Towards a Better Case Conference

Residency conferences are struggling with low attendance and poor retention as an evidence-based profession teaches with evidence-defiant methods

I spent last week at the Alliance for Academic Internal Medicine conference in New Orleans, where I had the chance to talk with representatives from residency programs around the country about the challenges they’ve been facing with their case conferences. Whether large or small programs at academic or community hospitals hosting morning report or noon conference, I heard a common refrain. Residencies are struggling to draw attendance, encourage participation, and teach material in a way their residents—and often medical students—will remember.

Some programs have resorted to tying attendance to incentives or even punitive measures, offering better elective choices or more favorable positions on the sick call list to residents who reliably show up to conference. These approaches, though, risk damaging the rapport between residents and their program leadership and fail to address any of the underlying problems that undergird residents’ reluctance to engage with teaching.

Some of these problems exist at systems levels that may be beyond a residency program’s ability to fix—hospital overcrowding, pressures to improve patient throughput, and increased patient complexity all draw residents’ attention away from the conference room and back to their computers. But many residents are skipping conference because they don’t think it’s worth their time, and that is because an evidence-based profession is teaching with evidence-defiant methods.

Rethinking the Sacred Hour

Too often, medical educators assume that the immutable quantity in a didactic session is the amount of information they must convey, a quantity usually set by a teacher who is more enthusiastic about the subject matter than their audience will be. A heart failure talk must not stop before the latest preprint on GDMT has been addressed; a case conference on schistosomiasis must continue until the epidemiology of all individual species has been discussed. And so an 60-minute lecture becomes a 70-minute lecture—or worse—in a sprint to that all-important last slide.

This is a basic mistake that leads us to teach too much for too long at once. The truly immutable quantities during any teaching activity are simpler: the amount of time allotted on the schedule and—more importantly—the human capacity to sustain attention and retain information, both of which are far more limited than our current teaching techniques would imply.

Without meaningfully participatory activities, adult learners’ attention lapses with 15 minutes and does not recover until moments before the end of a session.¹² If a lesson plan pushes those limits, the appropriate response is not to try to cram in all that information anyway, which would be wasted on an audience that is no longer listening; it is to reduce the amount of information included in the lesson to begin with.

Why, then, do we hew so stubbornly to the former approach? Part of it is our worry that, in a crowded curriculum, we may never get another chance to cover a particular bit of material, but that fact does not make a detail shared in the 50th minute of a dragging lecture any more memorable. Another issue is that many physicians tasked with designing and leading didactics have not received much formal pedagogical training, leaving them with only their memory of the sessions they once sat through themselves to use as a model and thus perpetuating the educational status quo.

A prime culprit and an obvious opportunity for intervention, though, is our longstanding custom that the appropriate length of didactics across medical education is one hour. Lectures during the preclinical years of medical school, small-group problem-based-learning sessions, and yes, noon conferences all default to the 60-minute tradition.

One hour is too long for a learner to stay engaged in just about any lecture-based environment (and a few questions posed to the audience along the way do not a lecture unmake). It is particularly ill-suited for a residency case conference, during which learners are simultaneously besieged by nursing pages, admissions, unstable patients, and impending discharges.

We have an chance to realign case conference with adult learning theory and the quotidian pressures of residency by reducing it to 30 minutes—or even shorter. When we assure learners that they will only be asked to press pause on their work for a few minutes to attend a session that is engaging, digestable, and retainable, we will see them start to return to conference—and remember it.

Over the next few weeks, I’ll share more strategies about how we can modernize case conference by adjusting the content we cover and the methods we use to teach it.

1. Samarasekera DD, Gwee MCE, Long A, Lock B. Lectures and Large Groups. In: Swanwick T, Forrest K, O’Brien BC, eds. Understanding Medical Education: Evidence, Theory, and Practice. Wiley-Blackwell; 2018:113-121.

2. Jeffries WB. Teaching Large Groups. In: Huggett KN, Jeffries WB, eds. An Introduction to Medical Teaching: Second Edition. Springer; 2014:11-26.