Changing Culture in Medical Student and Resident Education: A New Elective

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Changing Culture in Medical Student and Resident
EducationA New Elective

• Adam Trosterman, MD
• Jason McCarl, MD

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The Past

• Most previous resident teaching training programs
  have attempted to do several things
• 1. Provide residents with some of the basic
  tools and skills needed for teaching.
• 2. Help residents identify the barriers that
  exist to teaching and provide some solutions.
• 3. Provide didactic sessions and role playing
  in areas such as giving feedback, learning theory
  and setting goals and expectations for the
  learner and teacher.

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Learning Theory

• Many programs that exist today incorporate
  various learning theories into the development of
  their programs.
• Advantage to teaching learning theory is that the
  teacher may better anticipate and relate better
  with the learning difficulties students may
  encounter.

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Types of Learning Theory

• Motive Acquisition Teaching information that is
  temporarily in close proximity to when it may be
  applied.
• Adult Learning Theory Adults seek information
  with immediate applicability and that speaks to
  the challenges of daily life.
• Social Learning Theory Role modeling and
  teaching by example.

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Hypothesis

• We believe that most previous resident teacher
  training programs have fallen short in several
  areas
• 1. They have not stressed that teaching is a
  priority.
• 2. They have not addressed the need to change
  the cultural beliefs that exists about teaching.
• 3. They have not been longitudinal programs.

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Basic Outline

• Brief review of recent historical data.
• A more in depth review of several more
  substantial programs.
• What we are doing at UCHSC?
• Audience Brainstorming.

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Recent Historical Background

• 1993 Bing-You and Tooker
• 20 of IM programs offered teacher training
  program.
• 2000-2001 Morrison
• 1805 ACGME accredited programs in Family Med, IM,
  Peds, Psych, Gen Surg Ob/GYN.
• 50 of these programs offered some formal
  training in teaching skills.

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Did Things Really Change?

• Mean of Training Hours
• 1993 - 9 hours
• 2001 11.5 hours
• These are total hours throughout residency.

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How have they done it?

• Most programs have used a lecture style format.
• Programs have often been given within a one-time
  retreat or workshop teaching residents how to
  teach.
• Other formats small groups, role playing,
  critiqued teaching, longitudinal courses, large
  group teaching and standardized students.

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Advantage of teacher training programs

• Attendings increased time pressures for patient
  care, research and administrative duties have
  left less time to teach.
• Med student surveys 1/3 of their knowledge comes
  from residents teaching.
• House staff spend more time with students.
• Will enhance residents knowledge base.
• Improves communication skills.
• Enhances self-directed learning skills.

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• LCGME and ACGME
• Multiple studies show that Resident Teaching
  programs improve
• Knowledge
• Communication skills
• Residents self-assessed teaching confidence
• Student evaluations of resident participants

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Do resident teacher training programs make a
difference?

• Most studies show that resident teacher training
  programs
• Result in better student evaluations.
• May improve med student performance on objective
  exams.
• Have multiple positive impacts on residents.
• Can be done in many different formats i.e.,
  varying lengths and modalities.

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Pitfalls in the literature and teaching programs

• Most studies to date are low-powered, single
  institution and lack objective outcomes.
• Outcomes often based on subjective questionnaires
  self assessment.

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Pitfalls in the literature and teaching programs

• Highly variable formats between studies and
  programs make comparisons difficult.
• Many studies are not powered to measure
  significant changes in self-reported or
  learner-evaluated teaching effectiveness.
• Complexity of measuring outcomes rather than
  self assessment we need to measure how students
  and junior housestaff education is enhanced.
• Lack of longitudinal studies many single
  intervention studies have shown that residents
  may lose their teaching skills over time.

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Basic Outline

• Brief review of recent historical data.
• A more in depth review of several more
  substantial programs.
• What we are doing at UCHSC?
• Audience Brainstorming.

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To Teach is to Learn Twice

• Location Case Western Reserve SOM -1998
• Study Type randomized, controlled trial of 43
  pediatric residents.
• Design All residents were given a pre-test on a
  pre-determined topic and then randomly assigned
  to either teach or listen to a 30-minute lecture
  on that topic. 6-8 weeks later they took a
  post-test.
• Outcome Knowledge acquisition was significantly
  greater in the teacher group (p lt.01).

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Preparing 4th Year Med Students to Teach During
Internship

• Location UCSF SOM
• Study Course ratings questionnaire from all
  participants.
• Initially an elective from 2000-2002. Became
  required in 2003.
• Outcomes Students strongly supported the program
  with overall course rating of 4.4 (1-5 scale)
  over 6 years.

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Teaching MS4s

• Design of course four one hour sessions
  presented over 2 afternoons.
• 1.Teaching methods which promote understanding
  and retention in the clinical setting
  repetition, small increments, teachable moments,
  using special techniques.
• 2. Evaluating students fairly and providing
  constructive feedback being specific, timely,
  positive negative.
• 3. Resident Panel address student questions and
  concerns regarding the challenges of teaching as
  an intern.
• 4. Practicing and discussing teaching skills
  demystify the process and decrease anxiety.

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A Prospective Randomized Trial

• Location Southern Illinois SOM and USC 1998.
• Study Type prospective randomized
  trial-residents as teacher program.
• Design 62 surgery residents randomized to
  intervention vs. control. 10.5 hour course given
  over 2 days. 6-7 months after the course a
  5-station OSTE done.

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• Outcomes Infrequent significant differences
  between the two groups.
• Why?
• Long interval between class and OSTE
• No baseline pre-intervention measure done
• Sample size too small
• Too few OSTE stations (5 vs. 8)

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The Effect of a 13-hour Curriculum to Improve
Teaching Skills

• Location UCI SOM 2004
• Study Type Randomized, controlled trial of 62
  PGY2s several residency programs.
• Design 13 hour curriculum, 2x/month for 6
  months. Pre/Post OSTE rated by 50 medical
  students.
• Outcome Intervention group improved score by
  28.5 overall. No change in control group.
• -1 year f/u interview greater enthusiasm,
  comfort and desire to teach-intervention group.

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BEST Curriculum

• Design of Course
• Ten Sessions Intro, Leadership skills, Orienting
  learners, Giving feedback, Teaching procedures,
  Bedside teaching, Work rounds, Teaching charting,
  Giving Lectures
• www.residentteachers.com

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Mt. Sinai School of MedicineRTDP

• Created in 2001.
• 7 hour, multidisciplinary course, taught over one
  full day.
• Design
• Setting goals and expectations ask and tell.
• Teaching theory and technique learning theory,
  barriers and solutions, tips.
• Giving Feedback.
• Multiple discipline specific role play sessions
  to practice learned skills.

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UW IM Program 1989-1995

• Compared 3 years of PGY2/PGY3 evaluations from
  students and interns before and after the
  implementation of three 2 hour teacher training
  sessions into the residency program.
• Evaluations Clinical Teaching Assessment Form
  (CTAF) using a likert scale.
• They included all evaluations.
• Used analysis of variance to account for a
  variety of differences.
• Outcome Mean scores increased each year after
  their intervention (Plt.001).

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Basic Outline

• Brief review of recent historical data.
• A more in depth review of several more
  substantial programs.
• What we are doing at UCHSC?
• Audience Brainstorming.

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How Can We Improve?

• Increase Length of Course.
• Increase interactive components and decrease of
  lectures.
• Increase the time dedicated to teaching teaching
  skills.
• Create a longitudinal program.
• Make teacher training mandatory.
• Make teaching a primary part of residencyi.e.,
  change the culture.

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How Long Does it Take to Change Culture?

• At least one generation of residents
• IM 4 years.
• Should we start sooner? UCSF does it in their
  medical school.

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At CU

• Pilot program this June with our incoming 6 chief
  residents.
• Five to Six 3 hours sessions.
• Continue work on goal setting, giving feedback
  and teaching theory.
• Increase interactive component of the course.
• Increase opportunity for residents to review
  their teaching videotaping, attending reviews.
• Teach them how to be dynamic.

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The Immediate Future

• Add one morning report per month at each site
  dedicated to a topic from our elective. This
  will allow our chief residents to reinforce what
  they have learned and bring it to a majority of
  our residents.

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More Distant Future

• Create a mandatory course for all incoming
  residents?
• Create a teacher training course for our 3rd and
  4th year medical students?

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Questions and Brainstorming