Teaching Now-Teaching (TNT): self-assessment of OB/Gyn faculty and resident teaching skills pre- and post-intervention

Introduction: Though called upon to teach the next generation of medical students, residents and faculty at academic medical institutions are rarely given formal training in education. This lack of training, coupled with lack of time to devote to teaching, are leading obstacles for academic clinicians educating medical students. Methods: Faculty and residents in the Department of Obstetrics and Gynecology at the University of Arkansas for Medical Sciences (UAMS) were asked to complete a 10-item anonymous survey rating items regarding knowledge about teaching, attitudes towards teaching, and the value placed on teaching medical students. Faculty and residents then attended a 2-hour interactive seminar aimed at improving teaching techniques. After the seminar, the attendees were asked to complete the same 10-item survey. Results: Using roles to match pre-test and post-test responses, a paired samples t-test was analyzed. The faculty group showed significant improvement in two of the 10 items, both of which related to self-assessment of teaching skills. The resident group showed statistically significant improvement in eight out of the 10 items – pertaining to teaching knowledge, teaching skills, attitudes towards teaching, and value of teaching. Cohen’s d values showed large to very large effects on 5 of the 8 statistically significant items. Discussion: A brief teaching seminar given to residents and faculty in our department was successful in improving attitudes and knowledge related to teaching medical students.


Introduction
The burden to teach the next generation of medical professionals often falls to resident physicians and clinical Sward L, Ellis S, Mercado C MedEdPublish https://doi.org/10. 15694/mep.2020.000022.1 Page | 2 faculty in academic medical institutions across the country. Though these physicians are responsible for teaching medical students, the majority have never had any formal training in education (Lake, 2004). Many faculty members at teaching institutions lack either educational resources, the time to pursue the development of teaching skills, or both (Lake, 2004); (Gibson and Campbell, 2000).
Lack of training in education is only one of the challenges that clinician-teachers face. They also are pressed for time with increasing demands for clinical productivity (Lake, 2004); (Gibson and Campbell, 2000). It is understandable how education of medical students, a task that might seem daunting to those who have never been trained to do it, might fall by the wayside when compared to pressing clinical tasks.
The Association of American Medical Colleges (AAMC) conducts a yearly graduate questionnaire (GQ) of senior medical students. The GQ includes questions related to both pre-clinical and clinical experiences and includes benchmarks allowing a school to compare their performance to that of other LCME-accredited schools. Among the questions they are asked, graduating seniors must rate the education received on their clinical clerkships with the items "Faculty provided effective teaching on this clerkship" and "Residents provided effective teaching on this clerkship" (AAMC, 2019). The graduates of the University of Arkansas for Medical Sciences (UAMS) College of Medicine have historically rated their obstetrics and gynecology (OB/Gyn) clerkship poorly on these items compared to seniors at other institutions.
In addition to the AAMC GQ data, internal clerkship evaluation data of the OB/Gyn clerkship at UAMS has highlighted poor teaching efforts on the part of faculty and residents. Some comments from these evaluations included: "It appears that the residents and attendings are too busy to teach," "I was not asked questions or included in the dialog about the treatment plan," and "The biggest problem I had with the {clerkship} was the lack of teaching." The purpose of this study was to first assess the baseline knowledge of and comfort level with teaching and teaching skills among residents and faculty in the Department of OB/Gyn at UAMS and then to determine whether a seminar on teaching techniques for busy clinicians improved teaching knowledge and comfort levels.

Methods
This research study was considered by the Institutional Review Board for the University of Arkansas for Medical Sciences on February 7 th , 2018 (IRB #217738), and deemed exempt as it fell within the normal scope of resident education and faculty development. In addition, all research surveys were conducted anonymously and determined to pose no risk to participants. The research was conducted from March 28, 2018, through April 11, 2018, and in accordance with the Declaration of Helsinki.
Residents (PGY1-PGY4), fellows, and faculty members in the Department of OB/Gyn at UAMS were asked to complete a modified version of a validated self-assessment survey regarding teaching skills and attitudes towards teaching (Table 1). This survey was first published by Grady-Weliky and colleagues in Academic Psychiatry (Grady-Weliky, Chaudron, and Digiovanni, 2010) and a modified version was used with permission from its creator (Dr. Robert Swantz, Department of Pediatrics, University of Rochester Medical Center). The web link to the 10-item, 5point Likert scale questionnaire was emailed to all participants, and they were asked to answer anonymously. Residents and faculty members then attended a two-hour education seminar entitled "Teaching Now-Teaching" (TNT). One week after completion of the seminar, the same 10-item questionnaire was emailed again to all participants as a post-course suvey. Content for the TNT seminar was derived from the Association of Professors of Gynecology and Obstetrics (APGO) Effective Preceptor Series (Abbott, Espey, and Emmons, 2013); (Hampton and Forstein, 2014). The course utilized a mixture of PowerPoint slides, video demonstration, role-play, and team activities to teach two different teaching techniques.
The two different teaching techniques taught were the Five-Step Microskills Model of Clinical Teaching and the B.I.D. Model for teaching in the operating room (Abbott, Espey, and Emmons, 2013); (Hampton and Forstein, 2014). The Five-Step Microskills model, also called the one-minute preceptor, was originally described in 1992 by Neher and colleagues. It is useful in settings where learners begin by seeing patients and then seek out the guidance of a preceptor, such as in an ambulatory care setting. The preceptor prompts the learner to make a commitment and support that commitment with evidence. The remainder of the Microskills revolve around teaching a general rule, reinforcing positive portions of the encounter, and correcting learner mistakes (Neher and Stevens, 2003). The Briefing, Intraoperative Teaching, Debriefing (B.I.D.) model, originally described by Roberts et al. in 2009, is used for operating room teaching. This technique focuses on setting learning objectives, providing teaching during the surgical encounter, and then reflecting on what was learned -all in a manner than can be performed during the usual activities that a surgeon performs. For instance, the setting of learning objectives can be performed at the scrub sink, and the reflection can be performed during the closing portion of the procedure (Roberts et al., 2009).
At the completion of the seminar, attendees were given laminated reference cards as a visual reminder of the teaching techniques taught (Figures 1 and 2). Posters displaying the same content as the reference cards were also hung in strategic locations in clinics and on the wards where they could be seen by faculty, fellows, and residents.

Results/Analysis
The data collected was analyzed using SPSS version 25. A paired samples t-test using roles to match the pre-test and post-test responses were each analyzed: faculty and fellows (n=17) and residents, PGY 1-4 (n=15) (

Discussion
We found that knowledge about teaching, teaching skills, and attitudes towards teaching improved among OB/Gyn residents and faculty with a 2-hour seminar on teaching techniques. These improvements were especially evident amount the resident group of survey responders. Though both groups surveyed showed improvement in knowledge of teaching skills, the resident group showed improvements in knowledge regarding teaching roles, teaching skills, and attitudes towards teaching. The teaching seminar we conducted was brief and simple, teaching well-described models and concepts, and would be easily replicable for different groups of residents and faculty across departments and campuses.
There are limitations to our study. One limitation is that we examined personal perceptions of knowledge, skills, and attitudes related to teaching, as opposed to unbiased measurements. Second, there was no control group surveyed, as all residents and faculty that responded to the post-intervention questionnaire had participated in the TNT seminar. Finally, ours was a study of the knowledge and comfort levels of the teachers and was not designed to show how these perceived improvements in their teaching affected student opinions of the clerkship. While this would make for an interesting follow-up study, there would be too many confounding variables to establish a true causative relationship between our intervention and better student evaluations of their OB/Gyn clerkship. Though cause and effect would be impossible to measure, we believe that, as a result of our intervention, more knowledgeable and confident teachers will lead to improvements in student attitudes towards our clerkship. This is data that we desire to collect in the near future, using the AAMC GQ as well as internal clerkship evaluations.
Another interesting question would be whether or not the perceived improvement in teaching skills in our department leads to improvements in student education. This could be assessed by evaluating scores on National Board of Medical Examiners (NBME) shelf exams and OB/Gyn related items on the Unites States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge exam. Though again, due to confounding variables, an overall causative relationship would be impossible to establish between the TNT seminar and improved student education. We do feel, however, that creating better educators with simple useful teaching tools can only lead to better student education.

Conclusion
TNT was an easy-to-conduct educational seminar that led to improvements in perceived teaching knowledge, skills, and attitudes among OB/Gyn faculty and residents. It is our hope that these improvements will translate to better medical student perceptions of and education during their OB/Gyn clerkship.

Take Home Messages
Busy schedules and lack of formal training in education are challenges to clinicians as they teach the next generation of physicians. Teaching Now-Teaching (TNT) was a brief, interactive educational seminar on teaching techniques. The five-step microskills model and the BID model were taught to faculty and residents in the department of OB/Gyn at UAMS. Faculty and resident self-assessment of teaching skills improved after the TNT seminar.