Fellows as Teachers

Enhancing the Inpatient Consultation Learning Environment to Optimize Teaching and Learning

Subspecialty consultation is an increasingly used resource in inpatient medicine. Teaching the primary team is an important element of effective consultation and has many potential benefits. However, within academic medical centers many barriers to effective consultation and the consult learning environment exist. High workload, burnout, inexperience, lack of familiarity between teams, quality of the consult requests, and pushback may impede teaching and learning. Herein, the authors review the role of teaching and learning during consultation, challenges to effective consultation facing fellows, and interventions that can enhance primary team-fellow interactions and learning.

Teacher training for rheumatology fellows: a national needs assessment of fellows and program directors

INTRODUCTION

Teaching is an integral part of what we do as physicians, and exposure to training on how to effectively teach is not consistently implemented in the curricula within medical training.

METHODS

We administered anonymous, in-person surveys to fellows and program directors (PDs) at the 2017 American College of Rheumatology national conference to evaluate fellow and PD attitudes regarding development of programs dedicated to teaching fellows on how to teach.

RESULTS

One hundred seven of 150 fellows returned surveys (response rate 71%). About 60% demonstrated interest in pursuing a teaching-focused career. About 97% felt their teaching skills can be improved; 88% felt improved teaching skills will be valuable for their career. With 61% response rate (57/94 PD surveys), most PDs agreed their fellows could use additional instruction in teaching. About 90% noted this would be an asset for fellows' careers. When compared, 56% of fellows reported no structured training in education during fellowship, while 64% of PDs said this type of training was available. All agreed fellow teaching skills can be improved but significantly more fellows than faculty felt confident in the fellows' ability to give feedback (p = 0.03). Both groups identified time constraints and other faculty interest as barriers.

CONCLUSION

There is significant need to develop effective fellow-as-teacher programs aimed at enhancing fellows' teaching skills, with focus on giving feedback and working within fellow and faculty time constraints. The program can help address a curriculum gap identified by fellows as well as PDs before fellowship-to-faculty transition.Key Points• There is a notable gap between faculty physicians' expectations to teach as clinician-educators and the lack of training dedicated to learning how to teach during medical training. Despite the fact that past clinical educators have identified instructional design and assessment as low-confidence areas, there is a paucity of structured program dedicated to developing these teaching skills during fellowship training.• With 97% fellows and 84% program directors, both groups agreed fellows could use additional instruction in teaching skills, but there was a significant discrepancy between fellow and program director perspectives regarding fellows' ability to give feedback.• Consistent with past needs assessments in other medical specialties, lack of time and potential faculty interest were recognized as potential barriers, calling for a structured training program dedicated to education on didactics that takes into account trainee and faculty time constraints.• Our needs assessment can direct future research on analyzing effectiveness of fellow-as-teacher program implementation by focusing on improvement of fellow teaching and feedback skills.

Developing internal medicine subspecialty fellows' teaching skills: a needs assessment

BACKGROUND

For academic physicians, teaching represents an essential skill. The proliferation of educator training programs aimed at residents and medical students signals the increasing commitment of training programs to develop teaching skills in their trainees as early as possible. However, clinical fellowships represent an important opportunity to advance training as educators. In addition to enriching the pipeline of future teachers, developing fellows as teachers augments the training experience for more junior trainees and may impact patient care. Fellows' needs for programs to improve teaching skills have been largely unexplored.

METHODS

We conducted a multi-institutional needs assessment of internal medicine (IM) subspecialty fellows to gauge interest in teaching and improvement of teaching skills. We surveyed IM subspecialty fellows at three academic medical centers about their access to fellow-as-teacher programs and other mechanisms to improve their teaching skills during fellowship. We also elicited their attitudes towards teaching and interest in training related to teaching skills.

RESULTS

One hundred eighty-three fellows representing 20 programs and nine different subspecialties responded to the survey (48% response rate). The majority of participants (67%) reported having no specific training focused on teaching skills and only 12% reported receiving regular feedback about their teaching during their fellowship. Seventy-nine percent of fellows anticipated teaching to be part of their careers, and 22% planned to participate in medical education scholarship. Fellows reported a strong interest in teaching and programs aimed at improving their teaching skills.

CONCLUSIONS

The majority of fellows reported a lack of mechanisms to advance their teaching skills as fellows, despite anticipating teaching to be an important aspect of their future careers and having strong interest in such programs. Our findings at three academic medical centers confirm a lost opportunity among subspecialty fellowships to accelerate teaching skills development for future educators.

Fellow as Clinical Teacher (FACT) Curriculum: Improving Fellows' Teaching Skills During Inpatient Consultation

INTRODUCTION

Multiple barriers, including time constraints, a demanding teaching environment, and lack of longitudinal relationships with residents, make it challenging for fellows and learners to engage in effective teaching during consultation.

METHODS

The Fellow as Clinical Teacher (FACT) curriculum was developed to overcome such barriers and improve fellow teaching in the setting of inpatient consultation. The FACT curriculum consists of two 45- to 60-minute small-group sessions designed for subspecialty fellows. The first session focuses on overcoming barriers to teaching and application of the principles of adult learning theory. The second introduces the PARTNER (partner with resident, assess the learner, reinforce positives, teaching objectives, new knowledge, execute recommendations, review) framework for teaching during consultation and uses video examples to model the application of this framework, allowing fellows to practice its implementation through role-play.

RESULTS

Previously, the FACT curriculum was shown to improve teaching skills of rheumatology and pulmonary/critical care fellows as evaluated by objective structured teaching exercises. Here, the curriculum has been expanded to 51 internal medicine and pediatrics fellows in 15 different training programs. The curriculum improved fellow teaching skills as assessed by self-assessment surveys. It was highly rated by participants, and fellows reported being more likely to teach during consultation following this educational intervention.

DISCUSSION

The FACT curriculum can be integrated into subspecialty training programs to improve the teaching skills of internal medicine and pediatrics fellows in the setting of inpatient consultation. Ultimately, improved teaching from fellows may have broad-reaching effects for residents, patients, and the fellows themselves.

Teach the teacher: Training otolaryngology fellows to become academic educators

OBJECTIVES/HYPOTHESIS

Fellowship is the capstone of academic training and serves as preparation for an academic career. Fellows are expected to educate medical students and residents during and long after fellowship. However, little time is typically spent teaching fellows to become effective educators. We investigate a formal curriculum addressing teaching skills among fellows in otolaryngology-head and neck surgery (OHNS).

STUDY DESIGN

E-mail survey.

METHODS

We developed and implemented an educational program called Teach the Teacher to build skills as educators for fellows in OHNS. We conducted a survey of fellows from 2014 to 2017 in OHNS who participated in the course. The survey evaluated demographics, teaching experiences, and teaching limitations structured as yes/no and Likert-style questions (1 = strongly disagree, 5 = strongly agree).

RESULTS

Thirty fellows were surveyed with a response rate was 80%. Fellowship was rated highly as an experience that will make fellows a better academic educator (mean ± standard deviation: 4.54 ± 0.64). The most important components of teaching during fellowship were role modeling (4.67 ± 0.62), followed by teaching psychomotor skills in the operating room (4.29 ± 0.89), diagnostic reasoning (4.25 ± 0.66), and evidence-based medicine (4.25 ± 0.83). The Teach the Teacher course specifically was rated as a helpful experience (4.00 ± 0.90). The primary limitations to developing teaching skills during fellowship identified were lack of time, patient safety, and inexperience with hospital culture.

CONCLUSIONS

Fellowship is a key time to improve skills as academic educators. Fellows value formal efforts to teach academic skills.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:2034-2048, 2018.

Fellow As Teacher Curriculum: Improving Rheumatology Fellows' Teaching Skills During Inpatient Consultation

OBJECTIVE

Enhancing rheumatology fellows' teaching skills in the setting of inpatient consultation may have a broad positive impact. Such efforts may improve fellows' clinical skills and overall patient care. Most importantly, effective resident-fellow teaching interactions may not only increase residents' knowledge of rheumatology but may influence their career choice. However, a number of barriers to the resident-fellow teaching interaction have been identified, including fellows' teaching skills. We developed the Fellow As Clinical Teacher (FACT) curriculum in order to enhance fellows' teaching skills during inpatient consultation.

METHODS

The FACT curriculum was delivered in two 45-minute workshops during the 3-day Winter Symposium of the Carolinas Fellows Collaborative. We evaluated its effect with self-assessment surveys and fellow performance on the objective structured teaching exercise (OSTE) before and after participation in the curriculum.

RESULTS

Nineteen fellows from 4 rheumatology training programs participated in the pre- and post-curriculum OSTEs and 18 fellows completed pre- and post-curriculum surveys. OSTE scores improved on 5 of the 8 items assessed, and the total OSTE score improved as well (34.7 versus 29.5; P < 0.01) after the FACT curriculum. Fellows' self-assessment of their teaching skills and intent to teach during consultation also increased after participation in the curriculum.

CONCLUSION

The FACT curriculum, focused on teaching during consultation, improved fellows' teaching skills and attitudes toward teaching. Improving and increasing fellow teaching, particularly in the consultation setting, may impact patient care, resident and fellow learning, and teaching skills of future faculty, and could potentially influence residents' career choice.

Use of Fellow as Clinical Teacher (FACT) Curriculum for Teaching During Consultation: Effect on Subspecialty Fellow Teaching Skills

BACKGROUND

Subspecialty consultation in inpatient care is increasing. Teaching by subspecialty fellows in a consultation setting may be an important source of work-based learning for students and residents. However, teaching and evaluation of learners in this context may be challenging due to personal and systems-based barriers.

OBJECTIVE

We developed and evaluated a framework designed to overcome barriers to teaching and to improve fellow teaching skills during inpatient consultation.

METHODS

The PARTNER (Partner with resident, Assess the learner, Reinforce positives, Teaching objectives, New knowledge, Execute recommendations, Review) framework was delivered to rheumatology and pulmonary and critical care medicine fellows at 3 academic medical centers as part of a 2-session Fellow as Clinical Teacher (FACT) curriculum. Fellows' teaching skills were evaluated using an objective structured teaching exercise (OSTE) pre- and postcurriculum, and at the end of the academic year. Self-assessment surveys were used to evaluate fellows' self-perception of teaching skills.

RESULTS

Twelve of 16 eligible fellows (75%) participated in the program and completed 73 OSTE cases. Teaching skills measured by OSTEs and self-assessment surveys improved after administration of the FACT curriculum. There was no significant skill decay at the end-of-year evaluation. The curriculum was rated highly, and 73% (8 of 11) of fellows stated they would teach more frequently as a result of the intervention.

CONCLUSIONS

The FACT curriculum was practical and feasible, and significantly improved fellows' teaching skills teaching during inpatient consultation.

Fellows as Teachers: Raising the Educational Bar

Fellows are expected to educate trainees, peers, and patients, during and long after fellowship. However, there has been relatively little emphasis on the acquisition of teaching skills in fellowship programs. Challenges to teaching by fellows during subspecialty training include demanding clinical duties, their limited knowledge base in the field, brief contact time with learners during consultative roles, and, for new fellows, personal unfamiliarity with the learners and hospital culture. Fellows' teaching skills can be improved by formal curricula addressing teaching, and by direct observation and feedback of teaching akin to what is provided for learning clinical care. Further expansion of fellow-as-teacher programs will allow in-depth training for fellows seeking careers as medical educators. Even without such dedicated programs, emphasis on honing teaching skills during fellowship will telegraph the importance of teaching and help evolve divisional culture. Such efforts can have a positive impact on patients and learners, and enhance the teaching skills of future faculty.

Pulmonary and Critical Care Medicine Program Directors' Attitudes toward Training in Medical Education. A Nationwide Survey Study

RATIONALE

Many pulmonary and critical care medicine (PCCM) fellows are interested in improving their teaching skills as well as learning about careers as clinician educators. Educational opportunities in PCCM fellowship programs designed to address these interests have not been well characterized in U.S. training programs.

OBJECTIVES

We aimed to characterize educational content and structure for training fellows to teach in PCCM fellowship programs. We evaluated three major domains: (1) existing educational opportunities, (2) PCCM program directors' attitudes toward the importance of teaching fellows how to teach, and (3) potential components of an optimal teaching skills curriculum for PCCM fellows.

METHODS

We surveyed program and associate program directors who were members of the Association of Pulmonary and Critical Care Medicine Program Directors in 2014. Survey domains included existing teaching skills content and structure, presence of a formal medical education curriculum or clinician educator track, perceived barriers to teaching fellows teaching skills, and open-ended qualitative inquiries about the ideal curricula. Data were analyzed both quantitatively and qualitatively.

MEASUREMENTS AND MAIN RESULTS

Of 158 invited Association of Pulmonary and Critical Care Medicine Program Directors members, 85 program directors and associate directors responded (53.8% response rate). Annual curricular time dedicated to teaching skills varied widely (median, 3 h; mean, 5.4 h; interquartile range, 2.0-6.3 h), with 17 respondents (20%) allotting no time to teaching fellows to teach and 14 respondents (17%) dedicating more than 10 hours. Survey participants stated that the optimal duration for training fellows in teaching skills was significantly less than what they reported was actually occurring (median optimal duration, 1.5 h/yr; mean, 2.1 h/yr; interquartile range, 1.5-3.5 h/yr; P < 0.001). Only 28 (33.7%) had a formal curriculum for teaching medical education skills. Qualitative analyses identified several barriers to implementing formal teaching skills curricula, including "time," "financial resources," "competing priorities," and "lack of expert faculty."

CONCLUSIONS

While prior work has demonstrated that fellows are interested in obtaining medical education skills, PCCM program directors and associate directors noted significant challenges to implementing formal educational opportunities to teach fellows these skills. Effective strategies are needed to design, implement, sustain, and assess teaching skills curricula for PCCM fellowships.

A randomized trial of an intervention to improve resident-fellow teaching interactions on the wards

BACKGROUND

Subspecialty fellows can serve as a tremendous educational resource to residents; however, there are multiple barriers to an effective resident-fellow teaching interaction in the setting of inpatient consultation. We designed and evaluated a resident-directed intervention to enhance communication and teaching during consultation on the general medicine wards.

METHODS

Five medical teams were randomized to receive the intervention over a 3 month period (3 control, 2 intervention teams). The intervention was evaluated with pre and post-intervention surveys.

RESULTS

Fifty-nine of 112 interns completed the pre-intervention survey, and 58 completed the post-intervention survey (53 % response rate). At baseline, 83 % of the interns noted that they had in-person interactions with fellows less than 50 % of the time. 81 % responded that they received teaching from fellows in less than 50 % of consultations. Following the intervention, the percentage of interns who had an in-person interaction with fellows greater than 50 % of the time increased in the intervention group (9 % control versus 30 % intervention, p = 0.05). Additionally, interns in the intervention group reported receiving teaching in more than 50 % of their interactions more frequently (19 % control versus 42 % intervention, p = 0.05). There were no differences in other measures of teaching and communication.

CONCLUSIONS

We demonstrate that a time-efficient intervention increased perceptions of in-person communication and the number of teaching interactions between interns and fellows. Further studies are warranted to determine whether such an approach can impact resident learning and improve patient care.

Training the teachers. The clinician-educator track of the University of Washington Pulmonary and Critical Care Medicine Fellowship Program

The University of Washington was the first pulmonary and critical care medicine fellowship training program accredited by the Accreditation Council for Graduate Medical Education to create a dedicated clinician-educator fellowship track that has its own National Residency Matching Program number. This track was created in response to increasing demand for focused training in medical education in pulmonary and critical care. Through the Veterans Health Administration we obtained a stipend for a clinician-educator fellow to dedicate 12 months to training in medical education. This takes place predominantly in the second year of fellowship and is composed of several core activities: fellows complete the University of Washington's Teaching Scholars Program, a professional development program designed to train leaders in medical education; they teach in a variety of settings and receive feedback on their work from clinician-educator faculty and the learners; and they engage in scholarly activity, which may take the form of scholarship of teaching, integration, or investigation. Fellows are guided throughout this process by a primary mentor and a mentoring committee. Since funding became available in 2009, two of the three graduates to date have successfully secured clinician-educator faculty positions. Graduates uniformly believe that the clinician-educator track met their training goals better than the research-based track would have.

Teaching during consultation: factors affecting the resident-fellow teaching interaction

OBJECTIVES

The subspecialty consultation represents a potentially powerful opportunity for resident learning, but barriers may limit the educational exchanges between fellows (subspecialty registrars) and residents (house officers). We conducted a focus group study of internal medicine (IM) residents and subspecialty fellows to determine barriers against and factors facilitating resident-fellow teaching interactions on the wards, and to identify opportunities for maximising teaching and learning.

METHODS

We conducted four focus groups of IM residents (n = 18) and IM subspecialty fellows (n = 16) at two academic medical centres in the USA during February and March 2013. Participants represented trainees in all 3 years of residency training and seven IM subspecialties. Four investigators analysed the transcripts using a structured qualitative framework approach, which was informed by literature on consultation and the theoretical framework of activity theory.

RESULTS

We identified two domains of barriers and facilitating factors: personal and systems-based. Sub-themes in the personal domain included fellows' perceived resistance to consultations, residents' willingness to engage in teaching interactions, and perceptions and expectations. Sub-themes in the systems-based domain included the process of requesting the consult, the quality of the consult request, primary team structure, familiarity between residents and fellows, workload, work experience, culture of subspecialty divisions, and fellows' teaching skills. These barriers differentially affected the two stages of the consult identified in the focus groups (initial interaction and follow-up interaction).

CONCLUSIONS

Residents and fellows want to engage in positive teaching interactions in the context of the clinical consult; however, multiple barriers influence both parties in the hospital environment. Many of these barriers are amenable to change. Interventions aimed at reducing barriers to teaching in the setting of consultation hold promise for improving teaching and learning on the wards.

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.

Development of a gastroenterology educational curriculum for pediatric residents using fellows as teachers

OBJECTIVES

At many institutions, the teaching provided on subspecialty gastroenterology rotations is not structured. The purpose of the present study was to describe the development, implementation, and assessment of a structured gastroenterology curriculum for pediatric residents.

METHODS

A needs assessment was performed via a survey of former pediatric resident graduates presently working in general pediatrics. Topics for the curriculum were developed based upon the needs assessment. Second-year residents on the inpatient gastroenterology rotation attended 4 case-based, small group sessions per week for 1 month. Sessions were taught primarily by upper-level gastroenterology fellows. The curriculum was assessed via a pre-posttest, postrotation survey, and group feedback sessions.

RESULTS

Resident rating of education received during the rotation was high. Posttest scores increased slightly but significantly compared with pretest values. The curriculum has continued to be used >4 years after its development.

CONCLUSIONS

The creation of a structured subspecialty curriculum with the use of fellows as teachers is both feasible and effective despite limitations in available time for resident teaching.

Developing future faculty: a program targeting internal medicine fellows' teaching skills

INTRODUCTION

The increased demand for clinician-educators in academic medicine necessitates additional training in educational skills to prepare potential candidates for these positions. Although many teaching skills training programs for residents exist, there is a lack of reports in the literature evaluating similar programs during fellowship training.

AIM

To describe the implementation and evaluation of a unique program aimed at enhancing educational knowledge and teaching skills for subspecialty medicine fellows and chief residents.

SETTING

Fellows as Clinician-Educators (FACE) program is a 1-year program open to fellows (and chief residents) in the Department of Internal Medicine at the University of Iowa.

PROGRAM DESCRIPTION

The course involves interactive monthly meetings held throughout the academic year and has provided training to 48 participants across 11 different subspecialty fellowships between 2004 and 2009.

PROGRAM EVALUATION

FACE participants completed a 3-station Objective Structured Teaching Examination using standardized learners, which assessed participants' skills in giving feedback, outpatient precepting, and giving a mini-lecture. Based on reviews of station performance by 2 independent raters, fellows demonstrated statistically significant improvement on overall scores for 2 of the 3 cases. Participants self-assessed their knowledge and teaching skills prior to starting and after completing the program. Analyses of participants' retrospective preassessments and postassessments showed improved perceptions of competence after training.

CONCLUSION

The FACE program is a well-received intervention that objectively demonstrates improvement in participants' teaching skills. It offers a model approach to meeting important training skills needs of subspecialty medicine fellows and chief residents in a resource-effective manner.

MRI interpretation proficiency of musculoskeletal fellows in training

RATIONALE AND OBJECTIVES

The aim of this study was to evaluate the magnetic resonance imaging (MRI) interpretation proficiency of musculoskeletal fellows in training.

MATERIALS AND METHODS

Between July 2003 and June 2007, 14 musculoskeletal fellows were independently tested with 20 MRI studies of the knee and shoulder at four separate time points during their fellowship years. Trends in true-positive and false-positive interpretation results were evaluated. Fellows who completed their residencies at the fellowship institution (internal fellows) were compared with those from other residencies (external fellows).

RESULTS

There was a significant improvement in proficiency between the initial and final (9-month) evaluations (P < .0001). At the initial evaluation, there was a mean of 52.8% (41.7 of 79) true-positive results (range, 32-51); at 9 months, there was a mean of 71.0% (56.1 of 79; range, 40-72). The number of false-positive results also declined during this time period from a mean of 8.1 (range, 2-13) at initial evaluation to 4.7 (range, 2-8) at 9 months (P < .001). External fellows had more incorrect diagnoses initially but showed greater improvement than internal fellows at 9 months.

CONCLUSION

Fellows continued to improve their MRI interpretation skills throughout the first 9 months of their fellowships. External fellows were slightly less proficient at the start of their fellowships but slightly more proficient at 9 months compared to internal fellows.

Education of trainees in the intensive care unit

The focus on improving education in critical care medicine must begin early in medical school training and further be promoted during residency if there is to be an increase in intensivists in the hospital workforce. This is "critical" to healthcare reform movements that are endorsing full-time critical care coverage in U.S. urban intensive care units. There is, therefore, a need for more novel approaches in educating trainees in critical care medicine to better prepare future physicians to manage acutely ill patients and improve patient safety. This article will review methods to improve educational designs in teaching critical care medicine to medical students, residents, and fellows, including the use of simulation technology to enhance cognition and procedural skills.