key: cord-289931-wqgq0ci4
authors: Sutzko, Danielle C.; Martin, Colin A.; Chu, Daniel I.
title: Development and implementation of virtual grand rounds in surgery
date: 2020-07-08
journal: Am J Surg
DOI: 10.1016/j.amjsurg.2020.06.075
sha: 
doc_id: 289931
cord_uid: wqgq0ci4

nan

From the halls of Johns Hopkins in the late 19 th century with Sir William Osler to present day auditoriums, grand rounds have remained a hallowed tradition of academic medicine. And like any tradition, grands rounds has evolved with the times from the Osler era, which featured actual patients, to present-day PowerPoint-heavy presentations. Through all these changes, challenges have persisted with delivering effective grand rounds including poor attendance, inconvenient times/locations, uninteresting subject matters, high costs and ineffective teaching styles. 1 The unprecedented COVID-19 pandemic has further challenged this tradition through restrictions on large gatherings, institutional bans on travel and major budgetary constraints. At our institution, surgical grand rounds were cancelled for two months (March-April 2020) with the withdrawal of many visiting professors. Given the uncertainty of the duration of these restrictions, our Department created a virtual grand rounds system to overcome these challenges and to continue the long-standing tradition of grand rounds.

Over the last decade the advancement and widespread adoption of technology and Immersive Virtual Reality (IVR) has challenged traditional learning methods. Within the virtual reality realm, medical curriculums have evolved to include virtual didactics and have now expanded to even using the virtual environment for surgical procedural training. 2 Virtual meetings using the internet have been well-described before the COVID-19 pandemic. 3 sine qua non for most institutions and organizations, the COVID-19 pandemic has forced a reckoning of the traditional way of running meetings. As a result, these restrictions have accelerated the adoption, adaptation and application of modern internet-based technologies to all professional meetings including grand rounds.

In this manuscript, we aim to share our institutional experience with development and implementation of a virtual grand rounds. Specifically, we will detail the setup for a virtual grand rounds program, describe its step-wise implementation and review its advantages/disadvantage.

While every institution will have its own unique system, resources and culture, we aim to provide a broad framework to guide the continued evolution of grand rounds.

The setup and implementation for a successful virtual grand rounds is based on three principles: use of a versatile internet-based technology platform, ensuring security and effective moderating (Figure 1 ). While several technology platforms exist, our institution is licensed to use Zoom (Zoom Video Communications, Inc., San Jose, CA), a cloud-based peer-to-peer software platform that provides videotelephony and online chat services. Use of Zoom has grown significantly during the COVID-19 pandemic going from 10 million daily users in December 2019 to over 300 million daily meeting participants by April 2020. 5 Our institution provides a professional license which permits up to 300 unique attendees, unlimited time and important features including share screens, chat boxes and recording. The platform is versatile, easy-to-use and well-suited to host speakers and audiences from around the world as it permits one-click entry into sessions, screen-sharing and several levels of communication including direct audiovideo and chat boxes for questions.

For security, our virtual grand rounds requires pre-meeting registration, which registers the attendee and then provides a unique link for one-click login to the meeting. The pre-meeting registration link is embedded in calendar invites to the grand rounds, available on the Department website and easily shareable. On login after registration, all attendees are automatically muted with capability to turn on their video. Because we use the pre-registration function, our Department does not utilize the Waiting Room feature of Zoom, which provides another option for security by requiring a host/co-host to allow entry of every participant into the session. As the grand rounds audience is large, it would be onerous and resource-intensive to require manual entry for every participant based on their name. Importantly, the pre-meeting registration also allows tracking of all participants which is useful for recording attendance, assigning CME credits and having the ability for faculty to logon and complete an online quiz for maintenance of certification (MOC) Part II Credit from American Board of Surgery following the grand rounds presentation. While unwelcome participants could technically register and login (e.g., Zoom-bombing), another layer of security is provided by the "co-host" assignments (given only to the moderator, administrator and speaker) which gives only the co-hosts the ability to share screens and to mute/disable audio and video.

To ensure a successful virtual grand rounds, the role of the moderator has become increasingly important. Given the lack of audience feedback and physical interactions in virtual meetings, the moderator is essential to keeping everyone on-schedule, overcoming technological glitches and guiding all virtual interactions. As large audiences are usually muted and often have their videos off, the combined silence and empty screens can be disconcerting. It is in that space, however, that the moderator should aim to start grand rounds on-time, introduce the speaker and ensure sharing of the speaker's screen.

On occasion, there will be technological glitches such as an inability to share screens (e.g., make sure to enable co-host role for speakers on Zoom) and poor audio-video. We have minimized many of these glitches by running a "test" session 24-hrs before the actual virtual grand rounds with speakers to go over screen sharing and schedules. In this test run the speaker, On the day of grand rounds, once the speaker is introduced and beginning the presentation, the moderator should be scanning the chat box (where questions are often placed), observing the participant list for any alerts (such as raised virtual hands) and monitoring the time.

On conclusion of the talk, the moderator should begin the discussion. We have often experienced delays in questions from participants and therefore the moderator should be prepared to ask the first question. We have also observed that most participants prefer to ask questions in the chat box and in this case the moderator should repeat the questions aloud for those who are in the meeting by audio-only. On conclusion of the session, the moderator should end the virtual meeting for all participants.

Virtual grand rounds sessions have several advantages. First, we have found that attendance has sharply increased since changing to a virtual format secondary to the need for social distancing. Figure 2 demonstrates our average pre (111 attendees) and post (155 attendees) virtual grand rounds attendance (p <.001). This significant increase likely results from the flexibility of attending grand rounds from any physical location, the ability to advertise to a wider audience and opportunities to easily ask questions. In fact, a recent study on burnout interventions in surgery by Lebares et al, found residents to be increasingly stressed when they could not attend didactics because of their clinical duties. During the semi-structured interviews conducted with the trainees, an operationalized/practical step suggested was a summer hiatus from grand rounds. 6 With the virtual platform, this added stress could be decreased with trainees and faculty able to tune in to the grand rounds remotely and decrease the time away from necessary clinical duties. For some participants, walking 5-10 minutes across campus for grand rounds can be a barrier. Traveling to the hospital may also be difficult for emeritus faculty and alumni in the region. The virtual option allows them to participate in a meaningful way from their office or from the convenience of their home.

Second, there is an economic advantage to having virtual grand rounds. An in-person traditional visiting professorship often includes transportation, lodging, and a social gathering. In addition, the visiting professor steps away from clinical duties for 2-3 days which is a potential loss of clinical revenue. The virtual format saves on these costs and travel times. To maintain the personal and professional gains from a visiting professorship, however, we have incorporated one-on-one and small group virtual meetings into the agenda of all our visiting speakers to meet our faculty, trainees and staff. Third and finally, the virtual format allows for new partnerships within the institution and between institutions. Many of our virtual grand rounds have created unique opportunities for other institutional Departments and Centers to share their work.

Similarly, virtual grand rounds has created a mechanism through which we can now more easily join with other institutions across the country to share clinical expertise, experiences and research.

Although there are many advantages to the virtual grand rounds platform, this format comes with some disadvantages. One of the most significant disadvantages is the lost in-person experience during grand rounds presentations and immediately following the lecture for the question and answer session. The lack of in-person experience affects both the presenter and attendees. From the presenter perspective, the virtual format makes engaging the attendees in an interactive fashion, with few to no visual cues, increasingly difficulty. Techniques including live polls of the audience by raising their hands or asking the attendees in the audience to turn to their neighbor for a quick discussion on a certain topic are not easily executed on this platform. On the other hand, the ability for the attendee to ask the presenter a question directly from the audience is a much different, more personal experience in-person compared to when your question is read out loud by the moderator from a chat box. This being said, we do give the option for attendees during the virtual format to ask the question themselves which would bring their video screen to the presenter once the audio of the attendee is activated, but this option is seldom utilized and can be more arduous for the moderator.

Not only do the attendees have a different experience asking questions of the grand rounds presenter, but they also miss out on the downtime following the dismissal of the auditorium where they could have a one-on-one conversation with the speaker about further details or their presentation or research niche. These one-on-one conversations could be starting points for networking with the individual, and even opening doors for future opportunities including research projects or national committee opportunities. Furthermore, our grand rounds speakers are usually scheduled a complete 1-2 day itinerary before and after their talks. During this time, they meet with multiple faculty in various stages of their academic careers who may have an overlapping interest. These meetings are again lost on the virtual format. Although our committee has now adapted our virtual grand rounds to include an open "zoom" session where the grand rounds presenter will stay in a single zoom session with a shortened itinerary to attempt to resemble the one-on-one interviews that would have otherwise traditionally taken place.

As we continue through these unprecedented times with the COVID-19 pandemic and phases of gradual reopening of our hospital and university campus, it is unclear when the return of traditional in-person grand rounds will resume. However, with the many advantages and conveniences afforded by the new virtual platform, we believe that the new "normal" will likely include a hybrid format that can be viewed either in-person or virtually for participants that are unable to attend. This hybrid format will allow for greater flexibility for attendance, while still providing an in-person interactive session for those on-site. 

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