Resident physicians play an instrumental role to teach clinical skills to junior residents and medical students (Bree et al., 2014; Hill et al., 2012). Several studies have found that residents spend at least 25% of their time teaching, and one-third of medical students’ clinical skills and knowledge is attributable to their guidance (Bing-You and Sproul, 1992; Seely et al., 1999; Montacute et al., 2016). To improve resident teaching skills, Canadian and United States accreditation bodies require that residents be formally trained to teach students (ACGME, 2020; Frank, Snell and Sherbino, 2015). Increasingly, specialties have adapted Resident as Teacher (RaT) initiatives into their residency programs (Al Alchkar et al., 2017); (McKeon et al., 2019; Alaska et al., 2019; Ravichandran et al., 2019) by incorporating a variety of curricula and teaching methodologies (Habermehl, Habermehl and Kim, 2018; Tan et al., 2017; Watkins et al., 2017; Arya et al., 2018; Ricciotti et al., 2017). However, due to increased clinical responsibilities and time constraints, it is a challenge for programs to allocate enough time to enhance their skills (Ravichandran et al., 2019; Habermehl, Habermehl and Kim, 2018; Lacasse and Ratnapalan, 2009). 

Recently, information graphics, or infographics, have become an increasingly popular format for communication in both teaching and learning due to their ability to capture attention, engage and make complex concepts and/or knowledge easily and quickly understandable (Ozdamli and Ozdal, 2018; Ray Chaudhury, 2019). Well-designed infographics can be understood faster than text alone and are twice as likely to be retained (Scott et al., 2016). Healthcare professionals have begun to embrace images and graphics along with mobile technology (Thoma et al., 2018) to communicate. To our knowledge, there is a dearth in published data (Thoma et al., 2018; Chin et al., 2019) on using infographics to train residents on how to teach. 

The objective of this study was to investigate the engagement and acceptability of Just-in-Time-Teaching (JiTT) infographics, a novel approach adaptable to diverse RaT programs that deliver evidence-based clinically relevant teaching tips. The Kirkpatrick’s (Frye and Hemmer, 2012) model of evaluation was considered to assess the engagement and acceptability of this approach. We hypothesized that JiTT infographics would promote a culture of effective teaching via self-directed learning and provide a faculty development framework for residents and faculty across specialties.

This study took place during six-week rotations from July to September 2019 across 12 residency programs in six clinical specialties (Internal Medicine (IM), Neurology, Obstetrics/Gynecology (OB/GYN), Surgery, Psychiatry, and Pediatrics). There were 260 residents and 237 faculty from five tertiary-care hospitals within a large suburban health system. Faculty inclusion was based on feedback received from a prior pilot study among residents with a goal for faculty to help reinforce engagement with JiTT content among residents. 

Description of JiTT Infographics 

JiTT infographics [https://libguides.hofstra.edu/mededresources/teachingresources] were implemented as a pedagogical approach to provide teaching tips when residents need them to engage with students. Infographics included both general clinical teaching principles (e.g., bedside teaching, learning huddle, and 5-microskills) (Supplementary File 1) and specialty-specific (e.g., how to conduct an abdominal exam, evaluate for rupture of membranes/amniotic fluid, and review neurologic imaging) (Supplementary File 2).

Prior to dissemination, program directors of participating residencies were recruited and asked to appoint a core faculty and resident champion to support the new initiative. The responsibilities of each champion were to provide insight regarding the logistics of delivery, identify modality for distribution based on the programs’ communication culture, and prepare specialty-specific teaching content. With the assistance of centralized faculty development administrators’ infographics were created using Canva (Canva, Ltd, Australia), a graphic design platform. 

Outcomes measured 

Resident engagement was quantified through OpenMoves (an email marketing platform) by analyzing the rate of opened emails /total residents in each program. Subsequently, the acceptability of the study was analyzed using mixed-method analysis consisting of (1) a semi-structured focus group conducted with 36 resident and faculty champions to discuss end-user feedback, and (2) electronic resident and faculty surveys (Supplemental File 3), which were adapted from a previously published survey (Watkins et al., 2017); to collect data to support program evaluation at Kirkpatrick level 1 (satisfaction) and 2 (learning). 

Statistical Analysis

To ensure adequate data was collected we clustered data by clinical specialty. Quantitative data were analyzed using Prism 8 (GraphPad Software San Diego, CA). Differences between weekly engagement rates were analyzed using Chi-Square with Yates correction. p < 0.05 was considered statistically significant. 

Descriptive analyses (count, mean, standard deviation (SD), and percentage as appropriate) were used to assess acceptability metrics and outcomes. Qualitative survey questions and narrative text from the focus group were reviewed and coded independently by two members of the research team (KS and DO) using conventional content analysis (Hsieh and Shannon, 2005). This research study was deemed exempt by the Northwell Health Institutional Review Board (IRB) as a supplementary educational tool. 

Engagement Results

Over the 6-week period, 198 out of 260 (76.2%) residents opened weekly emails with an average engagement rate of 65.7%. The average specialty engagement rates were highest among pediatrics (71.4%) compared with neurology (67.8%), psychiatry (64.5%), IM (62.7%), surgery (62.2%) and OB/GYN (60.8%). 

Further analysis showed that while there was an 8.5% decline in weekly average engagement rate for all residency programs from 68.5% (178/260) in week 1 to 60.0% (156/260) in week 6; it was not statistically different (p = 0.054).

Acceptability Results 

A total of 44 (22.2%) residents and 60 (25.3%) faculty that opened JiTT completed the survey. Table 1 shows the results about the acceptability of JiTT infographics for residents.

As shown, 20 (45.5%) responded the role of resident as teach teacher “is one of my primary responsibilities”, 42 (90.9%) felt that opening the infographics prompted them “to think about teaching”, 33 (75.0%) found the frequency to be just right, and 31 (70.4%) changed their teaching styles as a result.   

Furthermore, 50 (83.3%) faculty felt the JiTT infographics were a useful resource to enhance faculty teaching skills in the clinical environment, whether with students or residents. 29 (48.3%) encouraged residents to review the JiTT infographics.  

Despite these promising results, these findings were only represented the acceptability and end-user satisfaction. However, further thematic analysis of qualitative data confirmed these findings (Table 2) with faculty solidifying the value of JiTT as well as their involvement to engage residents in the program and most important role model and develop resident skills to utilize the infographic content.

In the current US and Canadian graduate medical education curriculums residents have inadequate opportunity to learn how to teach due to limited time away from patient care responsibilities (Ravichandran et al., 2019); (Arya et al., 2018); (Sward, Ellis and Mercado, 2020). Kirkpatrick’s Evaluation Model guides programmatic evaluation of the impact of JiTT infographics on resident’s perception of their role as clinical teachers and faculty as role models. JiTT infographics has allowed us to positively influence resident’s perception of their teaching skills and reach Kirkpatrick level 1(satisfaction) and level 2 (learning). This study confirmed that infographics are adaptable to an array of clinical specialties and can be successfully implemented as a technology-enhanced pedagogical tool (Thoma et al., 2018); (Chin et al., 2019) providing residents with the capacity to apply teaching skills ‘just in time’ in the clinical setting. A positive outcome was faculty satisfaction with the JiTT program and their ability to role model teaching skills, which leads to a positive aura of the JiTT program in the clinical environment. This also aligned with a recommendation from residents in an earlier pilot program that faculty must receive the same content as residents. Finally, our system to launch the JiTT program included clinical specialty specific resident and faculty champions to assure the messaging about JiTT came from peers. This proved to be a very valuable starting point for this program to launch.  From the focus group and surveys we were able to ascertain several ways the JiTT infographics can improve its acceptability and usefulness which include: mini-podcast links attached to infographics making content audible and providing examples for each teaching tip; visual reminders of infographics in strategic locations, where they could be seen by faculty and residents; changes in dissemination frequency by shortening the number of distribution weeks, use of a consortium-based approach (e.g. a blend of general and specialty-specific JiTT infographics) and finally the future use of an APP to store all infographics (Supplementary File 4), which is currently in development. 

There are several limitations to our study. First, selection bias may influence the survey data -- users who opened the JiTT infographics may be more likely to complete an emailed survey. Second, our study focused on the short-term impact on residents and faculty, specifically receptiveness to a new form of clinical education using visuals and technology. Our current evaluation was unable to measure the longitudinal impact on resident teaching or medical student learning. To determine an overall causative relationship between an educational innovation and teaching and learning outcomes may be difficult due to an array of confounding variables in our diverse clinical environments and the uniqueness of each clinical program. In addition, we need to further use our resident and faculty champions to understand program culture that impacts infographic initial and consistent open rates. These initial findings are a valuable first step and further studies will refine logistics and measurement of longer-term impact of infographics to determine RaT and faculty best practices in busy clinical environments. 

In a mixed-method experiential study, we provided preliminary evidence that the creation of JiTT infographics is a viable technologically-enhanced strategy to develop and promote RaT in the clinical setting. Analysis showed the infographics were effective for 2 levels of Kirkpatrick to evaluate educational interventions. This adaptation to technology-assisted education that considers time sensitive delivery is especially important in light of the digital adeptness of residents and restricted duty hours. Most important we can say with certainty that the JiTT infographic program can be incorporated into diverse busy teaching and clinical settings.