Personal view or opinion piece
Open Access

See one, do one...teach one? Learning to be doctors, teachers, or both?

Nikita Habermehl[1], Gabriel Habermehl[2], Grace Kim[1]

Institution: 1. Rainbow Babies & Children's Hospital, 2. Cleveland Clinic Foundation
Corresponding Author: Dr Nikita Habermehl ([email protected])
Categories: Educational Strategies, Teachers/Trainers (including Faculty Development), Teaching and Learning, Postgraduate (including Speciality Training)
Published Date: 06/08/2018

Abstract

Most residents have a desire to teach, but no unified curriculum exists to help residents be the best teachers they can be. Further investigation reveals this to be a global problem and a pedagogic curriculum should be a well-defined expectation. While there are multiple requirements during residency, a well-implemented Resident-As-Teachers (RAT) curriculum should be incorporated into every program.

Keywords: Resident; Teacher; Pedagogy; Education.

Perspective

“Excuse me, doctor, I need you to speak to the patient’s parents in room 500 and explain how to use a spacer and albuterol,” the nurse states as she comes into the workroom. Immediately, the intern looks at me and asks, “How do I order this blood test, and can you help me with a venipuncture?” As I gather the supplies to obtain blood, the attending reminds me about my lecture on the basic management of anaphylaxis to the 3rd year medical students at the end of the week. It is the first day of my final year of residency, and I can’t believe that these teaching expectations have all accumulated within 10 minutes of each other.

The Latin root of doctor, docere, means “to teach” and one of the core reasons that residents pursue a career in medicine is to educate others. It is known that effective patient education can improve healthcare outcomes, and we as residents are at the forefront of this endeavor. Residents spend up to one quarter of their time teaching during residency and report that they enjoy it, consider it important, and believe that it improves clinical knowledge (Busari, 2002). Clearly, the role of the resident educator is extremely important but often underrecognized.

We must understand complex disease processes, teach it to junior peers, and educate patients who often do not have a medical background. The most apparent barrier is finding time to teach amidst substantial clinical responsibilities. A second barrier is educating others when we are still learning the intricacies of the disease processes that we are meant to be teaching. However, most significant is that residents are generally expected to become teachers with no formal education in the art of teaching. If residents do not receive any formal education in teaching, how can we be expected to succeed?

Some have recognized that there is a need to train residents in pedagogy before expecting them to educate effectively. A literature review from 2004 found the need for improved supervision and curriculum in pedagogy specific to residents (Busari, Scherpbier, 2004). However, effective action to incorporate this specific curriculum during medical training remains a rarity. 87% of pediatric residency program directors in the United States reported having a resident-as-teachers (RAT) curriculum, but only 17% considered the program to be very or extremely effective (Fromme, 2011). In family medicine, one study concluded that 85% of residencies offered a RAT program in 2014, though effectiveness was not measured (Al Achkar, 2017). Clearly, attempts have been made to implement RAT curriculums, at least in some residencies, but as a profession, we should consider making serious improvements. 

This issue not only affects residents in the United States but is both a multi-disciplinary and global education problem. For instance, in Canada, residents from 17 family medicine programs were surveyed regarding teaching opportunities and mentorship in teaching. While 79% of residents indicated they had opportunities to teach, only 33% had been observed during these teaching encounters (Ng, 2013). In another example, a systematic review of RAT programs in New Zealand from 1971 to 2008 found that the use of more objective outcome measures are needed to determine the true effectiveness of these RAT programs. Additionally, in a European study of pediatric surgery residents (Zundel, 2017), most residents (93%) had no RAT training program. The majority of teaching was peer to peer and the study concluded that RAT programs needed to be developed. In all instances above, it seems that opportunities for pedagogical improvement remain.

While we have touched on the systemic nature of this issue, we would like to highlight some efforts to improve resident teaching abilities. In one example, after recognizing the deficit abroad, emergency medicine residents in Iran completed an 8-hour RAT workshop and resident attitudes towards their teaching ability was significantly improved (Nejad, 2017). In addition, Children’s National Health System developed an intensive one-day RAT curriculum which included four 1-hour workshops focusing on adult learning principles using a flipped classroom approach (Chokshi, 2017). Their results showed statistically significant improvements in three core skills: giving feedback, orienting a learner, and teaching a skill. Another study examined programs that implemented a RAT video-based toolkit. This intervention was associated with improvements in teaching skills for residents in obstetrics and gynecology, emergency medicine, anesthesia, surgery, internal medicine, pediatrics, and dermatology. Furthermore, Baylor College of Medicine created the first Academy of Resident Educators (ARE) program, with the goal of developing educational expertise in clinician-educators and scholars (Moza, 2015). The academy provides opportunities for educational leadership, including six professional development sessions each year.

RAT programs have increased in number from the early 2000s to today, but can we do more? Implementing an effective RAT curriculum (or similar curriculum) in all residency programs could provide us with the training and confidence to become great teachers. As noted above, there are different types of RAT programs, and the following example focuses on a novel, dual approach wherein participants learn to teach and also learn medical content about mock codes. In a 2011 study from Duke Children’s Hospital, the resident educator’s (senior resident) objectives included teaching proficiency, leadership, debriefing and feedback, while objectives for resident participants (any resident level) focused on resuscitation and crisis management. In addition to improving knowledge in resuscitation skills for all participants, teaching proficiency of the resident educators was strengthened. We find the success of this program encouraging.

Furthermore, a teacher training program could be introduced as early as medical school, allowing opportunity for residents to further build upon basic pedagogic skills during their residency. In one teacher training program, medical students demonstrated improved content knowledge and had more positive attitudes towards different teaching styles as well as teaching confidence. Furthermore, they continued to use these skills 2-years post intervention as residents. Implementing these concepts and skills in medical school in addition to reinforcing and further developing these skills during residency training could make all the difference.

Here, the ACGME’s Common Program Requirements for all residency programs state that “residents are expected to develop skills and habits to be able to meet the following goals … participate in the education of patients, families, students, residents and other health professionals.” Thus, an implied RAT training goal is clear, but methods to help programs, help residents, become better teachers are not defined. We believe opportunities for RAT interventions are abundant and the data supports the benefits of a well-implemented RAT curriculum in all residency programs. Are we now at a place where a pedagogic curriculum should be a well-defined expectation and not an exception? We believe the answer is yes.

One proverb states, “if you are planning for a year, sow rice; if you are planning for a decade, plant trees; if you are planning for a lifetime, educate people.” Residents are excited to be lifelong physician-learners, but also aim to be the best teachers possible. Many residents aspire to effectively educate their patients and families, in addition to mentor and teach other trainees and colleagues. In the end, it is only when we unify as a profession and implement a system-wide curricular change, can we become the most successful of teachers across all forums, reaching students, colleagues, future physicians—and most importantly—our patients.

Take Home Messages

  • The role of the resident educator is extremely important but often underrecognized.
  • One barrier that residents face is that they are generally expected to become teachers with no formal education in the art of teaching.
  • Attempts have been made to implement resident-as-teachers (RAR) curriculums, but as a profession, we should consider making serious improvements. 
  • Opportunities for RAT interventions are abundant and there is data to support the benefits of a well-implemented RAT curriculum.
  • Implementing these concepts and skills in medical school in addition to reinforcing and further developing these skills during residency training may be a good approach. 

Notes On Contributors

  • Nikita Habermehl is a fellow in Pediatric Emergency Medicine at Rainbow Babies & Children’s Hospital.

  • Gabriel Habermehl is a fourth-year resident in Pathology & Laboratory Medicine at Cleveland Clinic Foundation.

  • Grace Kim is an Attending Physician at Rainbow Babies & Children’s Hospital and Assistant Professor of Pediatrics at Case Western Reserve University School of Medicine.

Acknowledgements

None.

Bibliography/References

Achkar, M. A., Hanauer, M., Morrison, E., Davies, M. K. et al. (2017) 'Changing trends in residents-as-teachers across graduate medical education,' Advances in Medical Education and Practice, Volume 8, pp. 299–306. https://doi.org/10.2147/AMEP.S127007

Busari, J. O., Prince, K. J., Scherpbier, A. J., Vleuten, et al. (2002) 'How residents perceive their teaching role in the clinical setting: a qualitative study,' Medical Teacher, 24(1), pp. 57–61. https://doi.org/10.1080/00034980120103496

Busari, J.O., Scherpbier A.J. (2004) 'Why residents should teach: a literature review,' Journal of Postgraduate Medicine, 50(3), pp. 205-210.

Chokshi, B. D., Schumacher, H. K., Reese, K., Bhansali, P., et al. (2017) 'A ‘Resident-as-Teacher’ Curriculum Using a Flipped Classroom Approach,' Academic Medicine, 92(4), pp. 511–514. https://doi.org/10.1097/ACM.0000000000001534

Fromme, H. B., Whicker, S. A., Paik, S., Konopasek, L., et al. (2011) 'Pediatric Resident-as-Teacher Curricula: A National Survey of Existing Programs and Future Needs,”'Journal of Graduate Medical Education, 3(2), pp. 168–175. https://doi.org/10.4300/JGME-D-10-00178.1

Moza, R., Villafranco, N., Upadhya, D., Mitchell, K., et al. (2015) 'Academy of Resident Educators: A Framework for Development of Future Clinician-Educators,' Journal of Graduate Medical Education, 7(2), pp. 294–295. https://doi.org/10.4300/JGME-D-14-00718.1

Nejad H.H., Bagherabadi M., Sistani A., Dargahi, H. (2017) 'Effectiveness of resident as teacher curriculum in preparing emergency medicine residents for their teaching role,' Journal of Advances in Medical Education and Professionalism, 5(1), pp. 21-25.

Ng V.K., Burke C.A., Narula A. (2013) 'Residents as Teachers Survey of Canadian family medicine residents.' Canadian Family Physician, 59, pp. 421-427.

Zundel S., Stocker M., Szavay P. (2017) '“Resident as teacher” in pediatric surgery: Innovation is overdue in Central Europe.' Journal of Pediatric Surgery, 52(11), pp. 1859-1865. https://doi.org/10.1016/j.jpedsurg.2017.05.029

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

This is a personal view and opinion piece where no patient based research was conducted and an ethics approval is not needed.

External Funding

This paper has not had any External Funding

Reviews

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David Taylor - (17/08/2018) Panel Member Icon
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This is a well-argued personal view of an important problem, and many of us reading this will recognise the issues raised, and share the authors’ hopes and concerns. There is a lot of literature about RATs programs and there are several examples of programs which appear to work well. AMEE has also published a guide (AMEE Guide No 106 - https://doi.org/10.3109/0142159X.2016.1147540) but my personal view is that there should be a continuum of training throughout one’s career– not least because even at undergraduate level most learning is from peers or near-peers. This is reflected, for example, in the “Promoting Excellence” agenda of the General Medical Council in the UK (https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/promoting-excellence). AMEE's various ESME courses are a popular way of addressing the issue and are available both on-line and face-to-face.
Michael SH Wan - (12/08/2018) Panel Member Icon
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An interesting and important topic for discussion. Having good clinical skills and competencies do not equate being able to teach effectively. It is important to 'train' the residents early in their career to become lifelong teachers. Being able to teach others effectively will also improve their own understanding of the topic. Many institutions implement "teaching on the run" style of courses for the clinical teachers hoping to improve their teaching skills. The author described the RAT curriculum which reflects the importance of this. A more detailed definition of the curriculum and a systematic way of implementation in the clinical setting would be valuable. Further studies on the outcomes of this RAT implementation would be useful.
John Dent - (09/08/2018) Panel Member Icon
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This paper highlights a common, practical problem which may confront junior healthcare staff without much notice. Being aware of this AMEE, launched the student-focussed, online course Essential Skills in Medical Education called ESME-Student three years ago. This was based on the successful 12- week post-graduate, ESME-online course which has now run for more than seven years online and for longer face-to-face. By providing initial outlines of principals in medical education these aim to provide participants, soon to find themselves with teaching responsibilities, with helpful frameworks by which to deliver memorable teaching events. It also provides a vocabulary and awareness useful when contributing to faculty or departmental discussions on undergraduate or continuing medical education. Of course, other resources with a similar purpose are available but the strength of these ESME-online courses together is that more than 1400 participants representing more than 35 countries have enthusiastically benefitted from them.
As a lead / tutor on the ESME online and ESME student courses I’ve been interested to read this paper. Thank you for drawing further attention to the need to train doctors, and other healthcare professionals, in the teaching skills they require. How important it is to "grow trees " for the future.
Gary D. Rogers - (08/08/2018) Panel Member Icon
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This is a thoughtful and interesting narrative piece on an important topic. Unfortunately, several in-line references have been omitted from the text, making it difficult for readers to follow up some of the studies cited. It would be appreciated if this were remedied in a revised version of the manuscript. During the process of revision, it might also be useful to modify the language, which currently has a strongly North American flavour. For example, a more general term such as ‘doctor in training’ rather than ‘resident’ would assist with comprehensibility for the many parts of the world where different terminology is employed. The issues raised in this paper also apply across the full range of health professions and have structural, as well as individual practitioner level, dimensions. The authors might be interested in the Gold Coast Declaration on Learning Through Practice in the Health Professions (see https://www.anzahpe.org/ and follow the link the bottom right corner of the page).
Meghana Sudhir - (07/08/2018) Panel Member Icon
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The title of this personal view article shows the confusion among residents. As the residents are expected to train students and fellow residents, incorporating a structured curriculum in education will be beneficial. More importantly, as adult learners, the residents also need to explore the ways to improve their teaching skills.

P Ravi Shankar - (06/08/2018) Panel Member Icon
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This is an interesting brief personal opinion article. The authors highlight the role of residents as teachers with examples from the literature and mention how most residents are not trained in their role as teachers. As mentioned by the authors being a teacher is important for residents and is mentioned as an important competency by various agencies. Residents are involved in didactic teaching in large groups and in bedside clinical teaching. The components of a resident as teacher (RAT) curriculum may need to be defined. At the other end of the spectrum there have been reports from some countries where the majority of undergraduate teaching has been carried out by residents and the involvement of faculty members in undergraduate education is becoming very limited. This may also have to be guarded against. This article will be of interest to a broad range of medical educators.
Carla Lupi - (06/08/2018)
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The central role of competency in education, for residents and students, is clear and the authors point out the relevant ACGME language to this competency. (I will add that there is a mandate to the medical education community that residents need to "be prepared for their roles in teaching and assessment of medical students" - (LCME standard 9.1) The authors do not offer a search strategy for their review, so the reader is unable to judge the completeness of the description of current efforts and remaining gaps. They have briefly described some of the literature on short-term outcomes of residents as teachers program, and highlighted an older review article from 2004. They have also drawn attention to the all-important question of how to effectively train residents. They refer to a "well-implemented curriculum" but do not describe details or help the reader better understand their criteria for such a curriculum.
Time is almost always the first issue when considering new curricular material. Other challenges include the development of both instructional approaches/materials and methods to assess meaningful and longer-term outcomes.
This work would be much improved with reporting of a deliberate search strategy, clarity on the components of what the authors consider to be a well-implemented curriculum, and delineation of specific strengths and gaps in instructional and assessment strategies for RATs curricula. The mention of initiating training during medical school is logical. This area would be the subject of an entirely separate work.
Johnny Lyon Maris - (06/08/2018) Panel Member Icon
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As a personal view piece the text cannot be argued against. We as doctors have a duty to educate other health professionals (GMC, duties of a doctor - UK regulator) and undeniably patient education leads to better health outcomes. What this paper needs is the case for the RAT curriculum and what happens when residents are not encouraged to teach. How does the workplace find 'time' for the education, or is it left up to the motivated to find a course to meet their needs.
Please try to find solutions to these problems or in your literature search look for literature where the issue of no time has been overcome. In this way you are able to take the academic practice of education one step further i.e. what next. Thankyou for submitting