Are Text Pages an Effective Nudge to Increase Attendance at Internal Medicine Morning Report Conferences? A Cluster Randomized Controlled Trial
Background: Despite the importance of medical educational conferences, low attendance remains an issue. The utility of reminder text pages as a behavioral nudge to increase attendance is unknown. Our objective was to determine whether reminder text pages increase daily morning report attendance.
Methods: We conducted a multiple-crossover cluster randomized controlled trial among medical students and internal medicine interns and residents (learners) at the Veteran Affairs Boston Healthcare System during the 2019 to 2020 academic year. During intervention periods, all residents and interns received a text page reminder 5 minutes before the upcoming 8:00 am morning report conference; no page was sent during control periods. The primary outcome was conference attendance 10 minutes after the start of the conference.
Results: The study period included 85 morning report conferences, which 211 unique learners were eligible to attend; outcome data were available for 100% of eligible learners. On days when no page was sent, 44.4% of eligible learners attended the conference by 8:10 am ; on days when a reminder page was sent, 49.5% of eligible learners attended (P = .007). Accounting for clustering within individuals and controlling for date and team, the adjusted risk difference in morning report attendance associated with a reminder page was 4.0% (95% CI, 0.5%-7.6%) compared with no reminder page. No effect modification by overnight admissions was detected.
Conclusions: Our results suggest that daily reminder pages may result in a small increase in conference attendance. Whether this small increase is educationally significant will vary across training programs that apply this strategy.
Limitations
This study has some limitations. First, it was conducted at a single VA medical center. An additional limitation was our decision to classify learners who arrived after 8:10
Unfortunately, due to the COVID-19 pandemic and the suspension of in-person conferences, our study ended earlier than anticipated. This resulted in an imbalance of morning report conferences that occurred during each period: 55% during the intervention period, and 45% during the control period. However, because we accounted for the clustering of conference attendance behavior within individuals in our model, this imbalance is unlikely to introduce bias in our estimation of the effect of the intervention.
Another limitation relates to the evolving landscape of educational conferences in the postpandemic era.18 Whether our results can be generalized to increase virtual conference attendance is unknown. Finally, it is not clear whether a 4% absolute increase in conference attendance is educationally meaningful or justifies the effort of sending a reminder page.
Conclusions
In this cluster randomized controlled trial conducted at a single VA medical center, reminder pages sent 5 minutes before the start of morning report conferences resulted in a 4% increase in conference attendance. Our results suggest that reminder pages are one strategy that may result in a small increase in conference attendance, but whether this small increase is educationally significant will vary across training programs applying this strategy.
Acknowledgments
The authors are indebted to Kenneth J. Mukamal and Katharine A. Robb, who provided invaluable guidance in data analysis. Todd Reese assisted in data organization and presentation of data, and Mark Tuttle designed the facesheet. None of these individuals received compensation for their assistance.
