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The Department of Medicine’s Chief Resident, Dr. Steven Pi, leading the patient case study segment of Morning Report.

Part MD, part PI, Morning Report keeps students in touch with the fundamentals of diagnostic thinking

November 27th, 2017
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While much of the city is still fumbling out of bed, more than 30 very alert looking medical students, interns and residents gather at 7:30 sharp each morning in a non-descript meeting room in the lower reaches of St. Paul’s.

This is Morning Report, where the team from Internal Medicine meets for an overview of the day ahead, and of what to expect when they break off into smaller groups and fan out across the hospital to do their rounds.

It is after the various patient updates are touched upon, however, that Morning Report moves on to the exercise that has given it a richly deserved reputation as a program of innovative learning: the patient case study.

Each week, from two to four patient cases are presented to the group, which is then invited to discuss the case with an aim of making a diagnosis. The process is part MD, part PI, as the evidence is presented, questions are asked and deductions are made.

The chief architect of Morning Report is Dr. Barry Kassen, Division Head of Community Internal Medicine at St. Paul’s, whose devotion to education was recognized in 2017 when he was presented with the Mikhael Award for Medical Education from Resident Doctors of Canada, an organization representing 9,000 medical residents across the country. The award recognizes Dr. Kassen’s contributions to improving undergraduate and postgraduate medical education in Canada.

Dr. Kassen arrives for Morning Report each morning at 7:15AM, and while he admits that he has never been a natural early riser, there is no hesitation in his voice when he calls Morning Report, “The best part of my day.”

Inspiring generations of medical students

As Morning Report is about to begin, Dr. Kassen, as is custom, settles in to watch and listen (“and learn,” he says) as he hands the reigns to the Department of Medicine’s Chief Resident, a position currently held by Dr. Steven Pi, a young physician (he’s 29) who is clearly enjoying his six-month term as Morning Report facilitator.

When he was in medical school, Dr. Pi says that Morning Report was a highlight and an inspiration, something he always looked forward to.

“Morning Report is special,” says Dr. Pi. “As a resident, you’re busy, you’re pulled in different directions. But with Morning Report, for this small window of time, you get to just engage in diagnostic thinking and reasoning. You get to forget about everything else, including the day ahead, and focus on the things that brought you into medicine in the first place. That yearning for knowledge, that desire to solve the problem. I’ve always found Morning Report captivating and now, as Chief Resident, I get to see that same intensity and focus on the faces of everyone in the room. It’s very special.”

The morning’s case

As he introduces the case study on this particular morning, Dr. Pi tells the room that the patient has a complex medical history and that there is “lots going on.”

He isn’t kidding.

The patient is a man in his sixties with a past history of papillary cancer of the thyroid and a carcinoma of his lung, both treated successfully. He has a ten year history of rheumatoid arthritis that has progressed steadily despite multiple disease modifying agents. In the last several months he has lost twenty pounds, is fatigued, has indigestion, anorexia and recent gastrointestinal bleeding. An endoscopy was performed at St. Paul’s and a new diagnosis was considered. It was around this time that the patient came to the attention of Dr. Kassen, which Dr. Pi says is not a surprise.

“Dr. Kassen has built his practice on these patients,” says Dr. Pi. “Patients who have had multiple investigations, patients where everything keeps coming back negative, patients with uncommon occurrences who prove to be so difficult to diagnose. This is your typical Dr. Kassen patient. And he never gives up on them, never takes no for an answer, is always pushing forward on their behalf. All physicians care about their patients, but with Dr. Kassen it is something even more.”

The diagnosis

The amount of patient information presented at Morning Report would overwhelm the uninitiated, but the students and residents in the room appear undaunted; on the contrary, they seem to become more engaged by this mysterious case as each new piece of evidence is revealed.

But on this day, no one cracks the case—and for good reason.

The pathology report from the patient’s endoscopy indicates the presence of an extremely rare bacterial infection, a case of which had not been diagnosed at St. Paul’s in many years—the students and residents at Morning Report, therefore, would not have encountered it in a patient before.

When the diagnosis was confirmed, the patient’s meds were changed and, almost immediately, he began what all agreed was a miraculous recovery. This was a patient who, not so many months before, had confessed to Dr. Kassen that he felt like he was dying.

The patient continues to follow up with Dr. Kassen every few months, which is especially important because his newly diagnosed condition has a fairly high relapse rate. When he joins Dr. Kassen to see this patient today, Dr. Pi is still amazed at his recovery, at how good he looks, and he says such moments are what he loves about being a doctor. Yet just as quickly, his diagnostic side takes over.

“The big learning point for everyone at Morning Report,” says Dr. Pi, “is not so much that it turned out to be a rare disease, it’s that this patient had been misdiagnosed for several years, on escalating therapy for this condition that never got better. So the lesson is that if you come up with a diagnosis and things aren’t improving, you have to keep going back to the start and asking yourself why. Why isn’t the patient getting better?”

Webcast brings Morning Report to the broader medical community

St. Paul’s Foundation was proud to assist Dr. Kassen and his team when the idea was put forth to begin podcasts of Morning Report in an effort to share the knowledge (and approach to learning) with a wider medical audience. The case of this patient, misdiagnosed over years until a rare infection was discovered, was presented as a podcast earlier this year.

Astrid Levelt, Director of Medical Affairs for Providence Health Care, sees the podcasts as an exciting and evolutionary moment in medical education.

“With its case study methodology and focus on deductive reasoning and clinical decision making,” says Astrid, “Morning Report is a wonderful training opportunity for our medical students at UBC and for our residents at St. Paul’s, yet now, with the podcasts, that same experience becomes available to students throughout the province and, for that matter, around the world.”

Morning Report is but one example of the role education plays at St. Paul’s and friends of St. Paul’s Foundation are encouraged to support education programs by making a gift. Your support and generosity today will support our caregivers of tomorrow.

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