Residents-as-teachers Training in U.S. Residency Programs and Offices of Graduate Medical Education

Abstract

Resident physicians provide a substantial proportion of the teaching that medical students and junior residents receive, 1,2 spending numerous hours every week teaching. 3 As stated in the Graduate Medical Education Core Curriculum of the Association of American Medical Colleges (AAMC), 4 residents' teaching skills are vitally important, particularly for those residents who teach third-year medical students in the so-called “core clinical clerkships,” which traditionally include internal medicine, pediatrics, obstetrics—gynecology, surgery, psychiatry, and family medicine. Although the residency review committee of only one of these specialties (psychiatry) currently mandates residents' training in teaching skills,5 the Liaison Committee on Medical Education (LCME) states that residents should “participate in teaching [clerkship] students” and “be prepared for their roles as teachers and evaluators.”6 Residency programs vary in their teaching-skills training for residents. Bing-You and Tooker 7 found in a 1993 survey of internal medicine residencies that only 20% offered teaching-skills improvement programs for their residents. In most specialties, no published studies have ever documented how many such residents-as-teachers programs exist. To clarify the prevalence and characteristics of residents-as-teachers curricula in U.S. graduate medical education, a group of investigators collaborating with the AAMC's Section for Graduate Medical Education surveyed directors of residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), as well as deans and directors of offices of graduate medical education (GME) at LCME-accredited medical schools. Method Subjects. We surveyed the directors of all ACGME-accredited residency programs in family medicine, internal medicine, pediatrics, psychiatry, general surgery, and obstetrics—gynecology (n = 1,805), using the American Medical Association's Graduate Medical Education Directory 2000–01. 8 For internal medicine and family medicine, we used the more extensive program directors' lists published by the Association of Program Directors in Internal Medicine (APDIM) 9 and the American Academy of Family Physicians, 10 respectively. In order to include in our survey any additional multidisciplinary residents-as-teachers programs not administered by individual residency programs, we also surveyed all individuals listed as deans or directors of GME offices (GME leaders) in the latest published membership list of the AAMC's Group on Resident Affairs (n = 252). 11 Survey instruments. The authors used the work of Bing-You and Tooker 7 and an extensive review of the published literature on residents-as-teachers curricula 12 in designing a two-page questionnaire (see List 1). A separate questionnaire used identical item formats and questions to query GME leaders about any additional multidisciplinary teacher-training programs offered through their GME offices that were separate from programs offered by individual residencies at their institutions. We asked each GME office not offering its own teacher-training program whether such a program was unnecessary because the “individual residency programs offer their own residents-as-teachers instruction.”LIST 1. Summary of the Authors' Questionnaire for Residency Program DirectorsSurvey administration. We pilot-tested a draft version of the residency questionnaire with two content experts who run teacher-training programs, and with 36 APDIM members on the APDIM electronic-mail list. Based on these responses, we revised the questionnaire and undertook our larger survey. In the summer and fall of 2000, we sent the questionnaires to potential respondents by electronic mail, fax, or standard mail, depending on the information they had provided on the published contact lists. Non-respondents received follow-up questionnaires one and two months later by standard mail, accompanied by self-addressed stamped envelopes. To explore potential differences between respondents and non-respondents, we conducted a separate telephone survey with 21 non-respondents (three non-respondents from each of the six residency specialties and three from the group of GME leaders, all purposively selected to represent different geographic areas and program types). We also compared the program sizes of 42 non-respondents (seven from each residency specialty) with those of a sample of 42 respondents, both groups randomly selected within each speciality. Basic descriptive statistics obtained from standard statistical software formed the foundation of our data analysis. We also used analysis of variance (ANOVA) and chi-square to evaluate interspecialty differences on selected variables. Because we used no scales in our questionnaires, we did not calculate reliability coefficients such as Cronbach's alpha. Results Comparison of respondents and non-respondents. Of the 2,057 individuals to whom we sent questionnaires, 1,346 responded (65%), including 1,191 residency directors (66%) and 155 GME leaders (62%). Pediatrics program directors had the highest response rate (162/208 or 78%), followed by obstetrics—gynecology (188/260 or 72%), surgery (169/256 or 66%), family medicine (322/494 or 65%), psychiatry (118/185 or 64%), and internal medicine (232/402 or 58%). In the post-hoc telephone survey, we reached 17 of the 21 selected non-respondents (81%). Their questionnaire responses closely resembled those of the main respondent group, with nine of the 17 residency directors indicating that they offered their residents teacher training (53% versus 55%, p = .460). Program sizes did not differ between the additional randomly selected groups of 42 non-respondents (mean = 33.1, SD = 26.2) and 42 respondents (mean = 30.0, SD = 20.3; p = .426). Overall characteristics of residents-as-teachers curricula. Overall, 55% of residency directors indicated that their programs “offer residents formal instruction in teaching skills,” as they defined it: 88% of joint residencies in medicine—pediatrics, 80% in pediatrics, 65% in internal medicine, 62% in psychiatry, 52% in family medicine, 38% in obstetrics—gynecology, and 31% in surgery. Chi-square analysis showed that internal medicine, pediatrics, and joint medicine—pediatrics programs were significantly more likely to offer teaching-skills training, while surgery and obstetrics—gynecology were less likely to do so (χ2 = 120.97, df = 6, p < .0005), with family medicine and psychiatry at intermediate levels. Fifty-four GME offices (35% of the 155 respondents) also offered multidisciplinary residents-as-teachers programs that were separate from any such programs offered by individual residencies at their institutions. A total of 86% of the respondents offering formal residents-as-teachers training indicated that this training was mandatory for all residents at some point during residency education, ranging from 75% in GME offices to 92% in psychiatry. Three specialties (surgery, obstetrics—gynecology, and family medicine) were significantly less likely to mandate teaching-skills training, while internal medicine and psychiatry were more likely to mandate it (χ2 = 12.78, df = 6, p < .05). The teaching-skills curricula offered residents a mean number of 11.5 hours (SD = 11.5) of total instruction during residency, ranging from 8.9 hours in psychiatry to 20.8 hours in surgery. A oneway ANOVA for mean total hours of teaching-skills instruction across all training years by specialty was highly significant (F = 6.96, df = 6,583, p < .0005), with surgery demonstrating significantly more training hours than did either family medicine or psychiatry. Because the specialties we sampled varied in the numbers of years of training they offered their residents, we performed a similar ANOVA for mean total hours of teaching-skills instruction per training year. There was no significant interspecialty difference when we controlled for the duration of residency training (F = 1.03, df = 6,583, p = .407). Because variances were heterogeneous, we calculated post-hoc comparisons of specialty means using Games—Howell adjusted p-values to control the per-experiment Type I error rate. Mean numbers of instructional hours per year were 4.5 hours in the first year of residency (SD = 3.8), 5.1 hours in each of the second and third years (SD = 4.3 and 4.0, respectively), and, for longer residency programs, 5.6 hours in the fourth year (SD = 5.4), 6.5 hours in the fifth year (SD = 6.7), and 5.0 hours in the sixth year (SD = 1.4). Programs offered by GME offices devoted a similar mean number of training hours to each year of training. The typical formats that residency programs and GME offices used for their residents-as-teachers curricula are described in Figure 1; overall, lecture and workshop formats prevailed. Internal medicine and pediatrics used one-time workshops significantly more often than did surgery and obstetrics—gynecology (χ2 = 51.56, p < .0005). Psychiatry and obstetrics—gynecology used lectures more often than did internal medicine and pediatrics (χ2 = 17.31, p = .008), while pediatrics used large-group discussions more than psychiatry did (χ2 = 23.75, p < .001) and used role-playing more than both psychiatry and surgery did (χ2 = 32.09, p < .0005).Figure 1: Formats of residents-as-teachers programs. Above each bar are shown the percentages of the study's respondents (residency program directors, white bars, and graduate medical education leaders, black bars) using each format. Respondents could indicate more than one format.Program evaluation. Most residency programs (79%) and GME offices (93%) evaluated their residents-as-teachers curricula. Many residency programs (57%) surveyed their residents about their satisfaction with the training; smaller numbers (15%) surveyed faculty about their satisfaction (most often in surgery and least often in family medicine and pediatrics; χ2 = 22.44, p = .001). A substantial minority of residency programs (41%) asked medical students or junior residents to evaluate their senior residents' teaching skills, more often in obstetrics—gynecology and medicine—pediatrics and less often in psychiatry (χ2 = 25.90, p < .0005). Fewer programs asked faculty to evaluate residents' teaching skills (28% overall and most often in surgery and obstetrics—gynecology; χ2 = 17.94, p = .006). Some asked residents to evaluate their own skills or attitudes (23%), or used an objective structured teaching examination (OSTE; 2%). Most GME offices also surveyed residents' satisfaction (87%). Some GME offices asked junior learners to evaluate residents' teaching skills (24%), asked residents to evaluate themselves (22%), or used faculty evaluations of residents' teaching skills (18%). Others surveyed faculty about their satisfaction with the curricula (18%) or use OSTEs (4%). No residency program director and only one GME leader (< 1%) believed that his residents received “more instruction than they need” in teaching skills. Only a minority of respondents perceived that their residents received “just the right amount of instruction.” Most respondents (75% of residency directors and 87% of GME leaders), in fact, indicated that their residents “would benefit from even more instruction.” For these questions, differences between specialties did not reach statistical significance (χ2 = 7.22, df = 6, p = .301). Programs not offering teaching skills curricula. We also asked those residency directors and GME leaders who did not offer residents-as-teachers curricula to discuss their reasons for this choice. Most of these residency directors (77%), but fewer GME leaders (52%), believed their programs lacked sufficient resources to offer such curricula, given other training needs. Some GME leaders (2%) and residency directors (15%) believed their residents did not need teaching-skills training because their teaching skills were already adequate. In write-in responses, 8% of residency directors without current residents-as-teachers curricula stated they were currently developing such curricula, and 6% wrote that their residents lacked curricular time to study teaching skills. Few residency directors (3%) or GME leaders (1%) stated that their residents did not need teaching-skills training because they did little teaching, with chi-square tests producing no inter-specialty differences (p = .164). Many GME offices (37%) chose not to offer separate multidisciplinary residents-as-teachers curricula because similar curricula were already offered by the individual residency programs at their institutions. Discussion We were fascinated to learn that approximately half of all residency programs in six specialties, and 35% of GME offices, offered what they considered to be at least some formal training in teaching skills for their residents. Since the 1993 survey by Bing-You and Tooker, 7 residents-as-teachers curricula have more than tripled in internal medicine residency programs. The mean number of training hours in teaching skills, however, has remained fairly constant (nine hours in 1993 versus 11.5 hours today). Although no published comparison data could be found for other specialties, it appears likely that residents-as-teachers training became more prevalent in many graduate medical education settings during the 1990s. The data present several interesting trends. Pediatrics, internal medicine, and combined medicine—pediatrics residencies were significantly more likely than were other specialties to offer teaching-skills training to their residents, with nearly 80% of pediatrics residencies offering this training. Fewer than 40% of all general surgery and obstetrics—gynecology residency programs offered their residents training in teaching skills, but the teaching-skills training the surgery residencies offered was significantly more extensive than it was in other specialties. The reasons behind this trend remain unclear, although surgery residents may provide more teaching for their clinical clerks than do residents in many other specialties, as was noted in a recent time study. 13 The six-year surgical residency could also permit a longer cumulative exposure to teacher training. Different medical specialties approach residents-as-teachers training differently, and there is no “one size fits all” approach that can be recommended for either training or evaluation. Most residency programs and GME offices use a lecture format—often within a one-time retreat or workshop—to teach residents how to teach. Like studies of faculty development programs, 14 controlled studies of various curricula to teach residents teaching skills have produced mixed results, 12,15–18 with no single approach demonstrating uniform efficacy. Some residents-as-teachers curricula use interactive teaching techniques, sometimes within longitudinal formats that may possibly be more effective in improving teaching skills. The majority of residents-as-teachers curricula included some type of evaluation. While most of this evaluation consisted of asking residents how satisfied they were with their teaching skills curricula, more than 40% of residency programs did ask junior learners to evaluate their residents' teaching skills, a valid and reliable evaluation technique when used with carefully selected rating scales and adequate numbers of prepared learners. 19,20 Although residents-as-teachers curricula are increasingly common in graduate medical education, three fourths of our survey respondents believed that their residents would benefit from even more instruction in teaching skills. Even residency directors who did not currently offer teaching skills training to their residents tended to suggest that they would choose to offer this training if limited resources allowed it. Indeed, remarkably few respondents stated that their residents did little teaching. The survey's high response rate provides further support that residency faculty believe their residents' teaching activities to be substantial and important. Our study has limitations. The survey's self-report format allowed respondents to define for themselves what they considered to be a teaching-skills “curriculum,” as was done in the 1993 internal medicine survey. 7 For simplicity's sake, we also chose to limit our sample to U.S. GME offices and residency programs representing six medical specialties. Internal medicine residencies had a relatively low response rate. had we included other specialties or used data other than self-reports, we might have found different results. Conclusion This survey offers a “snapshot” of residents-as-teachers training as a vital and growing trend in U.S. graduate medical education. Residency faculty and other GME leaders expend time and effort teaching their resident physicians how to teach despite lacking clear data to show which educational techniques best support this goal. 12 Medical educators need data to elucidate what constitutes effective training for their resident teachers. Future studies need to clarify which aspects of residents-as-teachers curricula most effectively improve educational outcomes. An evidence-based approach to residents' teaching-skills training can powerfully contribute to a critical arena of teaching and learning in graduate medical education.