Improving the Teaching Skills of Residents in a Surgical Training Program: Results of the Pilot Year of a Curricular Initiative in an Ophthalmology Residency Program.

ORIGINAL REPORTS

Improving the Teaching Skills of Residents in a Surgical Training Program: Results of the Pilot Year of a Curricular Initiative in an Ophthalmology Residency Program Yewlin E. Chee, MD,* Lori R. Newman, MEd,† John I. Loewenstein, MD,* and Carolyn E. Kloek, MD* *

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA; and †Shapiro Institute for Medical Education and Research, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA OBJECTIVE: To design and implement a teaching skills

curriculum that addressed the needs of an ophthalmology residency training program, to assess the effect of the curriculum, and to present important lessons learned. DESIGN: A teaching skills curriculum was designed for the

Harvard Medical School (HMS) Residency Training Program in Ophthalmology. Results of a needs assessment survey were used to guide curriculum objectives. Overall, 3 teaching workshops were conducted between October 2012 and March 2013 that addressed areas of need, including procedural teaching. A postcurriculum survey was used to assess the effect of the curriculum. SETTING: Massachusetts Eye and Ear Infirmary, a tertiary

care institution in Boston, MA. PARTICIPANTS: Overall, 24 residents in the HMS Resi-

dency Training Program in Ophthalmology were included. RESULTS: The needs assessment survey demonstrated that

although most residents anticipated that teaching would be important in their future career, only one-third had prior formal training in teaching. All residents reported they found the teaching workshops to be either very or extremely useful. All residents reported they would like further training in teaching, with most residents requesting additional training in best procedural teaching practices for future sessions. CONCLUSIONS: The pilot year of the resident-as-teacher

curriculum for the HMS Residency Training Program in Ophthalmology demonstrated a need for this curriculum and was perceived as beneficial by the residents, who reported increased comfort in their teaching skills after Correspondence: Inquiries to Yewlin E. Chee, MD, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114; e-mail: yewlin_chee@meei. harvard.edu

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C 2015 attending the workshops. ( J Surg Ed 72:890-897. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

KEY WORDS: resident-as-teacher, resident education, surgical education, procedural teaching COMPETENCIES: Medical

Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism

INTRODUCTION Residents recognize their role as educators and spend up to onequarter of their work hours supervising and teaching trainees.1 Although the importance of resident physician teaching is well demonstrated, few formal training opportunities exist for residents to learn how to teach effectively, and many residents do not feel prepared to assume this role.2,3 Surgical residencies in particular pose unique challenges in educating trainees on how to teach. Compared with nonsurgical specialties, there is often less time to devote to formal teaching. Resident-as-teacher programs in surgical specialties must also aim to build skills in procedural and intraoperative teaching, often considered the most challenging teaching scenarios for practicing surgeons.4,5 Effective procedural teaching requires a specific set of teaching skills to train novice surgeons to achieve competence in performing surgical procedures. The 3 stages of motor skill acquisition described by Fitts and Posner6 is the most broadly accepted theoretical model of surgical training; it comprises the cognitive, associative, and autonomous stages. To successfully teach a procedure, a surgeon must use specific instructional skills for learners to assimilate the intellectual and technical elements of a motor skill such that they eventually can complete the skill without conscious thought about its execution.7 The current paradigm for procedural teaching is largely unstructured with a

Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.03.002

foundation in graduated trainee responsibility and dependence on case volume exposure. There has been a call for a more structured approach to teaching procedures, which includes preparation outside the operating room and opportunities for feedback and assessment throughout the learning process.7-9 Cognitive task analysis, a technique that has been shown to improve the content of a surgical skills curriculum by eliciting knowledge that might otherwise be omitted by expert surgeons in their description of a particular procedure, is a procedural teaching method that has been shown to be effective in advancing novice surgeons’ abilities to perform a surgical task.10-13 Surgical simulation is widely used across many surgical specialties too as a tool to augment training; with the proper teaching methodologies, it can allow learners to refine their cognitive and technical skills outside of the operating room.14,15 Other effective procedural teaching strategies have been described in the literature including introducing learners to surgical procedures in a stepwise manner. This instructional approach uses a surgical framework with deliberate practice and feedback for each separate step of a surgery, followed by immediate opportunities for trainees to apply new learning both in and out of the operating room.7,16-18 Although these surgical teaching methods have been described for practicing surgeons in a variety of surgical subspecialties, there are few examples in the literature on how to best educate residents to teach procedures to other trainees.11-14,17 Resident-as-teacher curricula are well described in a number of nonsurgical specialties; however, there is limited literature to guide development of such curricula in surgical training programs, with the exception of obstetrics and gynecology.19,20 Moreover, there is little to no discussion about training surgical residents in procedural teaching practices. Recognizing that teaching is an essential professional skill and paying heed to the Liaison Committee on Medical Education requirement that residents who teach medical students are prepared for their role, the Harvard Medical School (HMS) Residency Training Program in Ophthalmology created and implemented a teaching skills program for our trainees.21 This curriculum aimed to train residents in key teaching skills, address additional teaching needs of a surgical training program, and do so efficiently given limited availability of time and resources. We hypothesized that piloting a teaching skills curriculum would transmit key educational principles and skills to the ophthalmology residents as well as uncover other specific topics in teaching where residents needed further support. To our knowledge, this is the first description of a resident-as-teacher curriculum designed for an ophthalmology residency program.

MATERIAL AND METHODS Exemption was obtained from the Massachusetts Eye and Ear Infirmary Institutional Review Board. We designed a teaching skills curriculum for the HMS Residency Training

Program in Ophthalmology following Kern’s 6-step approach to curriculum development.22 These steps include problem identification, needs assessment of targeted learners, establishment of goals and objectives, design and implementation of educational strategies, and program evaluation. Needs Assessment Survey and Development of Curriculum Objectives An online-targeted needs assessment survey was administered to the 24 ophthalmology residents in September 2012 to guide development of the curricular learning objectives. This anonymous survey collected information on resident demographics and prior resident teaching experience and examined resident attitudes toward teaching. Specifically, the residents were asked the following: Whether they had prior formal training in teaching To describe their previous experience with an effective teacher To define their current role as a teacher To rate their confidence in their ability to teach in different clinical scenarios To predict what role teaching would play in their future careers To predict if they would pursue a career in academics. Trainees were also asked to describe a challenging teaching scenario they had encountered as residents. These responses were analyzed and coded by 2 reviewers (C.K. and Y.C.) to identify common themes. The results of the needs assessment survey combined with previously well-described elements of adult learning theory were used to create learning objectives for the curriculum.22 The Curriculum: Interactive Learning Strategies to Achieve Educational Objectives Overall, three 2-hour-long interactive teaching workshops took place during regularly scheduled resident didactic time between October 2012 and March 2013. The workshops were led by a single faculty member (C.K.) with advanced training in medical education and were tailored to introduce basic teaching skills as well as target teaching challenges specific to this group of residents as identified in the needs assessment survey. A combination of activities was used to teach the workshop objectives including video clips, small group discussion, and buzz groups. Well-described teaching strategies were introduced to the residents over the 3-session course (Table 1). Postcurriculum Survey: Assessing the Effect of the Curriculum An online postcurriculum survey was administered to residents in May 2013. This anonymous survey examined

Journal of Surgical Education Volume 72/Number 5 September/October 2015

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TABLE 1. Outline of Workshop Objectives, Teaching Principles, and Learning Activities Objectives Workshop 1 (duration: 2 h) Define the need for building teaching skills in ophthalmology residency

Teaching Principles Adult Learning Theory

Compare and contrast effective and ineffective teaching strategies

Importance of creating a positive learning environment

State methods for dealing with challenging teaching scenarios as identified by the ophthalmology residents

Establishing relevance of topic to the learner Value of interactive learning

Learning Activities The residents as a group watched 2 5 min video clips of teaching interactions followed by a group discussion to identify effective and ineffective teaching strategies observed in those video clips Before the session, residents were asked to take 3 min to describe their most effective teacher and why the teacher had an effect. The residents were then divided into groups of 2 to discuss why these teachers were effective. These thoughts were shared with the group for discussion. Discussed challenging teaching scenarios identified in the needs assessment survey in small groups and brainstormed techniques for handling these situations Reviewed the “1-min preceptor” as a technique for teaching in time crunch

Ambulatory teaching strategies Teaching in a time crunch Workshop 2 (duration: 2 h) State the value of feedback in teaching

Role of feedback in a professional environment

Identify challenges in delivering effective feedback

Strategies for delivering feedback

Compare and contrast effective and ineffective methods of delivering feedback

Challenges to overcome in delivering effective feedback

Workshop 3 (duration: 2 h) Define the concept of spaced education and the importance of repetition in learning Identify challenges in surgical teaching

Fitts-Posner 3-stage theory of motor skill acquisition The briefing-intraoperative teachingdebriefing framework for surgical teaching

Residents participated in small group discussions sharing an effective piece of feedback that changed their behavior and were asked to specify what it was about that feedback that inspired them Residents watched 2 video clips of feedback being delivered in the medical setting, followed by a group discussion of the effective and ineffective feedback strategies observed Discussed the pros/cons of different techniques of delivering feedback as a group Role play of difficult feedback Watched video of a surgical teaching encounter followed by group discussion to identify challenges in surgical teaching Residents participated in small group case discussions in which they were asked to practice the briefing-intraoperative teaching-debriefing framework using example surgical cases

State 1 effective strategy for surgical teaching Practice surgical teaching in small groups

respondents about workshop attendance and the perceived effect of the curriculum on their understanding of teaching strategies and their own teaching skills. The postcurriculum survey was modeled in part on other previously published resident-as-teacher surveys.23 Residents were asked to report changes they made to their teaching because of the workshops and to make recommendations regarding the future direction of the teaching skills curriculum. 892

RESULTS Needs Assessment Survey The HMS Residency Training Program in Ophthalmology trains 24 residents in the 3-year training program. In total, 18 ophthalmology residents completed the needs assessment survey. There were 7 postgraduate year 2 (PGY-2), 5 PGY-


Percentage of resident respondents

FIGURE. Challenging teaching scenarios identified by residents.

3, and 6 PGY-4 residents who responded. One-third (n ¼ 6) reported prior formal training in teaching skills, all of which occurred before residency. Although residents were not asked to define what formal teaching skills they had received, several commented that they had limited prior exposure to teaching skills acquisition via workshops or lectures that took place during medical school or their PGY1 year covering teaching-related topics. Overall, 72% (n ¼ 13) reported they taught on at least a weekly basis, with 28% (n ¼ 5) reportedly teaching on a daily basis. All respondents (n ¼ 18) reported teaching medical students, 61% (n ¼ 11) reported teaching more junior residents, and 44% (n ¼ 8) reported teaching residents of equal training level. Of the 18 respondents, 16 described a challenging teaching scenario. The 2 most common themes described were teaching in a time crunch (n ¼ 11, 69%) and emergency room teaching (n ¼ 10, 63%) (Fig.). All responding residents indicated they felt teaching skills would be important or critical in their future careers. Moreover, 83% of all respondents (n ¼ 15) anticipated that teaching would be an important part of their future career, and 80% predicted a future career in academics whereas 20% were unsure if they would pursue an academic position.

Postcurriculum Survey In total, 22 (92%) residents responded to the online postcurriculum survey. Of them, 7 (32%) were PGY-2 residents, 8 (37%) were PGY-3 residents, and 7 (32%) were PGY-4 residents. Reported workshop attendance was 82% (n ¼ 18) for the first workshop, 64% (n ¼ 14) for the second workshop, and 45% (n ¼ 10) for the third workshop. All respondents reported they found the sessions to be extremely useful (n ¼ 11, 55%) or very useful (n ¼ 9, 45%), and all reported they would like more training on teaching skills in the future. Most noted an improved awareness, comfort, and confidence in their teaching skills after attending the workshops (Table 2). Of the responding residents, 2 noted that they disagreed with improvement in skills in all categories; both of these responding residents also indicated on the survey that the sessions were extremely useful, they would like more training in this area, and that the amount of time spent on this topic was insufficient. When asked which areas of the curriculum needed improvement, the most frequently reported critique was that not all residents were able to attend every session owing to clinical responsibilities (50%, 5 of 10 respondents). The most frequently requested topics for future workshops were best


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TABLE 2. Resident Responses to Self-Perceived Change in Teaching Skills and Attitudes on Completion of Workshops Strongly Disagree Disagree Neutral My understanding of effective teaching strategies has increased I am more aware of my own strengths and weaknesses as a teacher I feel more comfortable giving feedback I understand the importance of making my teaching relevant to the learner I value interactive learning I appreciate the importance of a positive learning environment I will seek to improve my teaching skills I feel more confident in my role as a teacher I feel better equipped to teach medical students in the emergency department

procedural teaching practices (n ¼ 12, 57%), how to give an effective lecture (n ¼ 12, 57%), and most effective teaching practices (n ¼ 8, 38%).

DISCUSSION The important role of resident physicians as teachers has gained increased recognition in the academic literature and medical training program accreditation.24 Although resident-as-teacher programs have been well described for nonsurgical training programs, the literature contains few examples of the design and implementation of such curricula for surgical specialties, which have a unique set of challenges including increased time constraints and the need to teach surgical procedures. We designed a residentas-teacher curriculum that, to our knowledge, is the first described in an ophthalmology residency program. The curriculum was designed based on the results of a needs assessment survey completed by residents, and instruction occurred over the course of 3 teaching workshops in 1 academic year. On completion of the sessions, residents reported a better understanding of teaching strategies, and largely felt more comfortable with their role as a teacher and were interested in further training in this subject matter. There were a number of limitations to this study. Given the small sample size, generalizability of this study to other ophthalmology residency programs could be hindered. Variable workshop attendance was another limitation of this study (ranging from 82% of residents for the first workshop to 45% for the last workshop). A major challenge for our curriculum was securing protected time for residents to attend the sessions, with 50% of resident respondents identifying the inability to attend the workshops as a critique of the curriculum. Although it is more than likely that resident absence was owing to competing clinical responsibilities, selective attendance could raise the potential for response bias where residents with more interest in the subject matter attended the workshops. This same bias may have affected the results of the postcurriculum survey. 894

Agree

Strongly Agree

10% 10% 10% 10%

(2) (2) (2) (2)

0% 0% 0% 0%

(0) (0) (0) (0)

0% 20% 20% 5%

(0) (4) (4) (1)

65% 45% 45% 25%

(13) (9) (9) (5)

25% 25% 25% 60%

(5) (5) (5) (12)

10% 10% 10% 10% 10%

(2) (2) (2) (2) (2)

0% 0% 0% 0% 5%

(0) (0) (0) (0) (1)

0% 0% 0% 20% 20%

(0) (0) (0) (4) (4)

35% 25% 35% 45% 40%

(7) (5) (7) (9) (8)

55% 65% 55% 25% 25%

(11) (13) (11) (5) (5)

Potential solutions include duplicating the sessions so residents have multiple opportunities to participate, or video recording the sessions for later access. A limitation that exists in much of the literature on resident-as-teacher curricula, present study included, is the difficulty in objectively assessing the effect of resident-asteacher programs on resident teaching skills. Kirkpatrick’s 4level model to evaluate training programs has been used as a measure of resident-as-teacher programs. Kirkpatrick’s level 1 outcomes demonstrate effect on participant reaction to the program; level 2 demonstrate a change in participant knowledge, attitude and skills; level 3 demonstrate a change in behavior; and level 4 demonstrate change in a population or organizational practice.25,26 The postcurriculum survey used in this study revealed improved resident awareness of their strengths and weaknesses as a teacher, better understanding of teaching strategies, and improved comfort and confidence in their role as a teacher, which correspond to Kirkpatrick’s level 2 outcomes. Reviews of resident-asteacher programs have found significant heterogeneity in outcome measures, with survey-based self-assessments as a commonly used evaluation method.23,25 Other studies have taken outcome measures further by administering surveys to both the resident workshop participants and to the residents’ intern and medical student learners.27,28 In a review of 29 resident-as-teacher programs, 20 programs included a questionnaire or survey in their outcome assessment, alone or in addition to another method of data collection.25 Although each method of evaluation has its advantages and disadvantages, there are certain methods that are considered more robust and could elevate a teaching skills curriculum to a Kirkpatrick’s level 3 or 4; these include videotaped evaluations and direct observation of resident teaching using predetermined criteria such as those used during the Objective Structured Teaching Exercise (OSTE).19 Key Lessons Learned Despite the aforementioned limitations, the pilot year of a teaching skills curriculum in the HMS ophthalmology


surgical training program was perceived as beneficial by residents and provided several lessons learned, which should be considered and adopted by other surgical training programs when developing a teaching skills curriculum. A Needs Assessment Survey is Critical We recommend that surgical training programs looking to develop a teaching skills curriculum administer a needs assessment survey to guide learning objectives. The results of the survey can be used to specifically target areas residents identify as a concern in the limited time available. As an example, the needs assessment survey administered for this pilot teaching skills curriculum identified an educational gap: only one-third of residents reported receiving prior training in teaching skills whereas 80% of residents intended to pursue a career in academics (historically, more than 60% of our residents do go on to academic positions), and 83% believed teaching will play an important role in their future career. This survey also showed the 2 most common teaching challenges identified by residents in our program were teaching in a time crunch and emergency room teaching. Subsequent discussion informed us that these perceived challenges were a result of the fast pace of patient care and teaching demands in the dedicated ophthalmology emergency room in the main training site of our residency program. Based on these results of the needs assessment survey, we were able to tailor learning objectives and structure the workshops to develop teaching skills in these areas. Understand the Resources Available to Support the Curriculum Resources needed to launch a curriculum can include faculty time, funding, space, resident time, and teaching tools such as surgical simulators. We anticipated that resident time would be limited and streamlined the content of the curriculum to be delivered over three, 2-hour long workshops; even with this minimal time commitment, reported resident attendance was at times low. With an online, survey-based outcome measure, this curriculum required very few resources for data collection. A curriculum could potentially require significantly more time, funding, and trained faculty if an OSTE was used as a measure of efficacy. The availability of resources must be carefully planned in advance before a curriculum is launched.22 Procedural Teaching is a Critical Component Compared with many surgical procedures, ophthalmology procedures are short with rapid turnover between cases, leaving only brief windows of time available in the course of the operative day for teaching and feedback. Additionally, most surgeries are performed with patients under conscious sedation, limiting the quality and quantity of feedback that can be delivered intraoperatively. Taking into consideration the teaching environment and limited available time allowed for the pilot program, we introduced residents to a systematic framework for

surgical teaching—the Briefing-Intraoperative TeachingDebriefing technique—which can facilitate efficient surgical teaching.16 As each surgical specialty has unique challenges and demands, the most appropriate procedural teaching methods for each specialty should be modeled, practiced, and incorporated into a resident teaching skills curriculum. The Hidden Curriculum is Powerful The benefits of a resident-as-teacher curriculum such as the one described in this study include both the formal, explicit education provided in the workshops and the informal, hidden curriculum associated with the development and administration of the course.29 The very act of creating and promoting a resident-as-teacher curriculum helps raise resident awareness of their role as a teacher and also demonstrates that, at the organizational level of the residency program, this role is valued. By completing the needs assessment survey, attending the resident-as-teacher workshops, and completing the postcurriculum survey, residents in this study were reminded of their role at several points. This could contribute to their reported increased awareness of their strengths and weaknesses as a teacher as indicated on the postcurriculum survey. Future Steps Although this curriculum was piloted and launched over the course of 1 academic year, we aim to create a longitudinal curriculum that spans the 3-year training program and includes targeted sessions for each resident year. For example, we now have a session dedicated to medical student emergency room teaching for the PGY-2 residents and a case-based teaching session for the PGY-4 residents. We have also expanded the participation of the general teaching skills workshops to include residents from other surgical disciplines; our residents are based at an ophthalmology and otolaryngology hospital, and we have found similar teaching themes and challenges across the 2 residency programs. Building surgical teaching skills was an important component of this pilot curriculum, and further training in surgical teaching was requested by 57% of resident respondents in the postcurriculum survey. In future versions of this curriculum, additional surgical teaching strategies will be introduced such as cognitive task analysis and simulation in ophthalmic surgical training. In addition, we aim to emphasize further surgical teaching by incorporating other associated learning activities, such as having senior residents provide procedural teaching to more junior trainees on an eye surgery simulator making procedural teaching an even more robust component of this curriculum. Although the self-assessment surveys completed in this study provided important information regarding how residents perceived the effect of the curriculum on their teaching skills, the effect of the curriculum on resident teaching skills would be better evaluated if the time and


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resources to conduct an observational evaluation such as an OSTE were available. Although we recognize and acknowledge that a major limitation of this study is piloting the curriculum for a single residency training program, thereby restricting the generalizability of the results, we hope that the process we followed to create this curriculum, as well as the lessons learned in doing so, can serve as a framework for future surgical training programs to create a teaching skills curriculum and elucidate best practices for training residents to teach in the operating room.

6. Fitts PM, Posner MI. Human Performance.

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port, CT: Greenwood Pub Group; 1979. 7. Reznick RK, MacRae H. Teaching surgical skills—changes

in the wind. N Engl J Med. 2006;355(25):2664-2669. doi: http://dx.doi.org/10.1056/NEJMra054785. 8. Bell RH. Why Johnny cannot operate. Surgery.

2009;146(4):533-542. doi:http://dx.doi.org/10.1016/ j.surg.2009.06.044.

CONCLUSION

9. Grantcharov TP, Reznick RK. Teaching procedural

Although residents play an important role as teachers of medical students, interns, and fellow residents, there are few formal curricula designed to educate residents how to be effective teachers. Even fewer programs are designed specifically for surgical subspecialties, which have unique challenges including increased time constraints and the need to incorporate procedural teaching in their curricula. We present a resident-as-teacher curriculum that, to our knowledge, is the first one described for an ophthalmology training program. There was a need for this curriculum, and it was ultimately perceived as beneficial by residents toward improving their teaching skills. Future directions for this curriculum include improving workshop attendance, targeting sessions to specific levels of resident training, strengthening the procedural teaching component, and improving outcome measures to better assess the effect of the curriculum on resident teaching.

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