounds for their CME credits.
But in the past 25 years, attendance at grand rounds has declined and in 2006, an article in the New York Times concluded that “Grand rounds are not so grand anymore.” A primary driver for the decline in attendance is the changing time demands on physicians that frequently place grand rounds at conflict with patient care activities.
There is no best time of the day
Grand rounds are usually held either in the early morning, at noon, or in the late afternoon. Historically, the early morning (typically 7:30 AM) time allowed physicians to round on their inpatients before attending the presentation. Their office hours would then start around 9:00 AM. Several changes to medical practice have made early morning no longer a tenable time for most physicians. With 15-18 inpatients, residents and hospitalists are not able to complete their morning rounds by 7:30. Moreover, they are under pressure to complete the day’s hospital discharges by late morning. The result is that they cannot realistically take time out of their busy mornings to attend grand rounds. Outpatient physicians are under pressure to start their office hours promptly at 8:00 AM in order for the office to run as efficiently as possible – whenever the doctor is not seeing patients during working hours, the office is losing money. For surgeons and anesthesiologists, early morning is prime operating room time and attendance at a hospital grand rounds is impossible. Proceduralists such as gastroenterologists, cardiologists, and radiologists are similarly constrained in the morning hours.
Noon has also become an untenable time for many physicians to attend grand rounds. Although hospitalists are usually able to combine their lunch hour with attending grand rounds, it is difficult for outpatient physicians to attend a noon lecture at the hospital. In the past, outpatient physician offices were located in medical office buildings adjacent to the hospital – a 3-minute walk from the office to the auditorium. But now, healthcare systems are increasingly decentralized with physician offices located far away, many miles from the hospital. As our nation’s hospitals have become larger, parking has become more challenging with parking areas frequently full and located farther from the hospital. The result is that physicians often need 30 minutes each way to travel to the hospital, find a parking place, and then walk to the hospital auditorium. A one hour grand rounds lecture at noon requires two hours for the outpatient physician to attend. Again, pressures to maximize operational efficiency in outpatient practice makes it very difficult for the physician to be away from the office for two hours in the middle of the workday.
Late afternoon is often equally untenable. After the last patient of the afternoon, outpatient physicians still have 1-2 hours of electronic medical record entry, patient phone calls, and paperwork. Outpatient physicians simply cannot get their daily work done in time to attend a 5:00 PM grand rounds. Physicians who perform shift work, such as hospitalists and emergency medicine physicians, are generally unwilling to drive to the hospital to attend grand rounds on their day off.
COVID changed everything
The COVID pandemic drastically changed education worldwide. Grade school and high school classrooms became virtual. College and medical school classes were often recorded for students to view on-demand. National medical conferences were canceled. Hospital grand rounds became on-line lectures. Now that in-person classes have returned, should we abandon our grand rounds Zoom format?
I would argue that hospital grand rounds should continue to be offered virtually. For all of the reasons previously stated, no single time of day is optimal or even possible for all physicians. Years ago, with mounting frustration at declining grand round attendance, our Chairman of the Department of Internal Medicine made in-person attendance mandatory… it didn’t work. It was not because the doctors did not want to attend, it was because they simply could not attend given the demands of modern medical practice.
There are advantages to in-person grand rounds, however. It is easier to pick up on the nuances of non-verbal communication by the lecturer. It is often easier to ask questions. Attendees are less likely to get distracted by emails, the electronic medical record, or the internet while sitting in an auditorium. Perhaps most importantly, it is easier to network with other physicians before or after the lecture. For these reasons, in-person grand rounds should continue.
But grand rounds should also be available online for those physicians who are unable to travel from remote outpatient offices and those shift-based physicians who are off duty. Grand rounds should also be available for on-demand viewing for physicians who are otherwise preoccupied with patient care during the regular “live” grand rounds hour.
The arguments for online grand rounds
About 15 years ago, we started video recording all of our first and second year medical student lectures and gave the students the option of attending in-person or on-line from home. Most students chose to view the lectures online and only about 20% of students now actually come to class. This was disturbing to many of the College of Medicine faculty who wanted to see a large live audience in the classroom. But the goal of medical education is to educate, not to fill the auditorium. And that means putting the needs of those to be educated first and not putting the egos of the educators first.
If you want your hospital’s doctors to be knowledgeable about the latest in medicine, then you need to reach as many of them as possible. Every grand rounds presentation needs to be available in multiple formats: in-person lectures, live online presentations, and video on-demand presentations. This allows the educational event to cross the barriers of geographic distance from the hospital, of conflict with patient care, and of time-of-day conflicts imposed by shift workers.
For hospitals in competitive markets, high quality continuing medical education is one of the best ways of demonstrating the expertise of the hospital’s medical staff, putting faces to the names of consultants, and showcasing the hospital’s services. The physicians in the hospital’s referral area are not going to travel to your hospital for a weekly in-person grand rounds but they will log-on to watch grand rounds online from their office during their lunch hour or in the evening. Online grand rounds should be free and readily available to anyone without requiring an account or log-in password.
At most hospitals, any physician who shows up to attend a grand rounds lecture in-person can get free CME credit hours from the hospital. The same should be true for physicians who watch your hospital’s grand rounds on-line. One hospital that I know offered CME credit to those physicians attending in-person or listening to the grand rounds live but refused to give CME credit to physicians listening to the exact same lecture on-demand later in the day. This is absurd. It is the same educational material regardless of when the physician views it.
Producing grand rounds can be costly. Outside speakers require an honorarium and payment for travel expenses. The technical work to film and maintain online video comes at a price. The good news is that the COVID pandemic has shown all of America that online video education can be produced at minimal cost. If you can’t finance the cost of providing CME free to your viewers through your education department, then go to your marketing department. The expense will be less than the price of producing a 20 second television commercial and the online grand rounds will reach more of the physicians who refer patients for the hospital’s services.
Its not about how you learn, its about how other physicians learn
All too often, decisions about the format of grand rounds are made by the medical staff senior leadership. These are typically older physicians (like me!) who are most comfortable with a traditional in-person lecture format because that is what they grew up with. But this is not how younger physicians learn – they want to get their medical education online. And if they can’t get your hospital’s grand rounds online, they’ll find some other hospital’s grand rounds that they can get online. Grand rounds is not about educating the physicians of yesterday, it is about educating the physicians of today and tomorrow.
June 10, 2022