Preparing residents to become more effective teachers: a priority for internal medicine

RaT race: A standardized open-access education resource provides a structured resident-as-teacher experience

Objectives

There is no unified approach for training residents to be teachers. Foundations of Emergency Medicine (FoEM) is a national program that provides free resident education in emergency medicine (EM) utilizing small-group, case-based instruction delivered by individual program faculty and residents. This study seeks to explore the FoEM resident-as-teacher (RaT) experience.

Methods

We conducted a mixed-methods study of FoEM faculty site leaders and resident teachers in 2022. Site leaders completed an online survey consisting of multiple-choice, completion, and free-response items. We calculated descriptive statistics and applied a thematic qualitative analysis to free-response items. We conducted semistructured interviews with resident teachers. Interview transcripts were analyzed using a thematic approach with a constructivist-interpretivist paradigm.

Results

A total of 133 of 180 (74%) site leaders completed the survey and 11 resident teachers were interviewed. Forty-nine (37%) programs utilize resident instructors. The frequency of residents teaching and degree of faculty supervision varied. Commonly identified advantages include reinforcement of core content for resident teachers (44/49), structured format (35/49), and reduced need for faculty instructors (30/49). The most commonly identified challenges include variable instruction by residents (33/49) and challenge to providing feedback on teaching (20/49). Resident teachers identified benefits including strengthening residency community, improved EM knowledge, and greater teaching skills. For nearly all resident participants, FoEM RaT impacted their career goals by affirming their interest in teaching.

Conclusions

The FoEM curricular model appears to be a valuable and feasible method to incorporate a RaT experience into EM residency training programs.

Unearthing Faculty and Trainee Perspectives of Feedback in Internal Medicine: the Oral Case Presentation as a Model

BACKGROUND

The case presentation is a fundamental activity used in both patient care and trainee education, partly due to feedback from supervisor to trainee. Although feedback in medical education is well studied, prior studies have not focused on the perceptions of feedback by Internal Medicine supervisors and trainees as it relates to clinical activities like the case presentation.

METHODS

Semi-structured interviews were conducted with eight Internal Medicine physicians, and 18 Internal Medicine trainees (5 medical students, 13 residents) at the University of Toronto. Purposive sampling was used. Interviews were conducted and coded iteratively within a constructivist grounded theory approach until saturation was reached.

RESULTS

Supervisors and trainees recognized feedback as an important part of the case presentation that can be (1) explicit, labeled feedback or (2) implicit, unlabeled feedback. Both trainees and supervisors perceived that not enough feedback occurs, likely stemming from a hesitancy by supervisors to label implicit feedback, calling it an interruption instead. Although trainees were keenly aware of non-verbal feedback from their supervisors as implicit feedback, they often interpreted explicit constructive feedback negatively. Interestingly, the same feedback from senior residents was regarded as highly educational, as it was uncoupled from assessment.

CONCLUSION

Feedback occurs more frequently in case presentations than previously described, particularly in an implicit, unlabeled format. Even though under-recognized, trainees identify and utilize implicit feedback from supervisors, and coaching from senior residents, to develop learned behaviors. This is reassuring in the age of Competency-Based Medical Education, as feedback has an essential role in workplace-based assessment and promotion.

Teaching skills for medical residents: are these important? A narrative review of the literature

BACKGROUND

There is extensive evidence, mainly from the United States and Canada, that points towards the need to train medical residents in teaching skills. Much of the "informal curriculum", including professional values, is taught by residents when consultants are not around. Furthermore, data from the 1960s show the importance of acquiring these skills, not only for residents but also for all doctors. -Teaching moments can be identified in simple daily situations, like discussing a clinical situation with patients and their families, planning patients' care with the healthcare team or teaching peers and medical students. The aim here was to examine the significance of resident teaching courses and estimate the effectiveness of these courses and the state of the art in Brazil.

METHODS

We conducted a review of the literature, using the MEDLINE, PubMed, SciELO and LILACS databases to extract relevant articles describing residents-as-teachers (RaT) programs and the importance of teaching skills for medical residents. This review formed part of the development of a doctoral project on medical education.

RESULTS

Original articles, reviews and systematic reviews were used to produce this paper as part of a doctoral project.

CONCLUSIONS

RaT programs are important in clinical practice and as role models for junior learners. -Moreover, these educational programs improve residents' self-assessed teaching behaviors and teaching confidence. On the other hand, RaT program curricula are limited by both the number of studies and their methodologies. In Brazil, there is no such experience, according to the data gathered here, except for one master's thesis.

Residents as teachers: Near peer learning in clinical work settings: AMEE Guide No. 106

This AMEE Guide provides a framework to guide medical educators engaged in the design and implementation of "Resident as Teacher" programs. The suggested approaches are based on established models of program development: the Program Logic model to guide program design, the Dundee three-circle model to inform a systematic approach to planning educational content and the Kirkpatrick pyramid, which forms the backbone of program evaluation. The Guide provides an overview of Resident as Teacher curricula, their benefits and impact, from existing literature supplemented by insights from the authors' own experiences, all of whom are engaged in teaching initiatives at their own institutions. A conceptual description of the Program Logic model is provided, a model that highlights an outcomes-based curricular design. Examples of activities under each step of this model are described, which would allow educational leaders to structure their own program based on the scope, context, institutional needs and resources available. Emphasis is placed on a modular curricular format to not only enhance the teaching skills of residents, but also enable development of future career educators, scholars and leaders. Application of the Dundee three-circle model is illustrated to allow for a flexible curricular design that can cater to varying levels of educational needs and interests. In addition, practical advice is provided on robust assessment of outcomes, both assessment of participants and program evaluation. Finally, the authors highlight the need for congruence between the formal and hidden curriculum through explicit recognition of the value of teaching by institutions, support for development of teaching programs, encouragement of evidence-based approach to education and rewards for all levels of teachers.

Providing rapid feedback to residents on their teaching skills: an educational strategy for contemporary trainees

OBJECTIVE

The objective of this study was to assess the attitudes of contemporary residents toward receiving rapid feedback on their teaching skills from their medical student learners.

METHODS

Participants consisted of 20 residents in their second post-graduate training year. These residents facilitated 44 teaching sessions with medical students within our Resident-as-Teacher program. Structured, written feedback from students was returned to the resident within 3 days following each session. Residents completed a short survey about the utility of the feedback, whether they would make a change to future teaching sessions based on the feedback, and what specifically they might change. The survey utilized a 4-point scale ("Not helpful/likely=1" to "Very helpful/likely=4"), and allowed for one free-text response. Free-text responses were hand-coded and underwent qualitative analysis to identify themes.

RESULTS

There were 182 student feedback encounters resulting from 44 teaching sessions. The survey response rate was 73% (32/44). Ninety-four percent of residents rated the rapid feedback as "very helpful," and 91% would "very likely" make a change to subsequent sessions based on student feedback. Residents' proposed changes included modifications to session content and/or their personal teaching style.

CONCLUSIONS

Residents found that rapid feedback received from medical student learners was highly valuable to them in their roles as teachers. A rapid feedback strategy may facilitate an optimal educational environment for contemporary trainees.

WATCH: Warwick Assessment insTrument for Clinical teacHing: Development and testing

OBJECTIVE

Medical education and teaching skills are core competencies included in the generic curriculum for specialty training. To support the development of these skills, there is need for a validated instrument. This study aims to develop and test an instrument to measure the attributes of specialty trainees as effective teachers.

METHODS

The study was conducted in two phases. In first phase, the content of the instrument was generated from the literature and tested using the Delphi technique. In second phase, the instrument was field tested for validity and reliability using factor analysis and generalizability study. Feasibility was calculated by the time taken to complete the instrument. Acceptability and educational impact were determined by qualitative analysis of written feedback. Attributes of specialty trainees were assessed by clinical supervisors, peers, and students.

RESULTS

The Delphi study produced consensus on 15 statements which formed the basis of the instrument. In field study, a total of 415 instruments were completed. Factor analysis demonstrated a three-factor solution ('learning-teaching milieu', 'teaching skills', and 'learner-orientated'). A generalizability coefficient was 0.92. Mean time to complete the instrument was five minutes. Feedback indicated that it was an acceptable and useful method of assessment.

CONCLUSION

This new instrument provides valid, reliable, feasible, and acceptable assessment of clinical teaching.

What Makes a Great Resident Teacher? A Multicenter Survey of Medical Students Attending an Internal Medicine Conference

BACKGROUND

Residents have a critical role in the education of medical students and have a unique teaching relationship because of their close proximity in professional development and opportunities for direct supervision. Although there is emerging literature on ways to prepare residents to be effective teachers, there is a paucity of data on what medical students believe are the attributes of successful resident teachers.

OBJECTIVE

We sought to define the qualities and teaching techniques that learners interested in internal medicine value in resident teachers.

METHODS

We created and administered a resident-as-teacher traits survey to senior medical students from 6 medical schools attending a resident-facilitated clinical conference at McMaster University. The survey collected data on student preferences of techniques employed by resident teachers and qualities of a successful resident teacher.

RESULTS

Of 90 student participants, 80 (89%) responded. Respondents found the use of clinical examples (78%, 62 of 80) and repetition of core concepts (71%, 58 of 80) highly useful. In contrast, most respondents did not perceive giving feedback to residents, or receiving feedback from residents, was useful to their learning. With respect to resident qualities, respondents felt that a strong knowledge base (80%, 64 of 80) and tailoring teaching to the learner's level (83%, 66 of 80) was highly important. In contrast, high expectations on the part of resident supervisors were not valued.

CONCLUSIONS

This multicenter survey provides insight into the perceptions of medical students interested in internal medicine on the techniques and qualities that characterize successful resident teachers. The findings may be useful in the future development of resident-as-teacher curricula.

How medical students learn from residents in the workplace: a qualitative study

PURPOSE

To explore what third-year medical students learn from residents and which teaching strategies are used by excellent resident teachers in their interactions with students in the clinical workplace environment.

METHOD

In this multi-institutional qualitative study between January and March 2012, the authors conducted focus groups with medical students who were midway through their third year. Qualitative analysis was used to identify themes.

RESULTS

Thirty-seven students participated. Students contributed 228 comments related to teaching methods used by residents. The authors categorized these into 20 themes within seven domains: role-modeling, focusing on teaching, creating a safe learning environment, providing experiential learning opportunities, giving feedback, setting expectations, and stimulating learning. Role-modeling, the most frequently classified method of teaching in this study, was not included in three popular "Resident-as-Teacher" (RAT) models. Strategies including offering opportunities for safe practice, involving students in the team, and providing experiential learning opportunities were not emphasized in these models either. Almost 200 comments representing the knowledge and skills students learned from residents were categorized into 33 themes within nine domains: patient care, communication, navigating the system, adaptability, functioning as a student/resident, lifelong learning, general comments, career/professional development, and medical content. Most of these areas are not emphasized in popular RAT models.

CONCLUSIONS

Residents serve as critically important teachers of students in the clinical workplace. Current RAT models are based largely on the teaching behaviors of faculty. The content and teaching strategies identified by students in this study should serve as the foundation for future RAT program development.

A novel survey tool to assess pulmonary and critical care fellows' attitudes regarding acquiring teaching skills during fellowship training

BACKGROUND

Important components of fellowship training include learning teaching skills and career development. Pulmonary and critical care medicine (PCCM) fellows' opinions of the importance of developing teaching skills and interest in careers in medical education have not been previously described, and there are no tools to assess interest in acquiring teaching skills.

OBJECTIVE

We describe the development and initial psychometric validation of a survey tool to assess trainees' attitudes toward and interest in acquiring teaching skills.

METHODS

A survey tool to assess attitudes toward teaching and medical education skills was designed and psychometrically characterized. We then anonymously surveyed fellows in 1 PCCM program to assess their perceptions of and attitudes regarding acquiring teaching skills.

RESULTS

The survey tool demonstrated acceptable psychometric properties. The survey showed that most fellows felt that acquiring teaching skills was "very important," and nearly half reported being "interested" or "very interested" in pursuing careers as medical educators. However, fellows disagreed with the feedback they received from attending physicians with regard to their teaching abilities (10% disagreed with feedback at the beginning of the year, 36% disagreed at the end of the year; P  =  .03).

CONCLUSIONS

Our survey demonstrates acceptable psychometric properties and performance characteristics in a single-site study of PCCM fellows during 1 academic year. Fellows are interested in improving their teaching skills but do not know how to become better teachers. Added research in multiple settings should explore the generalizability of our findings.

General surgical interns contributing to the clerkship learning environment of medical students

BACKGROUND

Junior doctors are increasingly promoted as clinical teachers but there is limited understanding of how they contribute to medical student clerkship learning.

AIM

To describe contributions made by general surgical interns to the student clerkship learning environment.

METHODS

The mixed-methods study involved two focus groups attended by volunteer interns and Year 4 students, and a student questionnaire collecting quantitative data. Focus group transcripts were evaluated using a qualitative analysis system.

RESULTS

Six interns and five students attended focus groups in June and August 2011. Qualitative analysis found that intern contributions to student learning can be grouped under four distinct roles: physician, supervisor, teacher and person. Data from 85 questionnaires (response rate 57%) revealed that intern-student encounters occurred daily in the surgical wards and emergency department. Interns demonstrated bedside procedures, clerical/administrative tasks and interpretation of laboratory and radiological investigations. Appreciated for approachability, friendliness and ability to relate to students, interns also played a crucial role in integrating students into the surgical team. This significantly correlated to clerkship enjoyment.

CONCLUSIONS

Surgical interns improve clerkship learning environments by demonstrating "personal" skills such as friendliness, approachability and relatedness. This has important implications for preparing interns as clinical preceptors.

General practice registrars as teachers: a questionnaire-based evaluation

Objectives

To determine how many General Practice (GP) Registrars in the London Deanery taught medical students during their final year of training. For those who did teach, to evaluate their experiences and for those who did not, to identify perceived barriers to teaching.

Design

Cross sectional survey of GP Registrars in the London Deanery completing their training in August 2010.

Setting

Online survey of GP Registrars sent after completion of training via the London Deanery GP Vocational Training Scheme (VTS) programme administrators.

Participants

GP Registrars in the London Deanery completing their training in August 2010.

Main outcome measure

The proportion of London Deanery GP registrars completing training in August 2010 who taught medical students during their registrar year.

Results

Over half of respondents were involved in some form of medical student teaching during their registrar year. Most of those who taught felt it enhanced their training, and the majority of those who did not teach would have liked to. Commonly cited barriers to teaching were: students not attached to the practice; not being given the opportunity to teach; and not having time to teach.

Conclusions

This evaluation demonstrated that GP registrars are either already involved with undergraduate teaching or want to get involved and the majority who teach feel that it enhances their training. A UK-wide study investigating the experiences and views of both GP registrars and GP trainers is warranted and qualitative work using focus groups or semistructured interviews would be valuable to develop the questionnaire for wider dissemination.

A systematic review of resident-as-teacher programmes

CONTEXT

Residents in all disciplines serve as clinical teachers for medical students. Since the 1970s, there has been increasing evidence to demonstrate that residents wish to teach and that they respond positively to formal teacher training. Effective resident-as-teacher (RaT) programmes have resulted in improved resident teaching skills. Current evidence, however, is not clear about the specific features of an effective RaT programme.

OBJECTIVES

This study was performed in order to investigate the effectiveness of RaT programmes on resident teaching abilities and to identify the features that ensure success. Methods of assessment used to ascertain the effectiveness of RaT programmes are also explored.

METHODS

The literature search covered the period between 1971 and 2008. Articles focusing on improving resident teaching skills were included. Each study was reviewed by two reviewers and data were collected using a standard abstraction summary sheet. Study outcomes were graded according to a modified Kirkpatrick's model of educational outcomes.

RESULTS

Twenty-nine studies met review inclusion criteria. Interventions included workshops, seminars, lectures and teaching retreats. Twenty-six studies used a pre- and post-intervention outcome comparison method. Subjective outcome measures included resident self-evaluation of teaching skills or evaluation by medical students, peers and faculty members. Objective outcome measures included written tests, evaluation of teaching performance by independent raters and utilisation of objective structured teaching examinations. One study objectively measured learning outcomes at the level of medical students, utilising the results of an objective structured clinical examination. Overall resident satisfaction with RaT programmes was high. Participants reported positive changes in attitudes towards teaching. Participant knowledge of educational principles improved. Study methodologies allowed for significant risks of bias.

CONCLUSIONS

More rigorous study designs and the use of objective outcome measures are needed to ascertain the true effectiveness of RaT programmes. Future research should focus on determining the impact of RaT programmes on learning achievement at the level of medical students.

Why medical students should learn how to teach

BACKGROUND

We reviewed the medical-education literature in order to explore the significance and importance of teaching medical students about education principles and teaching skills.

AIMS

To discuss reasons why formal initiatives aimed at improving teaching skills should be part of the training of all physicians, and how it could begin at the medical-student level.

DESCRIPTION

In this article, we propose several reasons that support formal undergraduate medical training in education principles: (1) medical students are future residents and faculty members and will have teaching roles; (2) medical students may become more effective communicators as a result of such training, as teaching is an essential aspect of physician-patient interaction; and (3) medical students with a better understanding of teaching and learning principles may become better learners. We suggest that exposure to teaching principles, skills, and techniques should be done in a sequential manner during the education of a physician, starting in medical school and continuing through postgraduate education and into practice. We outline learning objectives, teaching strategies, and evaluation methods for medical-education components in an undergraduate curriculum.

CONCLUSION

Medical students' informal teaching activities accompany, facilitate, and complement many important aspects of their medical education. Formally developing medical students' knowledge, skills, and attitudes in education may further stimulate these aspects.

Medical students' perceptions of the elements of effective inpatient teaching by attending physicians and housestaff

BACKGROUND

Most studies of effective inpatient teaching have focused on teaching by attending physicians.

OBJECTIVE

To identify and compare medical students' perceptions of behaviors associated with teaching effectiveness of attending physicians and housestaff (residents and interns).

DESIGN AND PARTICIPANTS

Third-year students who spent 4 weeks on a general internal medicine inpatient service during academic year 2003-2004 completed surveys using a 5-point Likert-type scale. Students evaluated numerous teaching behaviors of attendings and housestaff and then evaluated their overall teaching effectiveness.

MEASUREMENTS

Each behavior was correlated with the perceived teaching effectiveness in univariate and regression analyses.

RESULTS

Seventy-two students were taught by 23 attendings and 73 housestaff. Of 144 possible teaching evaluations, they completed 142 (98.6%) for attendings and 128 (88.9%) for housestaff. The mean rating for perceived teaching effectiveness was 4.48 (SD 0.82) for attendings and 4.39 (SD 0.80) for housestaff. For attending physicians, teaching effectiveness correlated most strongly with enthusiasm for teaching (R(2)=63.6%) but was also associated with inspiring confidence in knowledge and skills, providing feedback, and encouraging students to accept increasing responsibility. Housestaff teaching effectiveness correlated most strongly with providing a role model (R(2)=61.8%) but was also associated with being available to students, performing effective patient education, inspiring confidence in knowledge and skills, and showing enthusiasm for teaching. Regression models explained 79.7% and 73.6% of the variance in evaluations of attendings and housestaff, respectively.

CONCLUSIONS

Students' perceptions of effective teaching behaviors differ for attending physicians and housestaff, possibly reflecting differences in teaching roles or methods.

Fellows as Teachers

STUDY OBJECTIVES

Physicians undergoing medical subspecialty training, referred to as "fellows" in the United States, often serve as small group tutors. There are few reports, however, on whether fellows benefit from their experience teaching in the classroom. The purpose of this article is to describe the teacher-assistant requirement for fellows in a pulmonary and critical care training program and gain the perspectives of program graduates on their experiences as teacher assistants.

DESIGN, SETTING, AND PARTICIPANTS

The structure of the teacher-assistant requirement is described in detail. We also surveyed 55 consecutive graduates of our Pulmonary and Critical Care Fellowship program located in the United States on the educational value of teaching pathophysiology to preclinical medical students.

RESULTS

Fellows and one or two faculty members co-teach groups of 15 to 25 second-year medical students during 22 h of case-based conferences over a 6-week period. Weekly meetings for teacher assistants foster improved teaching skills and provide insight into the basic tenets of structuring and implementing the course. Fellows receive formal and informal feedback on their performance. Fifty of 55 graduates (91%) returned the survey. Respondents rated the acquisition of teaching skills and knowledge of pulmonary pathophysiology as the most useful aspects of their experience. Eighty-seven percent rated their overall experience favorably, and 90% agreed that teaching the course should remain a curriculum requirement. The responses of physicians in academic and community practice were comparable.

CONCLUSIONS

Graduates of our Pulmonary and Critical Care Fellowship valued their teacher-assistant experience. This article may serve as a model for other subspecialty programs that are interested in formally incorporating teaching into their training program and may provide an impetus for the additional exploration of teacher-assistant experiences at other institutions.

What medical students value most during their clinical clerkships from department chairs

OBJECTIVE

The purpose of this study was to evaluate the qualities that medical students value most in department chairs during clinical clerkships.

STUDY DESIGN

All fourth-year students were asked to complete an anonymous survey voluntarily. The students ranked nine qualities of a chair using a visual analog scale that ranged from "strongly disagree" to "strongly agree." Also assessed was the student's level of contact with each department chair during the six core clerkships.

RESULTS

Sixty-seven of 73 students (91.8%) completed the survey. Almost two thirds of the students (63%) had minimal or no contact with clinical chairs. The most desirable qualities of the department chair included advocating teaching by the residents and faculty, meeting with students (if possible, at the beginning, middle, and end of the clerkship), and participating in teaching in the classroom or clinic settings. Least important qualities involved knowing the student as a person and displaying an air of authority. The most common theme of written comments was that the department chair sets the tone for the department by advocating teaching and by encouraging respect for students.

CONCLUSION

Medical students want clinical chairs to be visibly proactive toward teaching, meet with them periodically, and participate in teaching.