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Radiology Resident Teaching Skills Improvement
Radiologic Education
Radiology Resident Teaching Skills Improvement: Impact of a Resident Teacher Training Program Andrea Donovan, MD Rationale and Objectives: Teaching is considered an essential competency for residents to achieve during their training. Instruction in teaching skills may assist radiology residents in becoming more effective teachers and increase their overall satisfaction with teaching. The purposes of this study were to survey radiology residents’ teaching experiences during residency and to assess perceived benefits following participation in a teaching skills development course. Materials and Methods: Study participants were radiology residents with membership in the American Alliance of Academic Chief Residents in Radiology or the Siemens AUR Radiology Resident Academic Development Program who participated in a 1.5-hour workshop on teaching skills development at the 2010 Association of University Radiologists meeting. Participants completed a self-administered, precourse questionnaire that addressed their current teaching strategies, as well as the prevalence and structure of teaching skills training opportunities at their institutions. A second postcourse questionnaire enabled residents to evaluate the seminar and assessed new knowledge and skill acquisition. Results: Seventy-eight residents completed the precourse and postcourse questionnaires. The vast majority of respondents indicated that they taught medical students (72 of 78 [92.3%]). Approximately 20% of residency programs (17 of 78) provided residents with formal didactic programs on teaching skills. Fewer than half (46.8%) of the resident respondents indicated that they received feedback on their teaching from attending physicians (36 of 77), and only 18% (13 of 78) routinely gave feedback to their own learners. All of the course participants agreed or strongly agreed that this workshop was helpful to them as teachers. Conclusions: Few residency programs had instituted resident teacher training curricula. A resident teacher training workshop was perceived as beneficial by the residents, and they reported improvement in their teaching skills. Key Words: Radiology; teaching; curriculum; residency training. ªAUR, 2011
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eaching is considered an essential competency for residents, as well as an accreditation standard by the Accreditation Council for Graduate Medical Education (1,2). Residents participate in the teaching of medical students and other residents and spend up to one quarter of their work hours teaching, evaluating, or supervising trainees (3). Although many residents enjoy teaching and consider it to be an important component of their training (4), many feel inadequately prepared to teach (5). Formal instruction in effective teaching methods is desired by resident trainees (6). The past decade has witnessed an increase in resident-focused workshops geared toward helping residents improve their teaching skills (7–9). In 2001, approximately half of Accreditation Council for Graduate Medical Education– accredited residency programs in family medicine, internal Acad Radiol 2011; 18:518–524 From the Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room AG 278, Toronto, ON M4N 3M5, Canada. Received September 25, 2010; accepted October 12, 2010. This study was supported by the RSNA/AUR/APDR/ SCARD Radiology Education Research Development Grant. Address correspondence to: A.D. e-mail: [email protected] ªAUR, 2011 doi:10.1016/j.acra.2010.10.021
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medicine, pediatrics, psychiatry, general surgery, and obstetrics and gynecology had established programs for residents to improve their teaching skills (8). A recent survey of radiology residency programs indicated that fewer than one third of programs offered training programs to enhance the teaching skills of residents (10). These programs may be challenging to incorporate into residency training for several reasons, including time pressures and a lack of faculty training in medical education (10,11). One solution may be to centralize teacher training opportunities by offering workshops at annual radiology meetings with high resident attendance (10,11). Competence in teaching is important in radiology given how common learner-teacher interactions are in daily practice (12,13). Instruction in teaching skills may assist radiology residents not only to become more effective teachers, but also to increase their overall satisfaction with teaching and potentially increase retention in academic teaching centers (8,9,14).
MATERIALS AND METHODS I designed and delivered a 90-minute workshop for residents on teaching skills. The course was held at the 2010 Association of University Radiologists meeting and was cosponsored by
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the American Alliance of Academic Chief Residents in Radiology (A3CR2), the Siemens AUR Radiology Resident Academic Development Program (SARRAD), the Association of Program Directors in Radiology, and the Alliance of Medical Student Educators in Radiology. Participant objectives for the workshop were: (1) to discuss the five principles of effective teaching; (2) to apply these principles to one-onone, small-group, and large-group teaching; and (3) to reflect on one’s own teaching. Following extensive review of the medical education literature, a questionnaire was designed and piloted for clarity. The questionnaire was divided into two parts, a preworkshop survey and a postworkshop survey. These were administered at the beginning and at the end of the workshop, respectively. In this study, a ‘‘resident teacher training program’’ was defined as a workshop or course within the radiology residency program that provided opportunities for residents to enhance their teaching skills. Institutional review board approval was granted for this Health Insurance Portability and Accountability Act–compliant study. The precourse survey consisted of two components. The first component included a survey of basic demographic information of residents, including gender, year of training and program setting (academic or private practice), and whether the resident had previously participated in a teacher training workshop outside of his or her institution. Specific information pertaining to the residency program was also collected, including the presence, duration, and format of any resident teacher training program in existence at the resident’s institution and resident teaching opportunities. The second component of the precourse survey included a self-administered questionnaire of the resident’s teaching skills. This survey was adapted from the Stanford Faculty Development Program questionnaire (15), a validated 26-point evaluation of specific effective teaching behaviors. The residents ranked 13 statements pertaining to teaching skills using a five-point, Likert-type scale (1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neutral,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree’’). The scores from all residents were averaged to produce a mean score for each of the 13 statements. The postcourse survey evaluated perceived effectiveness of the 90-minute course. Residents rated 12 statements using a five-point, Likert-type scale. The survey assessed whether the course was useful and whether it might help improve various aspects of their future teaching. Statistical analysis was performed using SAS version 8.2 (SAS Institute Inc, Cary, NC). Chi-square and Fisher’s exact tests were used for analysis of categorical data. P values < .05 were considered statistically significant for all analyses. RESULTS Demographics
Seventy-eight residents in the A3CR2 or SARRAD who attended the workshop completed the precourse and postcourse surveys. The exact number of attendants is not known.
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TABLE 1. Radiology Resident and Residency Program Demographics Characteristic Resident gender Male Female Year of residency training 1 2 3 4 Residency program setting Academic Private practice Resident teacher training program in radiology program Format of resident teacher training program if available Workshop Lecture
n (%) 58 (74.4%) 20 (25.6%) 2 (2.6%) 32 (41.0%) 42 (53.8%) 2 (2.6%) 65 (88.2%) 9 (11.8%) 17 (21.8%)
11 (64.7%) 6 (35.3%)
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions.
However, there were approximately 60 residents registered to attend the A3CR2 program and 22 residents registered for SAARAD. Respondent demographics are presented in Table 1. Fifty-eight of 78 residents (74.4%) were men, and 20 were women (25.6%). Most respondents were in the second year (32 of 78 [41.0%]) or the third year (42 of 78 [53.8%]) of radiology residency training (Table 1). Academic, rather than private practice, was the most common residency training setting (65 of 78 [88.2%]). Teaching Skills Training for Residents
A minority of surveyed residents indicated that their residency programs provided teaching skills training for residents. Seventeen of 78 (21.8%) stated that residents received instruction on teaching skills (Table 1). The most common format was a one-time workshop on teaching skills (11 of 17 [64.7%]), followed by a lecture on teaching skills (6 of 17 [35.3%]) (Table 1). One respondent indicated that the department of medicine offered a resident teacher training workshop to which residents across all specialties could apply but that is not mandatory for radiology residents. Radiology Resident Teaching Experiences
Thirteen of 78 respondents (16.7%) indicated that they had attended workshops on teaching skills outside of their own radiology residency programs (Table 2). Seven of those 13 respondents (53.8%) also had resident teacher training programs at their own institutions. The vast majority of respondents indicated that they taught medical students (72 of 78 [92.3%]). Most respondents taught their resident colleagues at case conferences (49 of 76 [64.5%]) and 519
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TABLE 2. Radiology Resident Teaching Experience Resident Teaching Activity Attended a workshop outside own radiology program on teaching Deliver case conferences Teach medical students Present at multidisciplinary conferences Present at grand rounds Feedback on resident-led teaching From faculty members From peers From both faculty members and peers No feedback Resident assigned a mentor to help with teaching preparation Residents feel their teaching is valued by the department Would like more training on teaching skills at their own institutions
n (%) 13 (16.6%) 49 (64.5%) 72 (92.3%) 45 (57.7%) 17 (21.8%) 10 (12.0%) 5 (6.5%) 21 (27.3%) 41 (53.2%) 12 (15.4%) 56 (73.7%) 66 (86.9%)
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions.
presented at multidisciplinary rounds (45 of 78 [57.7%]). Presentation at grand rounds by residents was less common. Seventeen of 78 respondents (21.8%) indicated that they were required to present at grand rounds in their residency programs (Table 2). Fewer than half of the respondents indicated that they received feedback on any aspect of their teaching (36 of 77 [46.8%]). Of those respondents who received feedback, the most common source of feedback was from both peers and faculty members (21 of 77 [27.3%]), followed by feedback from peers only (10 of 77 [13.0%]) and from faculty members only (five of 77 [6.5%]). Twelve of 78 respondents (15.4%) indicated that there were methods in place at their institutions to assign residents to mentors who could provide guidance with teaching activities, including preparation for grand rounds (Table 2). The majority of the respondents felt that their departments valued resident teaching efforts (56 of 76 [73.7%]). Sixty-six of 78 respondents (86.8%) indicated that they would like more training on teaching skills at their own institutions (Table 2). Resident Self-assessment of Teaching Effectiveness
A five-point, Likert-type scale was used to provide course participants with an opportunity to self-assess their current teaching prior to the workshop. The questionnaire was administered at the beginning of the workshop and consisted of 13 statements (Table 3). This survey was adapted from the Stanford Faculty Development Program questionnaire, a validated 26-item evaluation of specific effective teaching behaviors (15). Regarding the establishment of a positive learning climate, the majority of residents agreed or strongly agreed that they showed respect for learners in their teaching (78 of 78 [100.0%]), showed enthusiasm (74 of 78 [82.0%]), and encouraged learners to participate in discussion (61 of 78 520
[78.2%]). Fewer respondents indicated that they encouraged learners to bring up problems (46 of 78 [59.0%]). Regarding communication of goals, fewer than half of the respondents indicated that they regularly communicated goals at the beginning of the session (33 of 77 [42.9%]), and just over half stated the relevance of goals to learners (41 of 76 [54.0%]). Regarding the promotion of understanding and retention 49 of 78 (62.5%) of respondents related current information to learners’ previous knowledge when they teach. Most respondents indicated that they do explain to their learners why they are correct or incorrect after they ask them questions (59 of 78 [75.6%]). With respect to the use of evaluation in their teaching, approximately one third of residents evaluated their learners. Twenty-seven of 77 respondents (35.1%) stated that they evaluated learners’ knowledge of factual medical information, and 30 of 77 (39.0%) stated that they evaluated learners’ ability to apply medical knowledge to specific patients. Residents rarely gave feedback when they taught others. Thirteen of 74 respondents (17.5%) asked learners to self-assess their knowledge and skills. Twenty-two of 74 respondents (29.7%) offered learners suggestions for improvement. Finally, a minority of respondents indicated that they motivated learners to learn on their own (32 of 77 [41.6%]). Impact of the Resident Teaching Skills Training Workshop on Improvement of Teaching Skills
A postcourse self-administered questionnaire with a fivepoint, Likert-type scale was used to assess the impact of the teaching skills development course on improvement of teaching skills. The questionnaire was administered immediately following the completion of the workshop and consisted of 12 statements (Table 4). The majority of respondents agreed or strongly agreed that this course was effective in improving their teaching skills (Table 4). Course Evaluation
A five-point, Likert-type scale was used to assess participants’ perceptions of the course quality and obtain suggestions for future course format (Table 5). The majority of respondents agreed or strongly agreed that this course was well planned (75 of 78 [96.1%]) and helpful to them as teachers (78 of 78 [100.0%]). The majority of residents felt that this type of workshop would be helpful to incorporate early in the residency program (74 of 78 [94.9%]) (Table 5). Factors Associated with Self-reported Precourse Teaching Effectiveness Scores
Survey statement score averages were grouped into six categories of teaching behavior (learning climate, communication of goals, promoting understanding and retention, evaluation, feedback, and promoting self-directed learning). An analysis was performed to determine if there was a difference in self-
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TABLE 3. Residents’ Perceptions of Their Own Teaching Skills Prior to the Workshop
Survey Statement In my teaching interactions, I. Learning climate Show enthusiasm Encourage learners to participate in discussion Encourage learners to bring up problems Show respect for learners Communication of goals State goals clearly at the beginning of the session State relevance of goals to learners Promoting understanding and retention Relate current information to previous knowledge Explain to learners why they are correct or incorrect after I ask them a question Evaluation Evaluate learners’ knowledge of factual medical information Evaluate learners’ ability to apply medical knowledge Feedback Ask learners to self-assess their knowledge and skills Offer learners suggestions for improvement Promote self-directed learning Motivate learners to learn on their own
Strongly Disagree
Strongly Agree
Mean Score*
21 (26.9%) 22 (28.2%) 17 (21.8%) 54 (69.2%)
4.1 4.0 3.7 4.7
5 (6.5%) 12 (15.6%) 27 (35.1%) 25 (32.5%) 8 (10.4%) 3 (3.9%) 7 (9.2%) 25 (32.9%) 30 (39.5%) 11 (14.5%)
3.2 3.5
0 (0%) 1 (1.3%)
3.7 4.0
0 (0%) 0 (0%) 0 (0%) 0 (0%)
Disagree
Neutral
Agree
1 (1.3%) 13 (16.7%) 43 (55.1%) 4 (5.1%) 13 (16.7%) 39 (50.0%) 9 (11.5%) 23 (29.5%) 29 (37.2%) 0 (0%) 0 (0%) 24 (30.9%)
2 (2.6%) 0 (0%)
27 (34.6%) 41 (52.6%) 8 (10.2%) 18 (23.1%) 36 (46.1%) 23 (29.5%)
1 (1.3%) 11 (14.3%) 38 (49.3%) 20 (26.0%) 2 (2.6%) 8 (10.4%) 37 (48.0%) 24 (31.2%)
7 (9.1%) 6 (7.8%)
3.3 3.1
7 (9.5%) 29 (39.2%) 25 (33.8%) 12 (16.2%) 4 (5.4%) 14 (18.9%) 34 (46.0%) 18 (24.3%)
1 (1.3%) 4 (5.4%)
2.6 3.1
3 (3.9%) 12 (15.6%) 30 (39.0%) 25 (32.5%)
7 (9.1%)
3.3
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions. *Responses were made on a five-point, Likert-type scale (1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neutral,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree’’). TABLE 4. Residents’ Perceptions of How the Workshop May Affect Their Future Teaching Strongly Disagree Disagree
Survey Statement Following the course. My understanding of adult teaching principles has increased I am more aware of my own strengths and weaknesses as a teacher I believe that my enjoyment with teaching will increase I feel more confident that I will be able to teach in different settings I will be more likely to assess learner’s prior knowledge I understand better how to make my teaching relevant to the learner I will use one-minute preceptor in my future teaching I feel more comfortable to give feedback I feel more confident to give a large group session I appreciate the importance of a positive learning climate I will seek to continually improve my teaching skills I feel more confident in my role as a teacher
0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Neutral
0 (0%) 0 (0%) 0 (0%) 8 (10.3%) 0 (0%) 11 (14.1%) 0 (0%) 6 (7.8%) 1 (1.3%) 7 (9.2%) 0 (0%) 2 (2.6%) 0 (0%) 6 (7.7%) 0 (0%) 9 (11.5%) 0 (0%) 15 (19.2%) 0 (0%) 1 (1.3%) 0 (0%) 1 (1.3%) 0 (0%) 8 (10.2%)
Agree
Strongly Agree
Mean Score*
36 (46.2%) 34 (43.6%) 36 (46.2%) 40 (51.9%) 37 (48.7%) 36 (46.1%) 37 (47.4%) 40 (51.3%) 37 (47.4%) 30 (38.5%) 30 (38.5%) 40 (51.3%)
42 (53.8%) 36 (46.2%) 31 (39.7%) 31 (40.3%) 31 (40.8%) 40 (51.3%) 35 (44.9%) 29 (37.2%) 26 (33.3%) 47 (60.2%) 47 (60.2%) 30 (38.5%)
4.5 4.3 4.3 4.3 4.3 4.5 4.4 4.3 4.1 4.6 4.6 4.3
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions. *Responses were made on a five-point, Likert-type scale (1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neutral,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree’’).
reported teaching effectiveness scores within those six categories among residents with and without prior resident teacher training. Residents with prior resident teacher training (either in their own residency programs or at workshops outside their own programs) were significantly more likely to evaluate their learners (P = .041). There was no difference among the two groups of residents for the remaining five categories of teaching behaviors.
There was no significant difference in survey statement score averages and the number of years of residency training or the practice setting (academic vs private). DISCUSSION The goal of residency training is to help resident trainees achieve the key competencies needed to independently practice 521
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TABLE 5. Course Evaluation by the Residents
Survey Statement It would be helpful to incorporate a workshop like this early in the residency training program The workshop was well planned The duration of individual topics was appropriate The following topics should be included in the next workshop: Principles of teaching One minute preceptor Case conference Large group teaching Overall, this workshop was helpful for me as a teacher
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Mean Score*
1 (1.3%)
0 (0%)
3 (3.8%)
25 (32.1%)
49 (62.8%)
4.6
0 (0%) 0 (0%)
0 (0%) 1 (1.3%)
3 (3.9%) 4 (5.1%)
26 (33.3%) 35 (44.9%)
49 (62.8%) 38 (48.7%)
4.6 4.4
0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
2 (2.6%) 3 (3.8%) 2 (2.6%) 7 (9.0%) 0 (0%)
32 (42.1%) 23 (29.5%) 27 (34.6%) 26 (33.3%) 33 (42.3%)
42 (55.3%) 52 (66.7%) 49 (62.8%) 49 (57.7%) 45 (57.7%)
4.5 4.6 4.6 4.3 4.6
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions. *Responses were made on a five-point, Likert-type scale (1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neutral,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree’’).
medicine. In addition to clinical competence and skills to conduct research (16), many accrediting bodies now mandate that residents achieve key competencies as teachers (1,2,17,18). These competencies include the demonstration of effective teaching skills when teaching medical students, peers, other health professionals, and patients, as well as the ability to self-evaluate teaching effectiveness. In a previous study, radiology program directors agreed that it is important for residents to participate in a teaching role and that these teaching experiences help residents to become better radiologists (10). Resident trainees frequently teach medical students and other residents (3). At some institutions, resident teachers provide up to 70% of the clinical teaching received by medical students (7). In the present study, the vast majority of residents indicated that they taught medical students as well as other radiology residents. Both the learner and the resident benefit from resident-led teaching (19). Residents are often able to relate well to their learners and provide teaching in a safe, nonthreatening environment (20). The benefit for the resident providing the teaching is an increase in medical knowledge and clinical competence (21). Although residents are frequent participants in teaching encounters, many consider their teaching skills to be inadequate (22). Observational studies of teaching skills among internal medicine residents suggested that many residents teach ineffectively (23). For example, it is uncommon for residents to ask questions or to give feedback to learners (24). Residents in this study indicated that they rarely evaluated their learners or provided regular feedback. Furthermore, residents do not teach problem-solving skills or address psychosocial topics as often as attending physicians (25). Among the surveyed residents in this study, only one third of residents stated that they evaluated learners’ ability to apply medical knowledge. Interestingly, surveyed residents with prior resident teacher training were more likely to evaluate their learners. The majority of residents in this survey expressed a need for resident teacher training during residency and felt that this training should be started early in residency. Similarly, most program directors in radiology believe that their residents 522
would benefit from additional training in teaching skills development (10). Currently, approximately one third or radiology residency programs have established resident teacher training courses (10). This study identifies a need for teacher training for residents. There are several barriers to integrating a resident teacher training workshop into the radiology residency curriculum. The most notable are time constraints imposed by the clinical and research duties of faculty members, and a lack of trained medical educators in radiology. Inadequate recognition of faculty members who might ultimately lead such courses is another barrier that needs to be overcome (26). Institutions seeking to develop a resident teacher training course might consider initially implementing a faculty teacher development course. Thereafter, radiology faculty could be identified to lead a resident teacher training course. Other potential solutions to overcoming barriers to implementing resident teacher training courses within residency programs include establishment of teaching skills workshops led by experienced medical educators from other institutions (11). Previous studies have suggested that both short courses and longer electives improve resident teaching skills and satisfaction with teaching and teaching self-confidence and resulted in higher in learner evaluation of residents (8,9,27). Furthermore, residents who completed resident teacher training were more likely to want to continue teaching during and after residency training (19). Improvement in resident teaching skills may also lead to better doctor-patient communication (28), enhanced patient satisfaction, and possibly improved clinical outcomes (11,29). The majority of residents in this study agreed that the workshop helped them increase their understanding of adult teaching principles and that they will be more likely to give feedback and assess learners’ prior knowledge following the workshop. They felt that as a result of the workshop, their enjoyment of teaching would increase, they would feel more confident in their role as teachers, and they would seek to continually improve their own teaching skills. Overall, the participants felt that the workshop was helpful to them as teachers.
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Other potential means to promote resident teaching skill development are to establish collaboration between radiologists and medical educators at one’s institution (30) and to develop and disseminate a sample teaching curriculum to radiology program directors, as not all may be familiar with the opportunities that exist for resident teacher training (10). This curriculum would be designed with the primary goal of helping residents achieve key competencies as teachers. The secondary goal would be to introduce residents to the opportunities within academic radiology as clinicianeducators and to promote educational scholarship (11). Teaching has been cited by many as one of the top reasons that radiologists, among other physicians choose an academic career (19,31,32) (J. Collins, presented at the 2009 annual meeting of the Association of University Radiologists). There were several limitations to this study. First, a potential response bias exists from radiology residents in SARRAD and A3CR2 programs. These residents may be interested in resident-led teaching and may have overestimated the importance placed on the role of resident teaching during radiology residency training. Their teaching experiences may be broader compared with those of residents who did not participate in the programs. It is presumed that in survey responses, these residents represent their entire residency program. However, the results may not be generalizable to the greater population of radiology residents. The proportion of respondents in this survey who identified themselves as training practicing in an academic setting (88%) parallels the current proportion of academic programs in the entire Association of Program Directors in Radiology (84%). Second, this study did not evaluate the full extent of experience these residents have as teachers, although it did control for level of residency training. Furthermore, it is not known whether there are faculty mentors trained in medical education who help residents develop teaching skills outside of formal workshops or assigned mentorship. There are many methods to improve one’s teaching skills, and this study was not designed to capture the full spectrum of opportunities to improve teaching skills during residency training. Third, the course evaluation consisted of a resident satisfaction survey with the course, rather than evaluation of residents’ teaching effectiveness. Most resident teacher training workshop evaluations are conducted in the same manner (8). There are, however, a few studies that used standardized students in an objective structured teaching evaluation to evaluate outcomes (9,33,34). These require significant resources, including faculty members trained in medical education to evaluate the residents. It would be important to measure resident teacher training workshop effectiveness in the future on the students these residents teach. CONCLUSIONS Residents have an important role as teachers. Few residency programs had instituted resident teaching skills training curriculum. The resident teaching skills training workshop
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at the Association of University Radiologists meeting was rated highly and perceived as beneficial by the residents to improve teaching skills. Further studies are needed to evaluate which components of the workshop are most beneficial to the residents and to those they teach. ACKNOWLEDGMENT I would like to thank Marko Katic, biostatistician with the Institute for Clinical Evaluative Sciences, Toronto, for assistance with data analysis. REFERENCES 1. Accreditation Council for Graduate Medical Education. ACGME competencies introduction. Available at: http://www.acgme.org/acWebsite/ navPages/nav_commonpr.asp. Accessed November 17, 2009. 2. Royal College of Physicians and Surgeons of Canada. The CanMEDS 2005 physician competency framework. Available at: http://rcpsc.medical.org/ canmeds/index.php. Accessed November 17, 2008. 3. Seely A. The teaching contributions of residents. Can Med Assoc J 1999; 161:1239–1241. 4. Bing-You RG, Harvey BJ. Factors related to residents desire and ability to teach in the clinical setting. Teach Learn Med 1991; 3:95–100. 5. Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001; 76:390–393. 6. Morrison EH, Hollingshead J, Hubbell FA, et al. Reach out and teach someone: generalist residents’ needs for teaching skills development. Fam Med 2002; 34:445–450. 7. Bing-You RG, Tooker J. Teaching skills improvement programmes in US internal medicine residencies. Med Educ 1993; 27:259–265. 8. Morrison EH, Friedland JA, Boker J, et al. Residents-as-teachers training in U.S. residency programs and offices of graduate medical education. Acad Med 2001; 76(suppl):S1–S4. 9. Morrison EH, Rucker L, Boker JR, et al. The effect of a 13-hour curriculum to improve residents’ teaching skills: a randomized trial. Ann Intern Med 2004; 141:257–263. 10. Donovan A. Radiology residents as teachers: current status of teaching skills training in United States residency programs. Acad Radiol 2010; 17:928–933. 11. Gunderman RB, Kang YP, Fraley RE, et al. Teaching the teachers. Radiology 2002; 222:599–603. 12. Collins J, Hyde C, Gray L, et al. Radiology resident evaluation: a form that addresses the six competencies of the accreditation council for graduate medical education. Acad Radiol 2002; 9:815–816. 13. Mainiero MB, Collins J, Primack SL. Effectiveness of resident-prepared conferences in teaching imaging utilization guidelines to radiology residents. Acad Radiol 1999; 6:748–751. 14. Busari JO, Scherpbier AJ, van der Vleuten CP, et al. The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students. Med Educ 2003; 37:241–247. 15. Litzelman DK, Stratos GA, Marriott DJ, et al. Factorial validation of a widely disseminated educational framework for evaluating clinical teachers. Acad Med 1998; 73:688–695. 16. Hillman BJ, Gay SB. Research residents’ choices of academic radiology careers. J Am Coll Radiol 2005; 2:1030–1032. 17. Roberts CC, Chew FS. Teaching radiology residents, and radiology residents as teachers. Acad Radiol 2003; 10(suppl):S97–S101. 18. Halsted MJ, Perry L, Racadio JM, et al. Changing radiology resident education to meet today’s and tomorrow’s needs. J Am Coll Radiol 2004; 1:671–678. 19. Morrison EH, Shapiro JF, Harthill M. Resident doctors’ understanding of their roles as clinical teachers. Med Educ 2005; 39:137–144. 20. Bulte C, Betts A, Garner K, et al. Student teaching: views of student nearpeer teachers and learners. Med Teach 2007; 29:583–590. 21. Busari JO, Scherpbier AJ. Why residents should teach: a literature review. J Postgrad Med 2004; 50:205–210. 22. Neacy K, Stern SA, Kim HM, et al. Resident perception of academic skills training and impact on academic career choice. Acad Emerg Med 2000; 7: 1408–1415.
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29. Cegala DJ, Lenzmeier Broz S. Physician communication skills training: a review of theoretical backgrounds, objectives and skills. Med Educ 2002; 36:1004–1016. 30. Mann KV, Sutton E, Frank B. Twelve tips for preparing residents as teachers. Med Teach 2007; 29:301–306. 31. Donovan A, Donovan J. Mentorship in postgraduate training programmes: views of Canadian programme directors. Med Educ 2009; 43:155–158. 32. Donovan A, Donovan J. Mentorship in medicine: potential implications beyond the mentee-mentor relationship. Med Teach 2009; 31:874. 33. Wamsley MA, Julian KA, Wipf JE. A literature review of ‘‘residentas-teacher’’ curricula: do teaching courses make a difference? J Gen Intern Med 2004; 19:574–581. 34. Gaba ND, Blatt B, Macri CJ, et al. Improving teaching skills in obstetrics and gynecology residents: evaluation of a residents-as-teachers program. Am J Obstet Gynecol 2007; 196:87.e1–87.e7.
Radiology Resident Teaching Skills Improvement: Impact of a Resident Teacher Training Program Andrea Donovan, MD Rationale and Objectives: Teaching is considered an essential competency for residents to achieve during their training. Instruction in teaching skills may assist radiology residents in becoming more effective teachers and increase their overall satisfaction with teaching. The purposes of this study were to survey radiology residents’ teaching experiences during residency and to assess perceived benefits following participation in a teaching skills development course. Materials and Methods: Study participants were radiology residents with membership in the American Alliance of Academic Chief Residents in Radiology or the Siemens AUR Radiology Resident Academic Development Program who participated in a 1.5-hour workshop on teaching skills development at the 2010 Association of University Radiologists meeting. Participants completed a self-administered, precourse questionnaire that addressed their current teaching strategies, as well as the prevalence and structure of teaching skills training opportunities at their institutions. A second postcourse questionnaire enabled residents to evaluate the seminar and assessed new knowledge and skill acquisition. Results: Seventy-eight residents completed the precourse and postcourse questionnaires. The vast majority of respondents indicated that they taught medical students (72 of 78 [92.3%]). Approximately 20% of residency programs (17 of 78) provided residents with formal didactic programs on teaching skills. Fewer than half (46.8%) of the resident respondents indicated that they received feedback on their teaching from attending physicians (36 of 77), and only 18% (13 of 78) routinely gave feedback to their own learners. All of the course participants agreed or strongly agreed that this workshop was helpful to them as teachers. Conclusions: Few residency programs had instituted resident teacher training curricula. A resident teacher training workshop was perceived as beneficial by the residents, and they reported improvement in their teaching skills. Key Words: Radiology; teaching; curriculum; residency training. ªAUR, 2011
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eaching is considered an essential competency for residents, as well as an accreditation standard by the Accreditation Council for Graduate Medical Education (1,2). Residents participate in the teaching of medical students and other residents and spend up to one quarter of their work hours teaching, evaluating, or supervising trainees (3). Although many residents enjoy teaching and consider it to be an important component of their training (4), many feel inadequately prepared to teach (5). Formal instruction in effective teaching methods is desired by resident trainees (6). The past decade has witnessed an increase in resident-focused workshops geared toward helping residents improve their teaching skills (7–9). In 2001, approximately half of Accreditation Council for Graduate Medical Education– accredited residency programs in family medicine, internal Acad Radiol 2011; 18:518–524 From the Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room AG 278, Toronto, ON M4N 3M5, Canada. Received September 25, 2010; accepted October 12, 2010. This study was supported by the RSNA/AUR/APDR/ SCARD Radiology Education Research Development Grant. Address correspondence to: A.D. e-mail: [email protected] ªAUR, 2011 doi:10.1016/j.acra.2010.10.021
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medicine, pediatrics, psychiatry, general surgery, and obstetrics and gynecology had established programs for residents to improve their teaching skills (8). A recent survey of radiology residency programs indicated that fewer than one third of programs offered training programs to enhance the teaching skills of residents (10). These programs may be challenging to incorporate into residency training for several reasons, including time pressures and a lack of faculty training in medical education (10,11). One solution may be to centralize teacher training opportunities by offering workshops at annual radiology meetings with high resident attendance (10,11). Competence in teaching is important in radiology given how common learner-teacher interactions are in daily practice (12,13). Instruction in teaching skills may assist radiology residents not only to become more effective teachers, but also to increase their overall satisfaction with teaching and potentially increase retention in academic teaching centers (8,9,14).
MATERIALS AND METHODS I designed and delivered a 90-minute workshop for residents on teaching skills. The course was held at the 2010 Association of University Radiologists meeting and was cosponsored by
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the American Alliance of Academic Chief Residents in Radiology (A3CR2), the Siemens AUR Radiology Resident Academic Development Program (SARRAD), the Association of Program Directors in Radiology, and the Alliance of Medical Student Educators in Radiology. Participant objectives for the workshop were: (1) to discuss the five principles of effective teaching; (2) to apply these principles to one-onone, small-group, and large-group teaching; and (3) to reflect on one’s own teaching. Following extensive review of the medical education literature, a questionnaire was designed and piloted for clarity. The questionnaire was divided into two parts, a preworkshop survey and a postworkshop survey. These were administered at the beginning and at the end of the workshop, respectively. In this study, a ‘‘resident teacher training program’’ was defined as a workshop or course within the radiology residency program that provided opportunities for residents to enhance their teaching skills. Institutional review board approval was granted for this Health Insurance Portability and Accountability Act–compliant study. The precourse survey consisted of two components. The first component included a survey of basic demographic information of residents, including gender, year of training and program setting (academic or private practice), and whether the resident had previously participated in a teacher training workshop outside of his or her institution. Specific information pertaining to the residency program was also collected, including the presence, duration, and format of any resident teacher training program in existence at the resident’s institution and resident teaching opportunities. The second component of the precourse survey included a self-administered questionnaire of the resident’s teaching skills. This survey was adapted from the Stanford Faculty Development Program questionnaire (15), a validated 26-point evaluation of specific effective teaching behaviors. The residents ranked 13 statements pertaining to teaching skills using a five-point, Likert-type scale (1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neutral,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree’’). The scores from all residents were averaged to produce a mean score for each of the 13 statements. The postcourse survey evaluated perceived effectiveness of the 90-minute course. Residents rated 12 statements using a five-point, Likert-type scale. The survey assessed whether the course was useful and whether it might help improve various aspects of their future teaching. Statistical analysis was performed using SAS version 8.2 (SAS Institute Inc, Cary, NC). Chi-square and Fisher’s exact tests were used for analysis of categorical data. P values < .05 were considered statistically significant for all analyses. RESULTS Demographics
Seventy-eight residents in the A3CR2 or SARRAD who attended the workshop completed the precourse and postcourse surveys. The exact number of attendants is not known.
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TABLE 1. Radiology Resident and Residency Program Demographics Characteristic Resident gender Male Female Year of residency training 1 2 3 4 Residency program setting Academic Private practice Resident teacher training program in radiology program Format of resident teacher training program if available Workshop Lecture
n (%) 58 (74.4%) 20 (25.6%) 2 (2.6%) 32 (41.0%) 42 (53.8%) 2 (2.6%) 65 (88.2%) 9 (11.8%) 17 (21.8%)
11 (64.7%) 6 (35.3%)
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions.
However, there were approximately 60 residents registered to attend the A3CR2 program and 22 residents registered for SAARAD. Respondent demographics are presented in Table 1. Fifty-eight of 78 residents (74.4%) were men, and 20 were women (25.6%). Most respondents were in the second year (32 of 78 [41.0%]) or the third year (42 of 78 [53.8%]) of radiology residency training (Table 1). Academic, rather than private practice, was the most common residency training setting (65 of 78 [88.2%]). Teaching Skills Training for Residents
A minority of surveyed residents indicated that their residency programs provided teaching skills training for residents. Seventeen of 78 (21.8%) stated that residents received instruction on teaching skills (Table 1). The most common format was a one-time workshop on teaching skills (11 of 17 [64.7%]), followed by a lecture on teaching skills (6 of 17 [35.3%]) (Table 1). One respondent indicated that the department of medicine offered a resident teacher training workshop to which residents across all specialties could apply but that is not mandatory for radiology residents. Radiology Resident Teaching Experiences
Thirteen of 78 respondents (16.7%) indicated that they had attended workshops on teaching skills outside of their own radiology residency programs (Table 2). Seven of those 13 respondents (53.8%) also had resident teacher training programs at their own institutions. The vast majority of respondents indicated that they taught medical students (72 of 78 [92.3%]). Most respondents taught their resident colleagues at case conferences (49 of 76 [64.5%]) and 519
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TABLE 2. Radiology Resident Teaching Experience Resident Teaching Activity Attended a workshop outside own radiology program on teaching Deliver case conferences Teach medical students Present at multidisciplinary conferences Present at grand rounds Feedback on resident-led teaching From faculty members From peers From both faculty members and peers No feedback Resident assigned a mentor to help with teaching preparation Residents feel their teaching is valued by the department Would like more training on teaching skills at their own institutions
n (%) 13 (16.6%) 49 (64.5%) 72 (92.3%) 45 (57.7%) 17 (21.8%) 10 (12.0%) 5 (6.5%) 21 (27.3%) 41 (53.2%) 12 (15.4%) 56 (73.7%) 66 (86.9%)
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions.
presented at multidisciplinary rounds (45 of 78 [57.7%]). Presentation at grand rounds by residents was less common. Seventeen of 78 respondents (21.8%) indicated that they were required to present at grand rounds in their residency programs (Table 2). Fewer than half of the respondents indicated that they received feedback on any aspect of their teaching (36 of 77 [46.8%]). Of those respondents who received feedback, the most common source of feedback was from both peers and faculty members (21 of 77 [27.3%]), followed by feedback from peers only (10 of 77 [13.0%]) and from faculty members only (five of 77 [6.5%]). Twelve of 78 respondents (15.4%) indicated that there were methods in place at their institutions to assign residents to mentors who could provide guidance with teaching activities, including preparation for grand rounds (Table 2). The majority of the respondents felt that their departments valued resident teaching efforts (56 of 76 [73.7%]). Sixty-six of 78 respondents (86.8%) indicated that they would like more training on teaching skills at their own institutions (Table 2). Resident Self-assessment of Teaching Effectiveness
A five-point, Likert-type scale was used to provide course participants with an opportunity to self-assess their current teaching prior to the workshop. The questionnaire was administered at the beginning of the workshop and consisted of 13 statements (Table 3). This survey was adapted from the Stanford Faculty Development Program questionnaire, a validated 26-item evaluation of specific effective teaching behaviors (15). Regarding the establishment of a positive learning climate, the majority of residents agreed or strongly agreed that they showed respect for learners in their teaching (78 of 78 [100.0%]), showed enthusiasm (74 of 78 [82.0%]), and encouraged learners to participate in discussion (61 of 78 520
[78.2%]). Fewer respondents indicated that they encouraged learners to bring up problems (46 of 78 [59.0%]). Regarding communication of goals, fewer than half of the respondents indicated that they regularly communicated goals at the beginning of the session (33 of 77 [42.9%]), and just over half stated the relevance of goals to learners (41 of 76 [54.0%]). Regarding the promotion of understanding and retention 49 of 78 (62.5%) of respondents related current information to learners’ previous knowledge when they teach. Most respondents indicated that they do explain to their learners why they are correct or incorrect after they ask them questions (59 of 78 [75.6%]). With respect to the use of evaluation in their teaching, approximately one third of residents evaluated their learners. Twenty-seven of 77 respondents (35.1%) stated that they evaluated learners’ knowledge of factual medical information, and 30 of 77 (39.0%) stated that they evaluated learners’ ability to apply medical knowledge to specific patients. Residents rarely gave feedback when they taught others. Thirteen of 74 respondents (17.5%) asked learners to self-assess their knowledge and skills. Twenty-two of 74 respondents (29.7%) offered learners suggestions for improvement. Finally, a minority of respondents indicated that they motivated learners to learn on their own (32 of 77 [41.6%]). Impact of the Resident Teaching Skills Training Workshop on Improvement of Teaching Skills
A postcourse self-administered questionnaire with a fivepoint, Likert-type scale was used to assess the impact of the teaching skills development course on improvement of teaching skills. The questionnaire was administered immediately following the completion of the workshop and consisted of 12 statements (Table 4). The majority of respondents agreed or strongly agreed that this course was effective in improving their teaching skills (Table 4). Course Evaluation
A five-point, Likert-type scale was used to assess participants’ perceptions of the course quality and obtain suggestions for future course format (Table 5). The majority of respondents agreed or strongly agreed that this course was well planned (75 of 78 [96.1%]) and helpful to them as teachers (78 of 78 [100.0%]). The majority of residents felt that this type of workshop would be helpful to incorporate early in the residency program (74 of 78 [94.9%]) (Table 5). Factors Associated with Self-reported Precourse Teaching Effectiveness Scores
Survey statement score averages were grouped into six categories of teaching behavior (learning climate, communication of goals, promoting understanding and retention, evaluation, feedback, and promoting self-directed learning). An analysis was performed to determine if there was a difference in self-
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TABLE 3. Residents’ Perceptions of Their Own Teaching Skills Prior to the Workshop
Survey Statement In my teaching interactions, I. Learning climate Show enthusiasm Encourage learners to participate in discussion Encourage learners to bring up problems Show respect for learners Communication of goals State goals clearly at the beginning of the session State relevance of goals to learners Promoting understanding and retention Relate current information to previous knowledge Explain to learners why they are correct or incorrect after I ask them a question Evaluation Evaluate learners’ knowledge of factual medical information Evaluate learners’ ability to apply medical knowledge Feedback Ask learners to self-assess their knowledge and skills Offer learners suggestions for improvement Promote self-directed learning Motivate learners to learn on their own
Strongly Disagree
Strongly Agree
Mean Score*
21 (26.9%) 22 (28.2%) 17 (21.8%) 54 (69.2%)
4.1 4.0 3.7 4.7
5 (6.5%) 12 (15.6%) 27 (35.1%) 25 (32.5%) 8 (10.4%) 3 (3.9%) 7 (9.2%) 25 (32.9%) 30 (39.5%) 11 (14.5%)
3.2 3.5
0 (0%) 1 (1.3%)
3.7 4.0
0 (0%) 0 (0%) 0 (0%) 0 (0%)
Disagree
Neutral
Agree
1 (1.3%) 13 (16.7%) 43 (55.1%) 4 (5.1%) 13 (16.7%) 39 (50.0%) 9 (11.5%) 23 (29.5%) 29 (37.2%) 0 (0%) 0 (0%) 24 (30.9%)
2 (2.6%) 0 (0%)
27 (34.6%) 41 (52.6%) 8 (10.2%) 18 (23.1%) 36 (46.1%) 23 (29.5%)
1 (1.3%) 11 (14.3%) 38 (49.3%) 20 (26.0%) 2 (2.6%) 8 (10.4%) 37 (48.0%) 24 (31.2%)
7 (9.1%) 6 (7.8%)
3.3 3.1
7 (9.5%) 29 (39.2%) 25 (33.8%) 12 (16.2%) 4 (5.4%) 14 (18.9%) 34 (46.0%) 18 (24.3%)
1 (1.3%) 4 (5.4%)
2.6 3.1
3 (3.9%) 12 (15.6%) 30 (39.0%) 25 (32.5%)
7 (9.1%)
3.3
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions. *Responses were made on a five-point, Likert-type scale (1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neutral,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree’’). TABLE 4. Residents’ Perceptions of How the Workshop May Affect Their Future Teaching Strongly Disagree Disagree
Survey Statement Following the course. My understanding of adult teaching principles has increased I am more aware of my own strengths and weaknesses as a teacher I believe that my enjoyment with teaching will increase I feel more confident that I will be able to teach in different settings I will be more likely to assess learner’s prior knowledge I understand better how to make my teaching relevant to the learner I will use one-minute preceptor in my future teaching I feel more comfortable to give feedback I feel more confident to give a large group session I appreciate the importance of a positive learning climate I will seek to continually improve my teaching skills I feel more confident in my role as a teacher
0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Neutral
0 (0%) 0 (0%) 0 (0%) 8 (10.3%) 0 (0%) 11 (14.1%) 0 (0%) 6 (7.8%) 1 (1.3%) 7 (9.2%) 0 (0%) 2 (2.6%) 0 (0%) 6 (7.7%) 0 (0%) 9 (11.5%) 0 (0%) 15 (19.2%) 0 (0%) 1 (1.3%) 0 (0%) 1 (1.3%) 0 (0%) 8 (10.2%)
Agree
Strongly Agree
Mean Score*
36 (46.2%) 34 (43.6%) 36 (46.2%) 40 (51.9%) 37 (48.7%) 36 (46.1%) 37 (47.4%) 40 (51.3%) 37 (47.4%) 30 (38.5%) 30 (38.5%) 40 (51.3%)
42 (53.8%) 36 (46.2%) 31 (39.7%) 31 (40.3%) 31 (40.8%) 40 (51.3%) 35 (44.9%) 29 (37.2%) 26 (33.3%) 47 (60.2%) 47 (60.2%) 30 (38.5%)
4.5 4.3 4.3 4.3 4.3 4.5 4.4 4.3 4.1 4.6 4.6 4.3
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions. *Responses were made on a five-point, Likert-type scale (1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neutral,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree’’).
reported teaching effectiveness scores within those six categories among residents with and without prior resident teacher training. Residents with prior resident teacher training (either in their own residency programs or at workshops outside their own programs) were significantly more likely to evaluate their learners (P = .041). There was no difference among the two groups of residents for the remaining five categories of teaching behaviors.
There was no significant difference in survey statement score averages and the number of years of residency training or the practice setting (academic vs private). DISCUSSION The goal of residency training is to help resident trainees achieve the key competencies needed to independently practice 521
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TABLE 5. Course Evaluation by the Residents
Survey Statement It would be helpful to incorporate a workshop like this early in the residency training program The workshop was well planned The duration of individual topics was appropriate The following topics should be included in the next workshop: Principles of teaching One minute preceptor Case conference Large group teaching Overall, this workshop was helpful for me as a teacher
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Mean Score*
1 (1.3%)
0 (0%)
3 (3.8%)
25 (32.1%)
49 (62.8%)
4.6
0 (0%) 0 (0%)
0 (0%) 1 (1.3%)
3 (3.9%) 4 (5.1%)
26 (33.3%) 35 (44.9%)
49 (62.8%) 38 (48.7%)
4.6 4.4
0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
2 (2.6%) 3 (3.8%) 2 (2.6%) 7 (9.0%) 0 (0%)
32 (42.1%) 23 (29.5%) 27 (34.6%) 26 (33.3%) 33 (42.3%)
42 (55.3%) 52 (66.7%) 49 (62.8%) 49 (57.7%) 45 (57.7%)
4.5 4.6 4.6 4.3 4.6
Reported numbers are based on 78 or fewer respondents. Some respondents did not answer all questions. *Responses were made on a five-point, Likert-type scale (1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neutral,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree’’).
medicine. In addition to clinical competence and skills to conduct research (16), many accrediting bodies now mandate that residents achieve key competencies as teachers (1,2,17,18). These competencies include the demonstration of effective teaching skills when teaching medical students, peers, other health professionals, and patients, as well as the ability to self-evaluate teaching effectiveness. In a previous study, radiology program directors agreed that it is important for residents to participate in a teaching role and that these teaching experiences help residents to become better radiologists (10). Resident trainees frequently teach medical students and other residents (3). At some institutions, resident teachers provide up to 70% of the clinical teaching received by medical students (7). In the present study, the vast majority of residents indicated that they taught medical students as well as other radiology residents. Both the learner and the resident benefit from resident-led teaching (19). Residents are often able to relate well to their learners and provide teaching in a safe, nonthreatening environment (20). The benefit for the resident providing the teaching is an increase in medical knowledge and clinical competence (21). Although residents are frequent participants in teaching encounters, many consider their teaching skills to be inadequate (22). Observational studies of teaching skills among internal medicine residents suggested that many residents teach ineffectively (23). For example, it is uncommon for residents to ask questions or to give feedback to learners (24). Residents in this study indicated that they rarely evaluated their learners or provided regular feedback. Furthermore, residents do not teach problem-solving skills or address psychosocial topics as often as attending physicians (25). Among the surveyed residents in this study, only one third of residents stated that they evaluated learners’ ability to apply medical knowledge. Interestingly, surveyed residents with prior resident teacher training were more likely to evaluate their learners. The majority of residents in this survey expressed a need for resident teacher training during residency and felt that this training should be started early in residency. Similarly, most program directors in radiology believe that their residents 522
would benefit from additional training in teaching skills development (10). Currently, approximately one third or radiology residency programs have established resident teacher training courses (10). This study identifies a need for teacher training for residents. There are several barriers to integrating a resident teacher training workshop into the radiology residency curriculum. The most notable are time constraints imposed by the clinical and research duties of faculty members, and a lack of trained medical educators in radiology. Inadequate recognition of faculty members who might ultimately lead such courses is another barrier that needs to be overcome (26). Institutions seeking to develop a resident teacher training course might consider initially implementing a faculty teacher development course. Thereafter, radiology faculty could be identified to lead a resident teacher training course. Other potential solutions to overcoming barriers to implementing resident teacher training courses within residency programs include establishment of teaching skills workshops led by experienced medical educators from other institutions (11). Previous studies have suggested that both short courses and longer electives improve resident teaching skills and satisfaction with teaching and teaching self-confidence and resulted in higher in learner evaluation of residents (8,9,27). Furthermore, residents who completed resident teacher training were more likely to want to continue teaching during and after residency training (19). Improvement in resident teaching skills may also lead to better doctor-patient communication (28), enhanced patient satisfaction, and possibly improved clinical outcomes (11,29). The majority of residents in this study agreed that the workshop helped them increase their understanding of adult teaching principles and that they will be more likely to give feedback and assess learners’ prior knowledge following the workshop. They felt that as a result of the workshop, their enjoyment of teaching would increase, they would feel more confident in their role as teachers, and they would seek to continually improve their own teaching skills. Overall, the participants felt that the workshop was helpful to them as teachers.
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Other potential means to promote resident teaching skill development are to establish collaboration between radiologists and medical educators at one’s institution (30) and to develop and disseminate a sample teaching curriculum to radiology program directors, as not all may be familiar with the opportunities that exist for resident teacher training (10). This curriculum would be designed with the primary goal of helping residents achieve key competencies as teachers. The secondary goal would be to introduce residents to the opportunities within academic radiology as clinicianeducators and to promote educational scholarship (11). Teaching has been cited by many as one of the top reasons that radiologists, among other physicians choose an academic career (19,31,32) (J. Collins, presented at the 2009 annual meeting of the Association of University Radiologists). There were several limitations to this study. First, a potential response bias exists from radiology residents in SARRAD and A3CR2 programs. These residents may be interested in resident-led teaching and may have overestimated the importance placed on the role of resident teaching during radiology residency training. Their teaching experiences may be broader compared with those of residents who did not participate in the programs. It is presumed that in survey responses, these residents represent their entire residency program. However, the results may not be generalizable to the greater population of radiology residents. The proportion of respondents in this survey who identified themselves as training practicing in an academic setting (88%) parallels the current proportion of academic programs in the entire Association of Program Directors in Radiology (84%). Second, this study did not evaluate the full extent of experience these residents have as teachers, although it did control for level of residency training. Furthermore, it is not known whether there are faculty mentors trained in medical education who help residents develop teaching skills outside of formal workshops or assigned mentorship. There are many methods to improve one’s teaching skills, and this study was not designed to capture the full spectrum of opportunities to improve teaching skills during residency training. Third, the course evaluation consisted of a resident satisfaction survey with the course, rather than evaluation of residents’ teaching effectiveness. Most resident teacher training workshop evaluations are conducted in the same manner (8). There are, however, a few studies that used standardized students in an objective structured teaching evaluation to evaluate outcomes (9,33,34). These require significant resources, including faculty members trained in medical education to evaluate the residents. It would be important to measure resident teacher training workshop effectiveness in the future on the students these residents teach. CONCLUSIONS Residents have an important role as teachers. Few residency programs had instituted resident teaching skills training curriculum. The resident teaching skills training workshop
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at the Association of University Radiologists meeting was rated highly and perceived as beneficial by the residents to improve teaching skills. Further studies are needed to evaluate which components of the workshop are most beneficial to the residents and to those they teach. ACKNOWLEDGMENT I would like to thank Marko Katic, biostatistician with the Institute for Clinical Evaluative Sciences, Toronto, for assistance with data analysis. REFERENCES 1. Accreditation Council for Graduate Medical Education. ACGME competencies introduction. Available at: http://www.acgme.org/acWebsite/ navPages/nav_commonpr.asp. Accessed November 17, 2009. 2. Royal College of Physicians and Surgeons of Canada. The CanMEDS 2005 physician competency framework. Available at: http://rcpsc.medical.org/ canmeds/index.php. Accessed November 17, 2008. 3. Seely A. The teaching contributions of residents. Can Med Assoc J 1999; 161:1239–1241. 4. Bing-You RG, Harvey BJ. Factors related to residents desire and ability to teach in the clinical setting. Teach Learn Med 1991; 3:95–100. 5. Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001; 76:390–393. 6. Morrison EH, Hollingshead J, Hubbell FA, et al. Reach out and teach someone: generalist residents’ needs for teaching skills development. Fam Med 2002; 34:445–450. 7. Bing-You RG, Tooker J. Teaching skills improvement programmes in US internal medicine residencies. Med Educ 1993; 27:259–265. 8. Morrison EH, Friedland JA, Boker J, et al. Residents-as-teachers training in U.S. residency programs and offices of graduate medical education. Acad Med 2001; 76(suppl):S1–S4. 9. Morrison EH, Rucker L, Boker JR, et al. The effect of a 13-hour curriculum to improve residents’ teaching skills: a randomized trial. Ann Intern Med 2004; 141:257–263. 10. Donovan A. Radiology residents as teachers: current status of teaching skills training in United States residency programs. Acad Radiol 2010; 17:928–933. 11. Gunderman RB, Kang YP, Fraley RE, et al. Teaching the teachers. Radiology 2002; 222:599–603. 12. Collins J, Hyde C, Gray L, et al. Radiology resident evaluation: a form that addresses the six competencies of the accreditation council for graduate medical education. Acad Radiol 2002; 9:815–816. 13. Mainiero MB, Collins J, Primack SL. Effectiveness of resident-prepared conferences in teaching imaging utilization guidelines to radiology residents. Acad Radiol 1999; 6:748–751. 14. Busari JO, Scherpbier AJ, van der Vleuten CP, et al. The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students. Med Educ 2003; 37:241–247. 15. Litzelman DK, Stratos GA, Marriott DJ, et al. Factorial validation of a widely disseminated educational framework for evaluating clinical teachers. Acad Med 1998; 73:688–695. 16. Hillman BJ, Gay SB. Research residents’ choices of academic radiology careers. J Am Coll Radiol 2005; 2:1030–1032. 17. Roberts CC, Chew FS. Teaching radiology residents, and radiology residents as teachers. Acad Radiol 2003; 10(suppl):S97–S101. 18. Halsted MJ, Perry L, Racadio JM, et al. Changing radiology resident education to meet today’s and tomorrow’s needs. J Am Coll Radiol 2004; 1:671–678. 19. Morrison EH, Shapiro JF, Harthill M. Resident doctors’ understanding of their roles as clinical teachers. Med Educ 2005; 39:137–144. 20. Bulte C, Betts A, Garner K, et al. Student teaching: views of student nearpeer teachers and learners. Med Teach 2007; 29:583–590. 21. Busari JO, Scherpbier AJ. Why residents should teach: a literature review. J Postgrad Med 2004; 50:205–210. 22. Neacy K, Stern SA, Kim HM, et al. Resident perception of academic skills training and impact on academic career choice. Acad Emerg Med 2000; 7: 1408–1415.
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