antiangiogenic drugs for its treatment has changedthe outcomes in ARMD patients. However, thesetherapeutic options are relatively new and areunknown to many general practitioners (GPs),although earlier recognition of the problem isexpected to reduce associated disability and burdenof care.What was tried? A mail survey was used to identify thegaps in GPs’ knowledge of ARMD. The entire GPpopulation in the Spanish region of Castilla and Leon(n = 2365) was surveyed, giving a response rate of31%. There were no significant differences betweenresponders and non-responders with respect to theirdemographic or patient portfolio characteristics. Theresults of the survey were used to inform the design ofcourses to remediate these gaps in knowledge.

An Internet-based course was offered within thehealth regional government e-learning platform. Thisplatform allows the student’s progress to be tracked.Interaction among teachers and learners was pro-vided through an open forum and student commit-ment in return for access to subsequent onlinematerials was required.

A hybrid course was offered to doctors attending aSpanish GP congress. The objectives and contents ofthe online materials were identical to those of thematerials given to the previous group. Materials werefully accessible for 4 months and were providedwithin the e-learning platform of the congress, whichdid not allow any interactive activity. Organisersincluded a face-to-face course component thatconsisted of a 2-hour lecture delivered during theconference. There were no differences in sex, age andnumber of years in practice between the GPsparticipating in the Internet-based and conference-delivered courses.

The proportion of change in knowledge of ARMDafter the courses was calculated as a summation ofall off-diagonal proportions in contingence tables.The study was approved by the local ethics commit-tees.What lessons were learned? Serious deficiencies inknowledge of ARMD were detected in the survey,which highlights this as a high-priority teachingtopic. In a similar study, doctors demonstratedfavourable attitudes towards eye health management,but only 52% of respondents indicated they hadadequate knowledge to manage eye diseases.1 Theinitial evaluation of information provided by thepreliminary survey in this study contributed to thedesign of specific training programmes.

The Internet-based course was undertaken by 205GPs, 80% of whom passed the final examination. Thenumber of responses using the ‘not known’ optionreduced to almost zero and the probability that

ARMD would be suspected was higher after thecourse. The partial in-class course was undertaken by150 GPs, of whom only 33% passed the examinationand 52% admitted to not having read the onlinematerials. Statistically significant differences in resultsemerged between the two study groups, demonstrat-ing that the effectiveness of learning was worse in thein-class group. The mean ± standard deviation ageof course participants was 49.7 ± 9.4 years (range:29–65 years).

This study adds evidence of the effectiveness ofcontinuing medical education programmes toimprove care in ARMD. The use of information andcommunication technologies did not discourageolder practitioners from participating. We recom-mend that teachers and organisers of e-learningcourses select platforms that allow interaction toimprove the effectiveness of learning.

REFERENCE

1 Ammary-Risch N, Kwon HT, Scarbrough W,Higginbotham E, Heath-Watson S. Minority primary carephysicians’ knowledge, attitudes, and practices on eyehealth and preferred sources of information. J Natl MedAssoc 2009;101:1247–53.

Correspondence: Rosa M Coco, Instituto de Oftalmobiologia Aplicada(IOBA), Campus Miguel Delibes, University of Valladolid, Paseo deBelen no. 17, Valladolid 47011, Spain. Tel: 00 34 983 423559(ext. 3236); Fax: 00 34 983 423274 ⁄ 423022;E-mail: rosa@ioba.med.uva.es

doi: 10.1111/j.1365-2923.2012.04238.x

The ambulatory morbidity and mortalityconference meets the morning report

Christopher Wong & Ginger Evans

What problems were addressed? Internal medicinemorbidity and mortality (M&M) conferences usuallyfocus on in-patient care in a residency training settingand cases are chosen for their educational value forresidents, rather than for the likelihood of error.1

Typically, a case is presented and analysed in itsentirety by the speaker. Discussion is often short andbiased by knowledge of the outcome.

Improving quality by learning from adverse eventsis a lifelong activity in all domains of patient care, notonly the in-patient academic setting. Therefore, wesought to implement an ambulatory M&M confer-

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ence with the following features: (i) feasibility in anambulatory clinic; (ii) increased participationthrough a morning report-style presentation, and (iii)a focus on concrete steps to quality improvement.What was tried? We developed a multidisciplinaryM&M conference at an academic out-patientinternal medicine practice. Participants includeattending physicians, resident doctors, nursepractitioners, clinic management, and leaders of thefront desk, nursing and medical assistant staff. Casesare identified by querying the Patient SafetyNetwork� database and clinic personnel. Cases areselected based on the presence of a possible erroror patient harm. There is no predeterminedteaching point.

During the conference, the case is presented asunknown material, in the style of the morningreport. We often start with only a chief complaintand basic demographic information. Participants askquestions, experience the case as it unfolds, andactively contribute to the differential diagnosis andmanagement plan. The outcome of the case is thenrevealed.

Participants assign a level of harm (serious, minor,near miss) and identify contributors to the event.Opportunities for improvement are discussed andaction plans are developed. The results of each actionplan are reviewed at the subsequent M&M confer-ence.

From July 2009 to March 2011, 55 cases werereviewed. Thirteen cases were presented at six M&Mconferences. Examples include delayed diagnoses,management of infrequent situations (e.g. a patientwith homicidal ideation), medication-related adverseevents (e.g. involving reconciliation, refill protocols,drug interactions), and the administration of dupli-cate vaccinations. All action plans to date involvedprovider and staff education (10 of 13 cases; three areongoing); many generated system changes in theclinic (five of 13 cases).What lessons were learned? This format is feasible.The preparation work includes case finding, but doesnot require extensive root cause analysis or thefinding of an expert speaker.

Clinic leadership is essential. As action plans afterthe conference may require system changes, clinicleadership helps to establish priorities.

Non-doctor staff provide valuable input. Non-doc-tor staff may not be as familiar with the morningreport format, but this is not a significant barrier.

The M&M conference is not purely a housestaffactivity. Conferences that took place during facultystaff meeting time were well received. There is noreason why M&M conferences should stop at thecompletion of residency training.

The ‘unknown’ format is important. Participantsfelt that the morning report format promotes moreopen dialogue than a typical M&M case presentation.Almost the entire conference is discussion-based andinvolves all participants.

We believe that our M&M conference is a model formid-sized ambulatory practices in which providers arefamiliar with the morning report system.

REFERENCE

1 Orlander JD, Fincke BG. Morbidity and mortality con-ference: a survey of academic internal medicine depart-ments. J Gen Intern Med 2003;18:656–8.

Correspondence: Christopher Wong, Division of General InternalMedicine, Department of Medicine, University of Washington, 4245Roosevelt Way NE, Box 354760, Seattle, Washington 98115, USA.Tel: 00 1 206 598 3991; Fax: 00 1 206 598 5952; E-mail: cjwong@u.washington.edu

doi: 10.1111/j.1365-2923.2012.04254.x

Evaluation of electronic versus traditional formatposter presentations

Sung Joon Shin

What problems were addressed? Electronic posters(e-posters) have been adopted at many medicalcongresses, but few studies have reported on theirusefulness and effectiveness1. Their advantagesinclude the provision of video files, in which variousclinical and surgical procedures can be displayed.E-posters can also be synchronised to tablet PCs andsmartphones. This enables attendees of a congress tosearch for and look at e-posters anywhere and at anytime. Moreover, e-posters are provided not onlyduring but also after a meeting, and thus participantscan refer to e-posters and exchange their opinionswith authors at any time. However, e-posters are alsosubject to various problems, such as those associatedwith copyright infringement, and the costs associatedwith the set-up and maintenance of an e-poster systemare not negligible.What was tried? A total of 744 participants attendedthe 2011 Korean Society of Nephrology Congress.A total of 207 e-posters were displayed simultaneouslywith presentations using the traditional format. Afterthe meeting, participants were asked to completequestionnaires comprised of items on the legibility,readability, accessibility and scientific value of the

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