Resident Teaching Expectations and Medical Student Feedback

Abstract

Objective Much of resident teaching of medical students occurs in an informal manner, with bedside teaching a common focus. Hence, the ability to monitor such teaching is limited. Feedback about how students perceive the teaching is perhaps one way to more effectively monitor and influence resident teaching. Methods A “residents as teachers” program is described that includes specific resident teaching expectations. Students give feedback on whether the residents met these expectations; resident evaluations are reviewed by the Director of Medical Student Education and utilized by the Residency Training Director in the semi-annual resident reviews. Results Over the last two years, student satisfaction regarding teaching from residents during the psychiatry clerkship has greatly improved. Discussion Through providing specific resident teaching expectations, and with mechanisms in place to monitor teaching efforts, including the use of regular feedback to residents, student satisfaction with resident teaching can improve. Preparing residents as educators of medical students is required by the Liaison Committee on Medical Education. (1) Additionally, residency requirements also mandate that residents be prepared for their roles as educators. (2) Teaching activities may consume about 20% of their time in any given day. (3) One study found that medical students estimated that about 30% of their knowledge could be directly attributed to resident teaching. (4) Additionally, residents feel that through teaching students, they also learn more, especially about the assigned teaching topics. (5) However, a wide variation of training for these roles exists, from “residents as teachers” programs during internship orientation to month long electives. (6) Little is written in the literature about consistently incorporating teaching feedback by the medical students, and on developing programs to improve individual teaching abilities. Morrison et al, found in a 2001 survey that only about 55% of residency programs offered formal training in teaching skills, most often in internal medicine and pediatrics programs. (7) Perhaps, this explains why internal medicine and pediatrics clerkships had the lowest rates of dissatisfaction regarding resident teaching in the American Association of Medical Colleges (AAMC) annual graduation questionnaire (GQ). (8) The AAMC GQ reinforces that residents do not always provide the most effective teaching, with ranges from 10.1% for no opinion/disagree/strongly disagree in the internal medicine national average to a high of 31.9% in the obstetrics and gynecology national average concerning the statement “Residents and fellows provided effective teaching during the clerkship.” Psychiatry also showed that 26.7% of students nationally were not satisfied with resident teaching during the clerkship. (8) Despite these numbers, residents are often identified by medical students as being the most influential teachers. (9) Additionally, residents serve as role models for students, especially in modeling values and professionalism. (10) Given the importance of resident teaching, there are surprisingly few papers that evaluate the outcomes of these programs. Wamsley et al. in a 2004 literature review found only 14 outcome evaluations of residents as teachers programs, with the following findings: that these courses improved residents’ self assessed behaviors and teaching confidence and resulted in higher learner evaluation of residents. (11) A 2005 randomized controlled study by Morrison et al, examined differences in objective structured teaching examinations (OSTE’s) pre/post a teaching curriculum vs. a control group who did not participate in the curriculum, and found that those residents completing the 13 hours of teacher training had greater enthusiasm for teaching, utilized more learner-centered approaches to teaching and had a richer understanding of clinical teaching principles and skills. (12) A 2008 Canadian study of pediatric training programs found that training directors generally felt that residents needed more training in providing feedback; while residents wanted more guidance in bedside teaching. They also found that residents were generally uncertain of expectations and assessment methods. (13) In recent years, attention has focused on the concepts of the formal, informal and hidden curriculum in medical education, especially as it relates to professionalism and ethics. Hafferty defines the formal curriculum as “the stated, intended and formally offered and endorsed curriculum”; the informal curriculum as the “unscripted, predominantly ad hoc and highly interpersonal form of teaching and learning that takes place among and between faculty and students”; and the hidden curriculum as “a set of influences that function at the level of organizational structure and culture”. (14) As noted by Ozolins, there is little attention to the informal learning that occurs with students and how that may help them address the formal curriculum. (15) Several authors have noted that inconsistencies exist between aspects of the formal curriculum and the actual clinical experiences of students. (16, 17, 18) Only one study has examined this concept in a psychiatry clerkship. (19) Wear conducted focus groups of students, residents and attendings, finding themes that emerged around role modeling, time (with the theme that there was often not enough time for either teaching or patient care), and the curriculum as based more on experience and intuition vs. textbook learning. (19) Most interestingly, residents and students cited both positive and negative examples in each of these themes, whereas faculty primarily gave positive examples. This is similar to the findings by Adler, in which the study found that faculty may be unaware of how their curriculum is experienced by students. (20) After instituting a position of Education Chief Resident for Medical Student Education in 2007, as well as the Director of Medical Student Education (DMSE) meeting individually with students for a mid-clerkship session, it was apparent that discrepancies existed in our program between the formal curriculum and the informal and hidden curriculum. To address this issue, the “resident as teachers” program was expanded to include mechanisms to communicate more clearly to residents the teaching expectations as well as addressing with the residents the issues of the hidden and informal curriculum, utilizing feedback from the students.