Learning to Teach: Residents as Instructors of Medical Students Systems (PCMH) Patient Community Team Learning to Teach: Residents as Instructors of Medical Students David N. Little MD, Sahmon Fallahian MD, John Chisholm MD, Michelle Dorwart MD, MPH, David Swift MSIII, Charles Hackett MSIII, Martha Seagrave PA-C Department of Family Medicine University of Vermont College of Medicine

Objectives Review the literature on the roles of resident physicians as teachers of medical students Describe our own experiences at a medical school Department of Family Medicine (University of Vermont) which has a closely associated Family Medicine Residency (Fletcher Allen Health Care) Collaborate with attendees to describe the rewards, the pitfalls, and the best practices

Introductions Where are you from? What is your role as it relates to residents functioning as teachers? What is one thing you hope to take away from this session?

What Do We Know? Residents are widely involved in working on teams with third and fourth year medical students Settings include shared care of both hospitalized patients and outpatients Some institutions also involve residents in: Co-teaching elective and required workshops on clinical skills and knowledge Co-leading discussion sessions with Family Medicine Interest Groups Advising senior students preparing for residency applications and interviews Faculty Development activities alongside faculty

Key Features of Effective Faculty Development in Medical Education Use of experiential learning Provision of feedback Effective peer and colleague relationships Utilization of diverse educational methods Based on Steinert Y et.al. A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education; Medical Teacher 28(6): 497-526, 2006 (review of 53 studies)

Review of Resident Teaching Skill Programs Review of 29 studies showed that organized programs to improve resident teaching skills can result in: changes in attitudes, changes in knowledge, changes in behaviors (both self-reported and observed) Relative absence of studies that show changes in organizational practices or improved student outcomes (such as scores on tests of knowledge or skills) Based on Hill AG, Yu T, Barrow M, et.al. A systematic review of resident-as-teacher programmes; Medical Education 43: 1129-1140, 2009

Desirable Attributes of Residents as Teachers of Clerkship Students Demonstrated respect towards patients and families Demonstrated respect towards health care team Maintained patient confidentiality Created a safe environment Showed enthusiasm for teaching Solicited input from team members as appropriate Asked for feedback on his/her performance and ways to improve Provided clear expectations of the student Directly observed student performance Encouraged ownership of patients and families Made teaching relevant to patient care and student’s educational goals Demonstrated how to solve clinical problems Provided timely feedback in an appropriate setting Provided feedback that was constructive and included specific examples Based on Butani L, Paternitit DA, Tancredi DJ, Li ST Attributes of residents as teachers and role models – a mixed methods study of stakeholders Medical Teacher 35:e1052-e1059, 2013.

Evaluation of Resident Teaching by Objective Structured Teaching Examination (OSTE) One small controlled study was designed to test a teacher training program for OB-Gyn residents and utilized resident (self) and student assessments as well as scores on an OSTE to evaluate the effectiveness Conclusions: Student assessments favored positive educational climate, interpersonal connections with residents Resident self-assessments favored innovative teaching techniques like simulations Intervention group outscored the control group on the OSTE (n=20) Based on Keller JM, Blatt B, Plack M, et.al. Using a commercially available web-based evaluation system to enhance residents’ teaching. J Grad Med Educ 4(1): 64-67, 2012

Evaluation of a Three Hour Resident Teaching Skills Workshop Workshop focused on creating a positive learning climate and on providing effective feedback to medical students Randomized 44 residents in internal medicine into 2 groups (with and without the workshop) Assessment was by analysis of student evaluations The intervention group was significantly better in terms of learning climate and feedback skills, but not in terms of overall teaching skills Based on Spickard A, Corbett EC, Schorling JB Improving residents’ teaching skills and attitudes toward teaching. J Gen Intern Med 11(8): 475-80, 1996.

UVM’s Workshop 2012 October 2012 – Four hour workshop with combined emphasis on teaching skills and motivational interviewing 18 Family Medicine Residents trained alongside 25 faculty colleagues Format utilized the “One Minute Preceptor” system and asked participants to participate in an encounter with a standardized patient and a “standardized learner” (resident playing the role of a student) to practice skills in teaching and feedback

Learning Objectives Participants will advance their knowledge of Microskills concepts relevant to office-based clinical teaching Participants will practice skill development in a small group setting with a standardized patient, a “standardized learner”, and a faculty facilitator. The clinical context will involve teaching about motivational interviewing Participants will report back and discuss small group outcomes and tips

Faculty-Student Interaction Goals in Clinical Teaching Learner-centered: meet the learner where they are in professional development Time-limited: we don’t have lots and lots of time Build on successes: point out positive work in learning and suggest the next step Make it fun: appropriate use of humor and stress reduction as long as the patient’s needs are being met

Five-Step Microskills Model Neher JO,Gordon KC,Meyer B, Stevens N “A Five-Step Microskills Model of Clinical Teaching; J Am Board Fam Pract 1992; 5:419-24. Traditional teaching model: all attention is on patient care issues, faculty ask low level questions, faculty give mini-lectures, faculty provide precious little feedback (partly because they did all the talking) Five steps: get a commitment from the learner, probe of supporting evidence, briefly teach general rules, reinforce what is done correctly, correct mistakes

UVM Resident Teaching Activities Participating in elective skills (suturing, casting, injections) workshops with FMIG Precepting students in all 4 years in both outpatient and inpatient settings Mentoring students at our residency application and interviewing dinners Collaborating on scholarly projects and community need projects