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Hospital grand rounds in Australia

Richard Tarala and Alistair W Vickery
Med J Aust 2005; 183 (11): 592-594.
Published online: 5 December 2005

Abstract

Objective: To determine whether grand rounds are becoming less common in Australian hospitals.

Design and participants: Between November 2003 and April 2004, we surveyed 88 clinicians with educational responsibilities in Australian hospitals. A written questionnaire evaluated whether grand rounds were held and how frequently; the structure and percentage of attendees; and the perceived value of grand rounds with regard to education, professional development and general characteristics.

Results: Clinicians in 73/88 hospitals completed the survey (83% response rate). Of the 73 respondents, 63 reported that their hospitals continued to hold grand rounds, and most considered them to be valuable in the areas surveyed. Grand rounds were more common in larger hospitals, public hospitals, and those having junior medical officers. The proportion of clinical staff regularly attending grand rounds was estimated to be 10%–50% by most respondents.

Conclusion: Grand rounds continue in the majority of hospitals and are considered valuable for educational and professional reasons. There may be scope for improving attendance at grand rounds by greater emphasis on the specific needs of attendees.

The report of my death was an exaggeration.

Mark Twain (New York Journal, 2 June 1897)

Grand rounds have been an important educational activity in many Australian hospitals, but there is an impression that they have become less common and that in some hospitals they have ceased altogether. However, we could find no systematic information to support or refute this impression. There have been no published reports on the subject in the Australasian literature since 1985.1

There are many citations in the international literature containing the words “grand rounds”. However, few of these relate to how common grand rounds are, and many would not be considered the type of grand rounds we are familiar with in Australia. An editorial published over 25 years ago in a prominent US journal suggested that grand rounds were declining in popularity,2 but this suggestion was disputed.3,4

To establish whether grand rounds are becoming less common in Australia, we conducted a survey of people with educational responsibilities in Australian hospitals. In our survey, we defined grand rounds as “a recurring cross-disciplinary formal educational meeting, primarily but not exclusively of doctors, from the most junior to the most senior”. Our survey also sought information on the size and type of hospital, employment of junior clinical staff, and clinical attendance where grand rounds persist.

The educational validity of formal continuing medical education (CME) activities such as grand rounds has been questioned.5,6 We therefore also asked respondents to evaluate their grand rounds with regard to several areas grouped under educational, professional and general characteristics of the meetings.

Methods
Participants

A questionnaire was sent to clinicians who are responsible for educational programs in Australian hospitals. The list of potential respondents was drawn from names supplied by postgraduate medical councils, from directors of clinical training and from directors of postgraduate medical education in Australia. Data were collected between 12 November 2003 and 30 April 2004. We asked respondents to submit the completed survey by reply-paid envelope or email. Non-responders were sent a reminder, by email and letter, and another survey with a reply-paid envelope.

Questionnaires

Eighty-eight questionnaires were sent to departments of postgraduate medical education or their equivalent throughout Australia. The questionnaire contained 13 multiple choice or yes/no questions and 10 five-point Likert-style questions (with answers ranging from 1 [“strongly disagree”] to 5 [“strongly agree”]). Demographic data were sought regarding size of hospital, frequency of grand rounds, and structure and percentage of attendees. Respondents then answered questions on the value of grand rounds assessed according to nine subcategories. A project officer undertook the follow-up.

Results
Demographics

Of the 88 people sent questionnaires, 73 replied (83% response rate). Forty-five (62%) were directors of clinical training and 7 (10%) had multiple roles within training and administration; 49 (67%) worked in public teaching hospitals with junior medical officers (JMOs); 10 (14%) were in public hospitals without JMOs; 8 (11%) were in public hospitals with JMOs; and 6 (8%) were in private hospitals with JMOs. The proportion of those hospitals holding grand rounds is shown in Box 1. Fifty of the 73 hospitals (68%) were 100–500 beds in size, and 12 (16%) had over 500 beds.

Sixty-three (86%) of the 73 hospitals surveyed were conducting regular grand rounds; 51/63 (81%) of those were held once a week, 2 twice a week, 2 once a fortnight, and 4 once a month. Pharmaceutical companies provided sponsorship in over half (36/63) of the participating hospitals. Food was provided to attendees in 53 of the hospitals that held grand rounds. Respondents were also asked to estimate the proportion of clinical staff who regularly attended grand rounds. The majority estimated the proportion to be between 10% and 50% (Box 2).

Value of grand rounds

Of the respondents, 23/73 (32%) agreed and 38/73 (52%) strongly agreed with the assertion that grand rounds should continue. Of the 10 respondents who did not offer grand rounds, 2 reported having too few attendees and 1 too many meetings. The other 7 had never held grand rounds.

Evaluation of grand rounds in terms of nine subcategories (each assessed on a five-point Likert scale) showed that over 80% of respondents agreed that grand rounds are worthwhile in terms of education, hospital “climate” (ie, “the implicit beliefs, values, and loyalty within the hospital that motivate and shape the behaviour of staff and patients and define the unique culture of a hospital”7), presentation practice, a forum for general discussion, exchange of ideas, professional contact and “overall”. A lesser but still substantial proportion of respondents agreed that grand rounds were worthwhile in terms of CME (77%) and JMO education (68%) (Box 3).

Discussion

Our survey confirmed that grand rounds are still common in Australian hospitals, and that these meetings continue to attract audiences, with typically 10%–50% of clinical staff attending. It is our impression that the level of attendance, although significant, has diminished over the past 10 years, but with no previous surveys available, we are unable to confirm or refute this impression.

If attendance is less common than previously, a number of factors may have contributed to the change:

  • Increased clinical and administrative loads;

  • Managerial pressure and the requirement for clinicians to be increasingly accountable for their actions — the perceived difficulty of justifying non-patient contact time;

  • Increased numbers of specialised meetings, rather than whole-of-hospital or undifferentiated cross-disciplinary meetings; and

  • The perception that attendance is not necessary to fulfil specialist-college requirements for continuing education.

Although there was a good response rate to our questionnaire, a weakness of our data is that the people to whom we sent questionnaires were likely to be biased in favour of “educational” meetings such as grand rounds. However, there was no other easily identifiable group from whom such information could be sought.

We used a specific definition of grand rounds, which nevertheless encompasses considerable variety in style and content. Grand rounds may consist of the old-style ward round, comprising all consultants, registrars, house staff, nurses, allied health workers and students, with senior doctors sharing their wisdom and pronouncing ex cathedra on all the patients. They may also comprise didactic lectures, highly interactive small-group presentations or video presentations in lecture style broadcast to a remote audience. The educational value of such diverse presentations will be necessarily quite different.

As no single educational activity can optimally suit the needs of a disparate audience, it is not surprising that the educational validity of grand rounds has been questioned.5,6,8 According to one report, large-group didactic teaching (such as may occur in grand rounds) does not significantly affect physicians’ clinical performance, but “formal CME events may serve to heighten awareness and also facilitate personal ‘needs assessment’ by either confirming one’s current practice or highlighting discrepancies that the practitioner should address”.9

Organisers of grand rounds could improve the meetings by applying the adult learning principles described by Kaufman10 and others,11,12 namely:

  • having a meaningful and relevant topic;

  • pitching the material at an appropriate level;

  • having clear educational objectives, including active involvement; and

  • providing feedback to learners and presenters.

Some institutions have made formal moves to improve the educational quality of grand rounds. Organisers of the Mayo Clinic’s medical grand rounds have “tracked” participants to accurately gauge attendee numbers.13 Other institutions are actively providing feedback to presenters to improve presentation, including computerised audience-response systems.14,15 Surveys of attendees to elicit topics and specialties that accurately reflect participants’ needs have also been employed.16,17 Some Australian hospitals are using professional development for presenters, such as occurs in “Teaching on the Run” training modules, which were designed to help improve the quality of teaching and supervision by clinicians.18

Despite suggestions that grand rounds have been dying out, two recent reports from the Mayo Clinic13,14 supported continuation of grand rounds, although not of the kind that appears to be common in Australia. There has been criticism of meeting styles that focus too much on esoteric diagnoses.19

Although grand rounds are ostensibly for education, they also have non-educational benefits. Such benefits — including professional contact, a forum for general discussion and an opportunity for exchange of ideas — were considered valuable by our respondents. Most respondents also acknowledged a positive impact of grand rounds on “hospital climate”.

Should grand rounds continue? This is a question for clinicians within an institution to decide. It may be appropriate for each group of clinicians to carefully define the aims of their meetings. We recognise that grand rounds as currently run may be educationally flawed. However, our personal observations suggest that presenters and organisers are increasingly identifying desired outcomes and employing different formats and educational strategies to improve the value of these sessions.

In answer to the original question about whether grand rounds are diminishing or dying out in Australia, to paraphrase Mark Twain, “reports of their death have been exaggerated”.

1 Proportion of hospitals conducting grand rounds, by type of hospital


JMO = Junior Medical Officer.

2 Clinical staff attendance at grand rounds

3 Reasons for believing grand rounds to be worthwhile (expressed as proportion [%] of respondents giving each rating) (n = 72)

Reason

Strongly disagree

Disagree

Unsure

Agree

Strongly agree


Education

1

3

11

52

33

Hospital “climate”*

4

5

7

47

37

Continuing medical education

1

3

19

52

25

JMO education

3

10

19

49

19

Presentation practice

0

10

10

44

37

Forum for general discussion

0

5

8

55

30

Exchange of ideas

0

4

12

55

29

Professional contact

1

0

5

51

42

Overall

0

3

14

53

30


JMO = Junior Medical Officer.
* Defined as “the implicit beliefs, values, and loyalty within the hospital that motivate and shape the behaviour of staff and patients and define the unique culture of a hospital”.7

  • Richard Tarala1
  • Alistair W Vickery2

  • Department of Postgraduate Medical Education, Royal Perth Hospital, Perth, WA.

Correspondence: 

Competing interests:

None identified.

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