Developing a Resident Driven Teaching Elective in a Residency Program Tanner Nissly, DO, Kristen Helvig, MD, Joseph Brocato, PhD, Shailendra Prasad, MD, MPH, Department of Family Medicine and Community Health

Presentation Objectives List reasons for developing a teaching elective State types of “resident-teacher” models Describe development of a resident driven teaching elective Feedback on improving this

Graduate Medical Education at The University of Minnesota 67 accredited & 40 non-accredited training programs 850 residents and fellows

73 fulltime faculty and 994 non salaried community faculty Department of Family Medicine & Community Health University of Minnesota Founded in 1971 over 1,500 residency alumni 73 fulltime faculty and 994 non salaried community faculty 8 Residencies (five TC urban & suburban sites, two rural & small town sites) 175+ Residents 2 fellowships: Sports Medicine and Palliative Care

Broadway (North Memorial) Family Medicine Residency Program Urban FM residency large uninsured/underinsured population Unopposed program 35+ years of teaching family medicine High-volume, high-risk maternity care

ACGME/AOA General Competencies Practice Based Learning and Improvement: “Residents are expected to participate in the education of patients, families, students, residents, and other health professionals” Interpersonal Communications: “Work effectively as a member or leader of a healthcare team or other professional group” Professionalism: “demonstrate accountability to the patients, society, and the profession.”

Why are “Residents as Teachers” Important? Enhanced personal knowledge base of clinical knowledge & skills: increase in board scores (Seely,et. al) Better resident preparation than self-study or lecture attendance (Weiss and Needlman, 1998) Establishing future colleague networks Resident research opportunities Recruitment and retention of housestaff and teaching staff Job satisfaction increase (Morrison, 2005)

What we know about Residents as Teachers Residents have access & acceptability (Pelletier & Belliveau, 1999 Independent reading (6.10) Tutorials (6.10). Resident Teaching (5.74). Seminars (5.31) Ward/service rounds (4.98) Operating room (4.98) Clinics (4.48) Rounds & Didactics (4.33) Attendings (3.80) Nurses (2.60)

What we know about Residents as Teachers ? Residents are a “crucial link” Residents are medical students primary teachers for clinical skills 1/3 of a medical students knowledge attributable to residents 20% of resident’s time in teaching activities a higher percentage than that of any other teaching faculty. 55% of residencies provide some teaching instruction, average of 11 hours/resident during residency (Post, et. al, 2009)

Residents as Teachers (EBM Recommendations) Three hour or longer intervention + periodic reinforcement One minute preceptor model (five microskills) Most effective/least practical: OSTE, pre-post outcome measure of teaching improvement. Second most effective/moderately practical: videotape evaluations and shorter interventions. (Post, et. al, 2009)

Residents as Teachers (EBM Recommendations) Third most effective/highest practicality: third party evaluation (intern and medical student) Nothing mentioned about peer resident review… Unknowns: ideal length of program and necessary skills to become effective clinical teacher. (Post, et. al, 2009)

Barriers Toward Resident Teaching Perceived Lack of Clinical Expertise/ Residents Own Self-Learning Deferred Responsibility Lack of Time Deficient Pedagogical Expertise No Organized Curriculum Internal & External Motivation of the Teacher Educational Philosophies of the Teacher Competition?! Others??

The “Learning Partners” Model (adapted from Crim & Hood) Health care’s movement to more collaborative (and less competitive) models of education, means Residents must play multiple educational roles and have skills as… Facilitators Preceptors Partners in Learning Mentors Learners

Development of a teaching elective at Broadway Family Medicine Identify need for developing teaching skills in a residency program Describe methods/strategies Overview of future direction

Identify Need at Broadway Family Medicine: Residents are teachers: Of students Of each other Of ourselves Future of Family Medicine: Teachers (good and bad) influence direction of students Perception of program by potential future residents Direct application to patient care: We teach patients as well as one another

Methods/Strategies: Who is involved? Group of residents who: Have interest in teaching Have identified a need to improve skills Super enthusiastic about doing lots of extra work!!!!!

Methods/Strategies: Who is not involved? Not for everyone …yet

Methods/Strategies: Evolution Presented here as a linear process… but this is more how it went -

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Methods/Strategies: Step 1: Create Initial Objectives Personal reflection on: My own past teaching experiences Excellent teachers Less than excellent teachers Discussion with faculty well versed in teaching skills ***initial objectives were quite vague***

Methods/Strategies: Step 1: Create Initial Objectives Results: from 1st teaching elective week ever at BFM Improve my own teaching skills for the coming year Learn how to teach in different settings Create a teaching curriculum Prepare a lecture to share findings with other residents and faculty

Methods/Strategies: Step 2: Read Lit searches Google-ing References recommended by faculty mentors Join STFM

Methods/Strategies: Step 2: Read Results: Discovery of existing models MCW UCI Review of available resources (evaluations, curriculum, etc) Clinical Teaching Perception Inventory Guide to Planning and Implementing a Program R.E.D course at Univ of MN AAP curriculum guide STFM! Evidence Reviewed by Dr. Brocato

Methods/Strategies: Step 2: Read Programs have developed curriculum, required for residents Compare/contrast to Resident-driven creation

Established curriculum Pros organized required good support structure already has specific objectives Cons less opportunity for creativity tailoring to specific needs

Resident-created Pros Cons: Built from ground up which gives residents more investment/ownership More easily tailorable Cons: Less organization Less structure

Methods/Strategies: Step 3: Identify specific areas Compiled from reading step

Methods/Strategies: Step 3: Identify specific areas Large group presentation Small group/team/inpatient Outpatient/clinic Microskills Giving feedback Role modeling Orienting a learner Bedside teaching Teaching procedural skills Mini lecture Teaching charting Teaching when time is limited etc

Methods/Strategies: Step 4: Refine Objectives Identify various venues for teaching at BFM and which skill sets can enhance those experiences With better understanding of various areas, it is easier to identify particular areas of interest Goals for skills within context of residency vs. career goals Different residents identified a wide variety of specific interests/needs

Methods/Strategies: Step 5: Apply and Practice Request more time in clinic with medical students Intentionally identify specific areas to focus on with each teaching encounter (clinic, hospital, OB, etc) Do more case presentations Video review

Methods/Strategies: Step 6: Evaluate From UCI: Clinical Teaching Self Perception Inventory From American Academy of Pediatrics: Self evaluation pre/post test Student evaluation of teachers Reflective journaling

Future Direction: Refining the curriculum Add to Moodle Create Interest group Video review/faculty oversight Adjusted clinic time

Future Direction: Sustaining interest Create ‘menu’ of objectives from residents who have taken elective to facilitate designing future electives Expand availability to all residents

Future Direction: Evaluation Tools Further develop/utilize OSTE?

Future Direction: Moving on from basics Teaching difficult students Dealing with language/cultural barriers Curriculum development Logistics for program-wide instruction Using our new skills to evaluate/improve those who teach us

So…where do we meet? https://www.myu.umn.edu/metadot/index.pl?iid=1419415&op=show

How is it going? Successes: Excellent potential for tailoring elective to specific needs/interests Involvement of residents with different areas of interests makes for great collaboration Immediate ability to apply learning: Medical students in clinic Chief of service OB

How is it going? Frustrations: Lack of time Lack of resources Disorganization Based largely on experience of faculty, journal articles, etc. Little evidence. No good standardized method of evaluating experience/achievement of objectives

References and Resources (BEST): Residents’ Teaching Website http://www.residentteachers.com/ Post, Robert E. et. al. (2009). Residents as Teacher Curricula: a Critical Review. Academic Medicine, 84(3), 374-380. Schwenk, T. & Whitman, N (1993). Residents as Teachers: a Guide to Educational Practice.