Wenger and Shpiner, in this issue of Annals, address the content, rather than structure, of Morning Report at the UCLA Medical Center [3]. Given the reality of greatly diminished length of stay and a lack of continuity of care involving the residents caring for the hospital inpatients, they tested the hypothesis that a substantial number of patients remain undiagnosed by discharge or transfer. Within 6 months of discharge, 24% of patients presented at morning report had been assigned a diagnosis that differed from that initially presented at Morning Report. The authors contend that the failure of residents to learn of these changes is a major educational shortcoming stemming from heavy reliance on inpatient medical education.

Even if these findings are broadly applicable, I take the position that the accuracy of diagnoses presented at Morning Report 6 months later does not affect its educational value. An excellent format can exist for Morning Report with few links to truth in diagnosis. This stand is based on the advances in clinical education in medicine that are now incorporated into Morning Report.

Once, clinical medicine was taught primarily through intimidation; the defensive reactions by students and housestaff were not particularly honest ones but necessary for survival. Brancati's description of "Morning Distort" brings back painful memories of emotional trauma, even shame [4]: "Whether you call it morning report, morning retort, or morning distort, the rules remain the same around the country. The bottom line is style above substance". When house staff are shamed by attendings, they in turn are more likely to humiliate their patients in subtle or not so subtle ways [5].

At Stanford, we rely on The Stanford Faculty Development Program [6-8], designed and tested by Skeff and colleagues. Aimed at improving the instructional skills of clinical teachers, its successful dissemination to more than 800 faculty and residents from over 50 medical centers has resulted in the institution of the techniques at their parent institutions. This program highlights specific areas on which we focus in Morning Report.

1. Establishment of a positive learning climate. The session must be one that residents enjoy not simply because it provides food and a respite. We try to promote a climate where residents can both learn and teach in a nonintimidating environment.

2. Control of the teaching session. The Chief Resident is responsible for planning and organizing the session so that it is natural, unhassled, and spontaneous. Not an easy task! The Chief Resident must assure that residents arrive on time, that as many as possible become involved in discussions, that the presenter is supported, that the ebullience of the attendings and the Chairman is appropriately suppressed, and the session ends gracefully on time.

The session's agenda has a major effect on its learning value. Our ingredients for the 50-minute session are as follows:

a. Review of Medical Knowledge Self-Assessment Program questions relevant to the ongoing noon lecture series (10 minutes).

b. Review of patients admitted the previous day (or weekend), highlighting key learning points, and discussion of deaths and whether autopsies were obtained (0 to 5 minutes).

c. Case presentations by residents on a scheduled basis. Although there are usually two to five attending physicians, senior Fellows, and the Chief Resident available for support, back-up, and gratuitous opinions, the resident is responsible for having reviewed and obtained copies of relevant journal articles and for making the pertinent points (35 to 45 minutes).

3. Communication of goals. The Chief Resident describes plans for each day; expectations and learning goals are set for each month. This process encourages trust and reiterates the objective that residents teach each other.

4. Enhancement of understanding and retention. Morning Report provides the opportunity for in-depth, open discussion, allowing residents to grapple with and better understand the process of clinical problem solving as well as the content of medical practice. It is important for the Chief Resident, Chief of Medicine, and Program Director to listen and extract substance from the presentation and condense the important learning points into a daily take-home message. These may be scientific or therapeutic choices, an ethical issue, or a problem involving interaction among residents or with attending physicians.

5. Evaluation and feedback. When things are going well, those in "authority" have the tendency to take it for granted, and positive feedback declines. The Chief Residents do not let this happen. They give frequent positive feedback to residents, which, in turn, makes it easier to deliver constructive criticism in private or as part of the session.

6. Self-directed learning. My hope is that residents who present cases with pertinent literature will be stimulated into regular reading that is sustained by the excitement of discovering information that enables better patient care. This is why having the "correct" diagnosis on an individual patient is not so important. What is important is that the patient is doing well and that possibilities for diagnosis or alternatives for treatment have not been overlooked, as validated by peers and attending physicians and by appropriate literature.

This configuration of Morning Report results in a valid teaching instrument. But whether or not initial inpatient diagnoses are correct, our system does not address the increasing discontinuity in our internal medicine training programs caused by a decreased length of stay (now 5.4 days at Stanford) and an increased acuity level. Although I share the concern of Wenger and Shpiner, I believe that one solution to this is a vertical firm system (Melmon KL, Holman H. Proposal for vertical firms at Stanford University Medical Center. [Internal document.]), in which efforts of full-time faculty (trained principally in secondary and tertiary care) are linked with those of community faculty in a deliberate amalgamation to achieve optimal medical care and teaching. The same attending physicians and residents would care for patients both within and outside of the hospital. The ideal would be to provide complete medical care (for example, hospital, university clinics, clinical faculty offices, private physicians' offices, extended-care facilities, and the home). It is clear that if I am to effectively lead our house staff from a dependent position of clinical novitiates to a mature and independent stage of knowledge, new formats that involve use of the same patient in both inpatient and outpatient settings will be essential.

Morning Report is an effective forum for teaching and learning. That may or may not be true, however. Wenger and Shpiner [3] have done the right thing: They studied a teaching tool, set up a hypothesis, and followed through to the collection and discussion of the data. The best test for any teaching instrument is to evaluate it regularly and creatively. Let us, then, continue to evaluate our morning reports, one form of morning learning.