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Literature Review is the most critical part of a dissertation as it revolves around and builds upon the work that has been previously done in the subject being researched. There are several articles available on the topic of REP however not all of them focus on developing a curriculum for the resident as teacher program. A systematic review of literature was conducted using PubMed and Google Scholar. Keywords used for the search were: resident as teacher, teaching skills, curriculum. A list of 223 articles published from 1950 to 2009 was retrieved which was cross checked with the published updated selected bibliography on the resident as teachers subject. Extensive review of the full texts of the articles available and the abstracts resulted in selection of 29 articles which primarily focused on initiatives for improving the residents teaching skills.
"Residents in all disciplines serve as teachers and role models for students, colleagues, and other staff". (Residents-as-Teachers Programs in Psychiatry: A Systematic Review). Residents work closely with medical students in particular and have considerable opportunities to teach and influence students' knowledge, attitudes, and behaviors. Since the early 1970s, the literature on the residents' teaching role has emphasized the need to train residents as teachers as well as to evaluate the content and outcomes of instructional programs. Overall, the literature shows that residents wish to educate; they want to be qualified as 'teachers and leaders'. Most of the research available has been conducted in USA, UK and other developed countries, where the governing organizations are supporting this role of "residents as teachers".
"Residency" is a medical training stage of graduation. AÂ "resident physician"Â orÂ simply resident;Â is someone who has already completed the required degree in medicine. They are also referred to asÂ registrarsÂ in the U.K and other "Commonwealth" countries. They also practice medicine under the administration of the fully licensedÂ physicians, generally in hospitals and clinics. A residency often comes after the internshipÂ year or at some points includes the internship year as the 'first year' of the program. It can also come after the stage ofÂ fellowship. Here the general practitioner is trained or qualifies in a sub-specialty.
"Studies estimate that residents spend up to 20% of their time on teaching activities-regardless of their future career plans" ("Resident-as-Teacher" Curricula: Do Teaching Courses Make a Difference?) as suggested by Maria A. Wamsley, MD, Katherine A. Julian, MD, Joyce E. Wipf, MD in their article. According to the authors all residents know and understand their responsibility and role as far as teaching the medical students is concerned. Apart from the students they also teach interns and other fellow residents. As these research results were based on surveys; they have also demonstrated how residents not only enjoy teaching but consider it an important part of their own study. Secondly, they indicate how much the residents prefer teaching on call patients rather than attending lectures etc. Another survey that had been conducted for the research above highlighted how the medical students anticipated that 1/3 of their knowledge was attributed to the teaching in the house.
A survey was conducted in 2001 that showed that '55% of residency directors' thought that the programs offered to residents were official instructions regarding teaching skills. It is noticeable how "resident as-teacher" curriculum is becoming more widespread in the different residency programs, still the directors of these surveyed programs communicate that there is a need for "more resident instruction in teaching". Another point is that apart from having published studies available that describe the courses, many of these, need to be evaluated for their effectiveness.
Another proof is that these courses no doubt develop students' evaluation of participants. There are 3 nonrandomized restricted studies that calculate the ratings for the students and they showed through statistics a noticeable improvement in resident evaluations. "However, when impact is assessed by effect size, the percent change in evaluations after the intervention is small (2% to 11%), in part due to the concentration of evaluation scores in the upper half of the scale. Yet in the largest controlled study, these differences resulted in residents being perceived as "excellent" rather than "very good" teachers. (Maria A. Wamsley; et al)
We can further understand the importance of REP with the statement that these residents are not only specialist in their chosen fields but they are also apprentices or learners i.e. "learning on the job". (Basuri; et al) Majority of their learning takes place while they are performing their clinical duties and practice. The latter can be further illustrated by the following example. The extract was taken from the article related to Mount Sinai Hospital and the Resident Education Program. The Institute for Medical Education at the Mount Sinai School had developed a "Resident Teaching Development Program (RTDP)" in the year 2001. It was a 7 hour multidisciplinary program that had been initiated in this area of faculty development. The purpose was to concentrate on the significance of the residents as "medical educators" in IME. The main objective of this program was to build teaching skills in the residents who wished to teach the students at the school of Medicine at Mount Sinai. It would in turn prove beneficial for the improvement of the "quality of clinical teaching at the Mount Sinai Hospital and its affiliates". The development part of the program had the team reviewing all exiting work that had been done in the area. What were the other institutions doing and how they were doing it, and so on? They also consulted educators and conducted "needs assessment" surveys. After all the work they structured the course in a way that it not only included "active learning and opportunities for practice, integration of the residents' own experiences, feedback on their use of teaching behaviors, and problem solving activities". Another important part of all this is that the self-directed learning encourages the residents "to self-assess and create individualized teaching goals for themselves". The above clearly explains how important the REP is not only for any hospital or medical school but for the practicing residents as well as the interns and students who are attending these courses.
A research done on the competency based structure (B. Kanna; et al) suggested in its conclusion that "Internal medicine residents outlook in research can be significantly improved using a research curriculum offered through a structured and dedicated research rotation". It is further demonstrated by the progress that can be seen in the satisfaction of the residents, the rate of participation in various academic activities and outcome of the research for residents since the beginning of the "research rotation" in different areas of the programs and trainings
It is an established fact that residents as educators program was a unique idea that has been at work since 1960's. It has resulted in a positive turn out of the residents and the students who are both benefiting from such learning and skill based programs. All the research that has been conducted resulted in the same idea that more and more opportunities should be given to these residents and their skills and capabilities should be improved so that learning can increase. One interesting fact was often highlighted by different researchers in their reports. It was whether teaching improves the skills of the practicing residents or not? A hypothesis for a research highlights the following by stating that whether a "skilled teacher has an increased likelihood of becoming a competent teacher" or is the case opposite. Their investigation and surveys lead them to find that their result supported the hypothesis. "teaching improved the perceived professional competency of medical physician."(Basuri et al). However it was largely subjective with little quantitative evidence, still they did not find any study that disproved this point. In the first chapter we had established in the issues regarding the role of the residents that emphasis needs to be given on how to structure a more efficient REP program that will enhance not only the skills of these residents but in turn improve the quality of learning that takes place.
Another study found in Medical Teacher (Vol. 24, No. 1, 2002; Busari et al) indicated that the residents not only thought of teaching the medical students as their main responsibility but that they also learnt in the process. However, it is noticeable that teaching is limited due to time limitations that may be needed for the preparation and conduction of the course coupled with better teaching skills. In this study the views of Stewart & Feltovich (1988) were also confirmed who stated that "residents are in a unique position to teach and evaluate students because of their proximity to the students". Many of the views by the residents supported this notion and included the following points:
They felt that the residents were voluntarily available and had more contact time with students
They were in a better position as far as the evaluation of the students was concerned.
They were easy to approach as they were always in the hospital and on duty
From the students point of view the residents were better at explaining things.
Even though there was a common agreement that teaching was the one of the main roles that residents had, there was a substantial lack of the teaching time and the know-how which caused hindrances in their role. This lowered their position to someone just as an attending staff member. Many a times it was noted by the residents that while teaching the students their own skills were tested and they has time to critically reflect on their own knowledge. One should consider it to be an important motivational point which leads these residents to constantly update themselves and thus the process of learning goes on.
From the discussion and views presented above the conclusion is obvious. Before beginning the chapter it was established that work in this area was required for Pakistan as this concept is new to this part of the world. Although institutions like AKU and ISRA are sREPping up their work in the field of REP much more has to be done. Developing a curriculum for this area is indeed a challenge as to understand the significance of the efforts is required. From the above and many other discussions already published it is observed that residents were not given the actually accredited for the work that they have done or the job they perform. They have not been provided enough time to improve their skills and these results in certain lapses in the teaching of various programs. We can see this from the study conducted in another article which stated that there was proof that "teaching courses improve resident self-assessed teaching behaviors, self-confidence as a teacher, and result in higher learner evaluations of residents." (Wamsley et al.) it can be stated "that based on the seen 'positive effects', one might argue that all residency programs should require resident teaching instruction." There are many obstacles however, regarding the implementation of the course. Teaching different programs prove to be 'time intensive' for both the residents and faculty. It is also a challenge to provide the residents with continuous learning time. Majority of the time there is no support for creating and teaching these courses. "Competing curricular requirements for training may result in fewer time-intensive curricula." Furthermore we can establish that these restrictions might be a contributional factor towards the fact that nearly "half of all residency programs do not provide formal instruction in teaching."
We have at the beginning of this chapter highlighted the importance for REP with regards to Pakistan and also have identified areas where work needs to be done. Pakistani universities especially those dealing with medicine and hospitals like Aga Khan need to put in more effort in improving the status of residents as teachers. Understandably we have sREPped into this arena and no doubt worked progressively but as compared to what other countries have done we are still far behind. Thus we will conclude our review here and further this research thesis to chapter 3 which will focus on the need assessment for the resident as educator program and the development of the curriculum for the said.
Medical students frequently consider residents to be their most important teachers and look forward to a teaching role during residency (Barrow, 1966). Another study, conducted more than twenty five years later, confirms these findings (Bing-You & Sproul, 1992). Brown (1970), in a study of housestaff attitude towards teaching, found that residents provide the majority of clinical instruction. According to his findings, no one is more available to students and junior housestaff through all aspects of medical care, even through the night. He argues that without residents, clinical faculty would need to be available 24 hours a day. He found that all residents consider themselves to be teachers, and spend 20Â25% of their time supervising, evaluating, or teaching others. Residents also attribute 40-50% of their own teaching to other housestaff. These findings are in keeping with more recent studies. Undergraduate surgery students credited housestaff
for providing almost one third of the knowledge acquired during their rotation (Lowry, 1976). In another study (Bing- You & Harvey, 1991), students estimated that one third of their knowledge could be attributed to housestaff teaching.
Steward and Feltovich (1988) argue that "for teaching medical students, no one is more available or better qualified than a resident" (p. 4). Residents occupy an intermediate position between faculty and students in terms of knowledge, authority, experience, and are less intimidating to students. Their proximity, in terms of level of training, enables them to better understand the practical needs and problems of students. Tremonti and Biddle (1982) stress that residents' roles as teachers are complimentary, and not redundant, with that of faculty. Residents concentrate on daily patient care issues on a large number of patients and spend more time on the ward and at the bedside. Faculty, on the other hand, stress in depth discussion, psychosocial issues, and problem solving skills on a small number of patients.
The fact that residents spend more time with students and are "closer" to their level does not necessarily make them effective teachers. Irby (1978) found that although students rated residents as being more involved in their clinical teaching, residents were thought to be less effective than faculty. Only 10% of students in another study (Brown, 1971) "felt that housestaff teaching was particularly effective when it was done at all" (p. 93). Wilkerson, Lesky, and Medio, (1986) studied the teaching skills of residents during work rounds. "The results â€¦indicated that during work rounds the residents exhibited few of the teaching behaviours that can enhance learning in a patient care setting..., that students and interns were often passive members of the work team, with the majority of clinical decisions being made by
residents Clinical reasoning, problem solving and supervised
decision making were not recognized as learning goals that might be pursued while charts were being reviewed and patients were being visited....The resident appeared to conceptualize teaching as a classroom activity and equate it to
lecturing" (p. 827). Lewis and Kappelman (1984) noted that residents most frequently use an authoritarian lecture style in teaching. Ironically, this was residents' least favourite approach as learners. Medio, Wilkerson, Lesky, and Borkan (1988) observed residents during work rounds.
Residents did not often intentionally use daily patient encounters for teaching. When they did intend to teach during work rounds, they usually provided brief lectures. Not only did the study show the limited repertoire of teaching skills used by most residents, but it also delineated the many teaching opportunities that were being overlooked. For most residents, teaching had become synonymous with prepared lectures and was, therefore, incompatible with the unpredictable demands of patient care (p. 215).
Meleca and Pearsol (1988) urge that residents be made aware of and take advantage of their responsibilities and "teachable moments" (i.e., teaching opportunities). One study (Bergen, Stratos, Berman, & Skeff, 1993) compared the clinical teaching abilities of residents and attending physicians in the inpatient and lecture settings. Overall, residents and attendings received similar ratings. Where there was a difference, faculty were rated higher than residents. Of note, ratings for both groups were generally low in each category suggesting the need for participation in REPs by both groups.
Residents generally have a positive "attitude" towards their role as teachers. The vast majority of residents enjoy teaching (89% of 68 respondents) (Apter, et al., 1988). In this study, enjoyment of teaching was positively associated with increased preparation time and perception of positive results of teaching. Bing-You and Harvey (1991) are the first to address whether an association between a positive attitude towards teaching and perceptions towards teaching are associated with
better student evaluations of teaching. Twenty one (of 24) residents completed a questionnaire in order to survey their attitude towards teaching. They were subsequently evaluated by third year medical students over a one year period. Residents' desire to teach was most strongly correlated (0.77) with active involvement of students and was the only "attitude" correlating with overall teaching effectiveness (0.54). Unfortunately, no correlation was found between student ratings of residents as teachers and residents' self- assessment of teaching effectiveness. Of note, residents having participated in a REP were more confident as teachers, were rated more highly in actively involving students and in providing direction and feedback, and were also more confident as teachers.
Although residents have major teaching responsibilities, evidence exists that they may not receive enough support or preparation for this role and that barriers hinder optimal teaching. A US national survey of general surgical residency program directors (Anderson, Anderson, & Scholten, 1990) posed three questions: (1) To what extent do surgical residents teach and evaluate medical students? (2) How are surgical residents prepared for and evaluated on their teaching responsibilities? (3) What are the surgical program directors opinions about residents as teachers? Virtually all
(98%) surgical residents had teaching responsibilities. However, only 36% of programs provided residents with written evaluations of their teaching, and 60% of program directors did not believe it was important for residents to receive formal training in teaching skills. Only 14% of residents in this study had attended workshops on teaching. Two other studies (Callen & Roberts, 1980, Brown, 1971) report similar findings. Thirteen percent of 136 psychiatry residents, and 15% of 28 surgery residents had prior teacher training. A more favourable proportion (i.e., 38% of 21 residents) is cited in one study (Bing-You & Harvey, 1991). This likely reflects the author's prominent role in promoting and developing resident teaching skills at his institution. Schiffman (1986) asks: "How then do house officers learn how to teach? The obvious answer is that the house officer has had twenty years of observation of his or her own teachers upon which to model his or her style" (p. 55). This remains inadequate.
If most residents do not have prior teacher education, do they at least receive useful feedback on the teaching that they do? In 1978, the American Association of Medical Colleges (AAMC) surveyed departments of internal medicine, pediatrics, psychiatry, surgery, and family medicine (Tonesk, 1979). Only 87 of 319 (27%) programs included teaching
performance as part of residents' evaluations, and those that did usually only required a global assessment of teaching ability. The data on supervision of teaching is equally bleak. Apter, Metzger, and Glassroth (1988) report that only 13% (of 68) residents felt that faculty supervision of their teaching was optimal, and 58% indicated that they had never been supervised. In one study (Callen & Roberts, 1980), 78% (of 136) psychiatry residents thought that "the main reason residents are required to teach medical students is to free up time, time for faculty to do research and other things." On average, these residents estimated that they spent 9 hours per week in teaching activities. Despite this large teaching commitment, only 32% of residents thought that they should be required to attend REPs. When the question of attending a resident REP is posed differently, 53% (Apter, et al., 1988) to 66% (Brown, 1970) of residents stated they would be interested in attending a workshop if it were offered.
In addition to less than satisfactory support for their teaching role, residents face other impediments. Time and conflicting demands seem to be most important. Eighty seven percent of residents cited either their own or their students' time- consuming ward duties as the greatest obstacle to teaching
(Apter, et al., 1988). Post call exhaustion was also an important factor (49%) making teaching difficult.
Kates and Lesser (1985) identify what they consider to be major problems faced by residents when teaching. They quote the AAMC report cited above (Tonesk, 1979) and admonish post graduate programs for the lack of emphasis placed on residents' teaching role. Beyond this, residents' may be unclear about what their actual role is in terms of supervising - teaching junior housestaff, and as mentioned, they are usually unprepared for their teaching function. Residents are usually unfamiliar with the learning objectives of the juniors they supervise and teach. Despite this, they are usually called upon to help evaluate them. The residents' own supervisors often provide inadequate supervision and support for residents. This, in itself, may downplay the importance of teaching for the resident. Finally, few programs make any specific efforts to coordinate teaching opportunities for residents with a special interest in education.
Acknowledging the many problems faced by residents when teaching, and their less than optimal preparation for their teaching role, not much is known regarding the needs of residents in terms of designing a REP. Boule and Chamberland (in press) addressed this issue from a residents' perspective by
asking them "What kind of training do you need to teach more effectively?" Eighty residents responded. Two thirds of their answers corresponded with needs usually addressed by REPs, while one third were concerned with medical competency and time management. Nine key words were most frequently cited in their responses (in order of priority): (1) division of work / teaching time, (2) teaching methods, (3) medical
knowledge, (4) objectives, (5) synthesis skills, (6) feedback, (7) motivation, (8) psychology applied to teaching, and (9) student problems. More research needs to be done in the area of the teacher education needs of residents. Other
perspectives and other sources of information should compliment that of residents.
Empirical Research on Resident REPs
An extensive review of the medical education literature was undertaken to identify existing studies of resident REPs. Twenty-six references were identified between 1963 and 1991. Of the 26 reports, one study was described in three different publications (Greenberg, et al., 1984; Greenberg, Jewett, & Goldberg, 1988; Jewett, et al., 1982), and two studies were reported twice (Camp & Hoban, 1988; Camp, Hoban, & Katz, 1985) and (Lazerson, 1972; Lazerson, 1973). Furthermore,
chapter nine (Edwards, Kissling, Paluche, & Marier, 1988b) of Edwards and Marier's (1988) book, Clinical Teaching for Medical Residents: Roles Techniques, and Programs, outlines a resident REP used for two studies ("Phase I" and "Phase II) that were reported elsewhere (Edwards, Kissling, Brannan, Plauche, & Marier, 1988a; Edwards, Kissling, Plauche, & Marier, 1988). This program was also used for a third study (Edwards, Kissling, Plauche, & Marier, 1986). Therefore, a total of 21 different studies and 19 different resident REPs were identified. Of the 19 resident REPs, two actually depict undergraduate medical school electives: one offered as a third year elective (Craig & Page, 1987), the other as a fourth year elective (Sobral, 1989). Another program (Lazerson, 1972; Lazerson, 1973) can be more accurately described as a teaching experience under supervision rather than a resident REP. This study describes the experience of psychiatry residents given the opportunity to teach undergraduate psychology at a community college. Although these residents received feedback on their teaching skills, no formal teacher training was undertaken. Consequently, only 18 studies described 16 programs in which residents underwent a curriculum with a specific goal of developing teaching skills.
A database was created extracting information from all studies for easy comparison. The information was organized into the
following fields: (1) Participation (voluntary or mandatory); (2) n (i.e., number); (3) Specialty (of residents); (4) level (i.e., postgraduate year (PGY) of training of resident); (5) Goals & Objectives (of REP); (6) Methodology (i.e., study design); (7) Program Format; (8) Instructor(s) (i.e., professional educators or physicians); (9) Consultation(s) (i.e., whether or not professional educators were involved in program development or implementation); (10) Timeline (i.e., number of hours over what time frame); (11) Content (of REP); (12) Program Evaluation (results); (13) Study Results; (14) Problems (identified); (15) Recommendations (practical).
The first resident REP reported (Husted & Hawkins, 1963) dates back to 1963. This case study was initiated as a pilot project. The investigators asked department chairmen to invite two residents each to participate in the program. Given the voluntary nature of the course, residents could decline the invitation. A total of seven residents participated in the six "lecture-discussion" sessions. No attempt was made to assess outcome measures. Even the program itself was not assessed with any rigor. The authors conclude that "participants were certain enough that the pilot venture was of sufficient benefit to them to lead to the suggestion that the orientation be repeated and the invitations expanded..." (p. 115). The teaching role of residents has become increasingly more
prominent over the years, with 17 of the 26 references being published since 1985, and the recent publication of books on the subject (Edwards & Marier, 1988; Schwenk & Whitman, 1984; Weinholtz & Edwards, 1992). A summary of the medical education literature on this subject will be the focus of the remainder of chapter two.
Participation in the REP was "voluntary" in 9 studies, "mandatory" in 6, and not stated in the remaining 7. Various arguments can be made for and against both strategies, but no conclusions can be drawn from these studies. Allowing residents to "opt-out" of REPs, however, may result in neglecting those residents who need it most.
General internal medicine is the most represented of all specialties among the studies reviewed. Internal medicine residents were involved in 11 of the 22 programs. Those studies (e.g., Edwards, et al., 1988) looking for distinctions between specialties generally found no significant differences.
No consensus exists as to when is the best time to introduce a resident REP. A quick glance at the target audience (i.e., post graduate year of training) of the various REPs outlined makes this clear. Five programs were geared to PGY 1 residents and four programs were geared to all levels of residency. Two
programs were undergraduate medical school electives. Other levels were the target in five programs and no information was available for the remaining six. Only one study (Bing-You, 1990) addressed program outcomes in relation to level of training. Further studies are needed to define the best time to implement REPs. "Readiness" to learn, level of professional competence, competing demands / availability, and cost effectiveness (e.g., final year residents only have a short teaching career remaining) are only a few of the factors to be considered.
Goals and Objectives
Goals and Objectives varied considerably between programs. Although none of the programs formally stated the theoretical underpinnings from which the goals and objectives emanated, the language used to describe them is revealing. The desire to
"transfer" information is prominent. Programs alternatively wanted to "acquaint residents with" (Husted & Hawkins, 1963), "provide information" (Brown, 1971), "introduce concepts" (Lewis & Kappleman, 1984), or have residents "gain knowledge / become familiar with" (Camp & Hoban, 1988;
Camp, et al., 1985). Standard behavioural objectives were also common. For example, one program (Husted & Hawkins, 1963) expected participating residents to be able to "(a) select the appropriate (teaching) technique and (b) begin to develop skill in self-appraisal of their ability to effectively function in their teaching role" (p. 111), while another (Edwards, et al., 1988b) expected residents to "give feedback to learners" (p. 159). The wording in two further studies alludes to constructivism: (1) "The workshop's aim is not to teach "teaching skills," such as lecturing or running a tutorial, but to explore the organizational aspects of supervising a student such as the relationship between the resident and their own supervisor, and their understanding of the objectives of the clerk's rotation" (italics mine) (Kates & Lesser, 1985, p. 418), and (2) "to expand the residents' concept of teaching" (italics mine) (Medio, et al., 1988, p. 214). Finally, one study (Edwards, et al., 1988b) had increased self-confidence in teaching (cf., teaching self-efficacy) as a program goal.
It is beyond the scope of this dissertation to discuss the methodologic flaws of the studies reviewed. The patient- centred pace of hospital practice and postgraduate medical training make it difficult to run educational experiments in this context. The authors of the reviewed studies should be commended for their efforts and innovative attempts to pose and answer questions. Of the 22 database entries, 19 are case studies. Two of these make an attempt at an experimental design: "quasi-experimental" (Snell, 1989), and "case-control, pre- and post- observation" (Medio, et al., 1988). Both of these studies used residents who did not attend the REP as a comparison (i.e., control) group. The mere fact that they did not choose to attend makes them different; any differences found between the two groups may just as likely be attributed to the characteristics of the individuals in the respective groups as to the intervention (i.e., REP). Conclusion from these studies should be interpreted with caution. One of the database references is a simple program description with study results reported elsewhere. The remaining two studies (one of which is reported three times) (Edwards, et al., 1988a; Greenberg, et al., 1984; Greenberg, et al., 1988; Jewett, et al., 1982) have a randomized case control design. Both have a relatively small total number of study subjects, 22 and
Overall, an attempt was made to use instructional methods that actively involve residents. For the most part, however, this simply meant having residents take part in group discussions (cf., authentic activities e.g., Collins, et al., 1991). Lave and Wenger (1991), in their discussion of discourse and practice, stress the important differences "between talking about a practice from outside and talking within it" (p. 107). They argue "that for newcomers then the purpose is not to learn from talk as a substitute for legitimate peripheral participation; it is to learn to talk as a key to legitimate peripheral participation" (original emphasis) (p. 109). As discussed in an earlier section of this chapter, Lave and Wenger (1991) distinguish between a learning curriculum consisting of situated opportunities and a teaching curriculum constructed for instruction. From their perspective, then, learning becomes a question of access to legitimate practice as a learning resource rather than providing instruction. Most of the programs described, it seems, have little grounding in a social / situated perspective of adult education. A few studies, however, did attempt to
emphasize the important role of experience as part of the REP: microteaching, with and without video playback (Lawson & Harvill, 1980; Medio, et al., 1988; Pristach, et al., 1991; Snell, 1989), and role playing (Edwards, et al., 1988b; Sobral, 1989).
In Jarvis' (1992) discussion of learning in the workplace, he reminds us "that there are two basic forms of experience: primary and secondary experience. The former involves the actual experience people have in a given situation; this type of experience moulds their self-identity to a great extent. The latter involves experiences in which interaction or teaching occurs over and above the primary experience" (p. 108-181). Although microteaching and role playing may be (or come close to being) authentic activities, they would still be classified as secondary experiences from Jarvis' point of view. It must be remembered that whether or not residency programs decide to develop and implement REPs, residents will still have major teaching obligations (and opportunities). Most programs did not take specific advantage of residents' current teaching assignments as a learning resource. One program (Snell, 1989) did mention that residents had "an opportunity to practice the (newly learned teaching) skills on
the wards during the weeks between sessions" (italics mine) (p. 125). Another program, consisting of two three-hour workshops, separated both workshops by 5 months so that "the experimental group had an opportunity to apply these (teaching) skills in their daily activities" (italics mine) (p.
361). Unfortunately, without structure and follow-up, students (including residents) do not always take advantage of opportunities. None of the programs specifically structured and included such learning activities.
The first decision when deciding on a timeline for a program is deciding whether to offer a "one-shot" or a longitudinal experience. A second decision also involves timing: should residents take part in a REP only while they have teaching responsibilities? A program based on a longitudinal experience while residents have teaching responsibilities can take advantage of Jarvis' so-called primary experiences. The program developed as part of this dissertation was specifically designed with these ideas in mind and included a "Task for the Week" between sessions (see chapter three). A teaching "task" was assigned at the end of the each seminar based on that seminar's content. A lab-coat pocket sized reminder card was handed out to residents. The task became the focus of a reflection (and review) exercise at the beginning of the next weekly session.
Of interest, none of the studies were specifically designed to measure the impact of a teaching responsibility itself on outcomes measures. This is one of the research questions addressed by this dissertation.
In those studies commenting on timeline, about half provided a longitudinal experience while the other half offered a "one- shot" exposure (e.g., 7 hour "Teachathon" (Maxmen, 1980)).
Program content, where provided, variably included the following topics: (1) theories / models of teaching, (2) theories / models of learning, (3) large group teaching / lecturing, (4) small group teaching / discussion, (5) one-on- one teaching, (6) bedside teaching, and (7) evaluation / feedback.
All programs were rated favourably; there was a high degree of satisfaction with both instruction and content. Residents considered the experience valuable and useful.
Impact of resident REPs.
All but one of the studies designed to investigate the impact of resident REP demonstrated a positive effect. Brown (1971) used a pre- and post- 50 item multiple choice test to assess changes in residents' knowledge of teaching and learning. No significant difference was found at the 0.05 level (i.e., mean 24.0 vs. 24.7). On the other hand, Edwards, Kissling, Plauche, & Marier (1986) report that after one year, 67% of residents could still recall specific points presented, and 61% reported using ideas from the course in their teaching. Overall, knowledge was not an important outcomes measure in the studies reviewed.
Improvements in teaching behaviours have been the main focus of most studies assessing outcomes. Sources of perceptions have included residents (i.e., self), students, peers (i.e., other residents and faculty), as well as professional educators. Improvements in self-concept and self-reported behaviours were demonstrated in four studies (Bing-You & Greenberg, 1990; Edwards, et al., 1986; Edwards, et al., 1988; Snell, 1989). Student ratings of residents who attended a teaching skills workshop were significantly higher (p<0.05) on
four of nine dimensions including "overall teaching effectiveness" (Edwards, et al., 1988). In another study (Edwards, et al., 1986) an attempt was made to study the effect of a resident REP on student ratings of resident teaching; unfortunately, the data was too "scanty" to be interpreted validly.
Improvements in resident teaching behaviours have also been studied by observation methods. One study (Camp & Hoban, 1988; Camp, et al., 1985) used direct informal observation of resident teaching by educators to assess change. Faculty observers "believed that the participants showed that they had put into practice many of the skills that had been discussed and demonstrated in the course on teaching..." (p. 212). More formal attempts to observe and measure changes in resident teaching behaviours, using observation instruments, exist. A case-control pre- and post- observation study (Medio, et al., 1988) demonstrated an improvement in the "treatment"
group as compared to "controls." Each resident (6 treatment and 6 controls) was observed during one work round while reviewing an average of ten patients. Unfortunately, the small sample size, and the fact that "controls" consisted of residents not participating in the program (i.e., non-random) make interpretation of the results difficult. Snell (1989), using a similar experimental design with 9 subjects and 5 controls
showed that post-intervention scores increased in all three areas measured (i.e., lecture, tutorial, and discussion (p < 0.05)). Observation studies using videotaped resident teaching also demonstrated a positive impact of REPs on teaching behaviours (Bing-You, 1990; Edwards, et al., 1988a; Greenberg, et al., 1984; Greenberg, et al., 1988; Jewett, et al., 1982; Lawson & Harvill, 1980).
Need for reinforcement / long term effect.
How long are improvements in teaching skills maintained after a REP? One group of investigators (Edwards, et al., 1988a) noted that improvement in residents' skills (videotaped teaching) had declined when measures were repeated six months later; ratings were, however, still higher than pre- instruction. The authors suggest that residents may need periodic short "refresher" courses to reinforce teaching skills throughout their residency. Of interest, another study (Edwards, et al., 1986) using the same REP found that post course improvements in self-rated teaching skills "endured without decay for at least a year and a half" (p. 970). Furthermore, "residents could still recall and explain major teaching points and reported that they had used these teaching points 18 months after the course" (p. 970). Similarly, Snell (1989) found that increased ratings of
teaching behaviours (based on observations) were maintained for eight months after a REP. Overall, little is known about the rate of "decay" of residents' teaching skills after a REP. An interesting, and unanswered, question is whether or not focusing on "attitude" and "self-efficacy" (cf., specific teaching behaviours) has any effect on the rate of decay.
"Confidence" / self-efficacy.
Although the construct of self-efficacy has not specifically been used as an outcomes measure, self-reported "self- confidence" has. Interestingly, those studies assessing changes in self-confidence did not seek to demonstrate an association with changes in teaching behaviours. Further, the impact of a teaching assignment itself (i.e., experience) on self-confidence has not been explicitly addressed. All three of these issues are specifically addressed in the study described in this dissertation.
Snell (1989) measured self-confidence pre- and post-course by self assessment questionnaire. Significant increases in "confidence in teaching" were found in the treatment group (p < 0.05). Snell goes on to comment that "eight months after the course, the residents all thought that they were more
confident in their teaching" (p. 126). Unfortunately, the data is not presented nor is the analysis. Also, no mention of "control" group comparison is made.
Bing-You and Greenberg (1990) assessed residents' confidence as teachers and perceptions toward teaching using a pre- workshop questionnaire. However, no post-workshop questionnaire was given; therefore, no comment on the impact of the REP on self-confidence can be made. At the beginning of the program, 25% of residents felt confident or very confident as teachers (68% somewhat confident, and 7% not confident). Perceived feedback of their teaching was similar to confidence levels, with 32% reporting positive or very positive feedback.
Bing-You (1990) used a pre- and post-workshop questionnaire to assess residents' "attitude towards teaching." In addition, trained raters assessed videotapes of resident teaching at the end of the workshop and again at a mean of 6.3 months later (2-11 months). However, no inferences can be made regarding the relationship between teaching attitude and teaching behaviours given the two different study designs for each outcomes measure (i.e., pre-post vs. immediate and
delayed post). After the workshop, both residents and interns rated themselves as more effective (p < 0.05) as teachers in
the area of knowledge (using references) but only the interns felt more effective in their technical skills (p < 0.01). Without direct access to the questionnaire items, it is difficult to determine whether "use of references" and "technical skills" represent attitude or self-reported behaviours.
The most interesting and best designed of the studies looking at self-confidence has been reported three times (Greenberg, et al., 1984; Greenberg, et al., 1988; Jewett, et al., 1982). The investigators used a pre-test / post-test control design to study the impact of the workshops: random assignment of 27 in the experimental group attended workshop and consultation sessions; 26 in the control group had no intervention. Three outcomes measures were assessed: (1) self-assessment: preÂ& post-questionnaires assessing residents' teaching attitude and perceptions of teaching, (2) peer, student, and faculty evaluation of resident teaching, and (3) videotaped sessions of resident teaching were analyzed by nonphysicians using an instrument deigned to categorize residents' behaviour every 3 seconds.
Forty-nine of the 53 residents completed both self-assessment questionnaires: 18% of residents were "confident" or "very confident" as teachers at beginning of study. After the course, 42% of the experimental group and 22% of the control group
(p < 0.05) were "confident" or "very confident" as teachers. Also, 87% of experimental group felt their teaching skills were improving (vs. 52% control).
After the course, faculty, students, and peers rated 52% of experimental residents as "effective" (vs. 27% of controls; approaching statistical significance). No attempt was made to demonstrate an association of change in attitude with a change in behaviour.
The authors report that "a number of significant correlations were found between the confidence of residents in both groups (experimental and control) as teachers and their perceptions of teaching as a responsibility" (p. 362). Perception of teaching as a responsibility was divided into 4 categories: (1) attitude towards teaching, (2) their role as a teacher, (3) teaching methods, and (4) improving clinical teaching. The range of reported correlation coefficients (absolute value) was 0.26-0.58. If "confidence as a teacher" is accepted as a measure of teaching self-efficacy, it can be assumed that this one item measure of degree of "confidence as a teacher" using a Likert scale is neither as valid nor as reliable as a multi-item scale assessing the same construct. Therefore, one can postulate that the "confidence as a teacher" item in this study is a generic or global (albeit
imperfect) measure of teaching self-efficacy. Of interest, many of the items in Greenberg, Goldberg, and Jewett's (1984) instrument assessing residents' perception of teaching responsibility could arguably be said to assess the various dimensions of teaching self efficacy as described by Ashton (1984). For instance, "Teaching medical students is one of the primary responsibilities of the resident" (p. 362) corresponds with the dimension of "Personal Responsibility for Student Learning" (p. 29) of Ashton's eight dimensions of teaching self-efficacy. It is not surprising, therefore, to find so many (and statistically significant) correlations between "confidence as a teacher" and perceptions of teaching as a responsibility. Most of the items in the perceptions of teaching as a responsibility simply tap the various dimensions of teaching self-efficacy. Further support for this argument will unfold in the methods and results chapters of this dissertation, as many of the items from Greenberg, Goldberg, and Jewett's (1984) instrument assessing residents' perception of teaching responsibility were incorporated into the dissertation's study instrument where good internal consistency reliability was found.
Camp and Hoban (1988) identified the teaching settings encountered by residents: (1) Case presentations; (2) Teaching on work rounds; (3) Teaching clinical skills course to undergraduate medical students; (4) Large group presentations / lectures; (5) Small group presentations / seminars. Although residents are occasionally called upon to lecture and do presentations, most
of their teaching occurs in small groups using a dynamic tutorial style. Apter, Metzger, and Glassroth (1988) quantified the most frequent teaching settings among residents: patients' bedside (45.5%); one-to-one supervision of junior team members (25.5%); "sit-down" ward rounds (23.6%).