The word “doctor” is derived from the Latin verb “docere,” meaning “to teach.” First used in the 14th century, its persistence over 800 years as a designation for a practitioner of medicine underscores the importance of teaching in medical practice and medical education. Teaching as a necessary skill and duty has been reaffirmed by the Liaison Committee on Medical Education and Accreditation Council for Graduate Medical Education (ACGME), the major accrediting bodies that oversee medical student and resident training in the United States, respectively.1,2
Providing teaching skills to doctors-in-training has roots in graduate medical education. Residents are charged with the educational responsibility of teaching their medical students and peers. So crucial is their teaching role that 67% of medical students in one survey felt that residents played a significant part in their learning and that one-third of their knowledge could be attributed to residents' teaching.3 In response to the need to make residents better teachers, training programs established residents-as-teachers curricula. A 2001 survey of U.S. residency programs revealed that 740 out of 1,346 (55%) offered formal instruction in teaching skills.4 Evidence suggests that such programs have been increasing, especially with the advent of the ACGME competencies.2 For example, between 1993 and 2001, internal medicine programs offering teaching instruction more than tripled: from 20% in 1993 to 65% in 2001.4
In the 1990s, at the same approximate time as the initiation of the first residents-as-teachers programs, published accounts of medical students serving as teachers began to appear. The rationale for the emergence of medical students-as-teachers (SAT) training programs at the undergraduate level is summarized in a recent literature review by Dandavino et al5: Medical students are future residents and faculty members who will have teaching roles; as teaching is an essential aspect of physician–patient interaction, medical students may become more effective communicators as a result of such training; and medical students with a better understanding of teaching and learning principles may become better learners. A case can be made for senior medical students in particular as candidates for SAT programs. Having had four years of medical training and about to transition to the teaching responsibilities of internship and residency, they are at a developmentally ideal stage for training as teachers.
Although it is difficult to precisely chronicle the evolution of SAT programs, Pasquinelli and Greenberg6 recently reviewed all published reports of such programs from 1974 to 2005, finding 25 in which students served as teachers, and of those, 19 offered their students some form of teacher training. They also found seven published accounts of courses specifically devoted to the theory, principles, and practice of teaching and learning, ranging in length from just four hours to 12 sessions over 10 months. Because their review was limited to published reports, we assumed their numbers likely underestimated the number of operative programs.
In 2005, leaders at eight Northeast Group on Educational Affairs (NEGEA) schools, each with active SAT programs, began a collaboration leading to several workshops and discussion groups presented at various venues, including three Association of American Medical Colleges (AAMC) annual meetings.7 The energy, enthusiasm, and innovation from participating educators convinced the NEGEA group (represented by the authors of this report) that it would be useful to document programs that were occurring around the country. To this end, we conducted a survey of accredited MD-granting U.S. medical schools to elucidate the prevalence and characteristics of SAT programs. We anticipate that the results of this survey, including a description of the opportunities and barriers to creating these curricula, will provide valuable information for those seeking to begin, redesign, or improve their SAT programs.
We surveyed 130 accredited MD-granting U.S. medical schools represented by the AAMC. The survey was addressed to the dean, the dean for medical education, or the associate dean for curriculum at these institutions. We used the work of Morrison and colleagues4 as a template in designing the survey. Their national survey on residents-as-teachers focused on programs offering formal instruction in resident teaching skills. We pilot-tested a draft version of the survey with a steering committee of 11 faculty members from our group of eight NEGEA member institutions with SAT programs. On the basis of their responses and feedback, we revised the final survey. In January 2008, we sent the URL for the online survey to potential respondents by electronic mail. We tracked nonrespondents and sent them periodic reminders via electronic mail. Directed telephone calls were also conducted encouraging completion of the survey. The online survey was closed to respondents in April 2009.
The survey contained 23 items. The first 4 were to be completed by all respondents: 3 demographic questions and a fourth question, “What teaching role do medical students have in your institution?” The remaining 19 survey questions were to be completed exclusively by respondents with formal SAT programs. We defined “formal program” as a course wherein students must register and receive course credit and students must complete some type of classroom education that focuses on teaching skills training. Sixteen of these 19 questions were designed to characterize formal programs' student participants, programmatic features (formats, teaching methods, content, hours, special benefits for students), and evaluation methodology. These items presented respondents with a series of choices (“check as many as apply”), including “other” as the final choice. For each item, respondents could also write free-text comments.
The last 3 of the 19 items were open-ended questions: Describe benefits of your program; describe barriers; and describe anything else. Qualitative methods were used to analyze the data collected from the last 3 open-ended questions. The responses to the “anything else” question were incorporated into the analysis of the benefits and barriers questions. Through inductive analysis the investigators searched the data for clusters and patterns of meaning, which were labeled as themes. Comments were matched to the identified themes. Two researchers (S.J.P. and L.K.) independently analyzed the raw data, and verbatim quotes were used to support the themes that emerged. A third researcher (N.S.S.) served as peer reviewer to confirm the accuracy of the results obtained. Basic descriptive statistics obtained using SPSS/PASW Statistics 18.0.1 formed the foundation of our data analysis.
Of the 130 institutions to which we sent questionnaires, 99 responded (76%). Mean school student class size was 143 (range 31–308). Medical students in each and every one of these institutions were assigned some educational role, including peer tutor or peer mentor, teaching assistant in various courses, and/or contributor to curriculum design in their medical school (Table 1).
Respondents with formal programs
Although medical students made significant teaching contributions in all of the 99 responding institutions, only 43 (44%) of these schools offered a formal teaching skills program.
Forty-one (95%) of the 43 respondents with formal SAT programs indicated that this training was offered to Year 4 students; 7 (16%) to Year 3 students; 5 (12%) to Year 2 students; and 5 (12%) to Year 1 students. Four medical schools indicated that the training was mandatory for all Year 4 students.
The number of students who participated in these formal teaching skills programs ranged from 2 to 230. In 6 (15%) of these 43 institutions with formal teaching skills programs, each student taught more than 30 hours per academic year, in 17 (39%) between 12 and 30 hours, in 6 (15%) between 6 and 12 hours, and in 10 (23%) between 3 and 6 hours per academic year.
Reported benefits for students participating in the SAT programs included course credit (32 institutions, or 74%) or a note of commendation in the dean's letter or their medical school transcript (18, or 43%). Three institutions provided stipends for their students ($15 per teaching session for two institutions and $3,000 per academic year for the other).
The majority of these SAT programs were taught by a combination of MDs and PhD, EdD, or master-level educators (23 institutions, or 53%). Nine (21%) of these programs involved other health-related educators such as social workers, nurses, and physician assistants. Faculty MDs taught solely in four (9%) of the SAT programs, whereas another four (9%) programs involved MD plus MD trainees such as residents and/or fellows. PhD, EdD, or master-level educators solely taught in three (7%) programs.
Thirteen (31%) SAT programs were offered as two-week or four-week electives, 13 (31%) as periodic sessions longitudinally over the academic year, and 12 (28%) as a one-time retreat or workshop. Twenty-one (49%) of the 43 respondents indicated “other” in response to this question about their SAT program format. Free-text responses revealed innovative formats more complex than the survey options. One included structuring the program as an area of concentration in medical education, culminating with a capstone project. Another integrated it throughout the four years of undergraduate training. A third integrated its senior students into first-year basic science courses as field experience. A fourth described a curriculum ambassador program that connected students with faculty members who have a curriculum improvement project within the institution.
Overall, small-group work (34 programs, or 79%), lectures (31, or 72%), and role-playing (28, or 65%) were the predominant teaching strategies that these 43 institutions used for their formal teaching skills curricula. Less commonly used strategies included direct observation of actual (20, or 47%) and simulated (13, or 30%) teaching sessions. Free-text responses revealed still other methods: students learning through interviewing faculty who were known to be effective teachers and students learning through analyzing directed readings. There was variability in the hours of instruction offered to medical students in these SAT programs. Nine institutions (23%) offered more than 30 hours of instruction time, 12 (30%) offered 12 to 30 hours, 7 (18%) between 6 and 12 hours, 6 (15%) between 3 and 6 hours, and another 6 (15%) less than 3 hours.
Small-group facilitation (33 institutions, or 77%) and giving effective feedback (33, or 77%) were the predominant content areas of formal teaching skills curricula. Other content areas included principles of adult learning (28, or 65%), teaching a physical examination or procedural skill (23, or 53%), teaching around a case (19, or 44%) or in the presence of the patient (12, or 28%), and supervising medical students' care of patients (7, or 16%). Other interesting content areas emerged in the free-text responses: teaching students to serve as standardized patients and as standardized students, and teaching students to be team leaders.
Forty-one (95%) of the 43 SAT programs evaluated the teaching performance of their student participants (Figure 1). The majority of these programs (30, or 72%) asked medical student recipients of the teaching to evaluate the skills of their student–teachers. Direct observation and/or videotaping of actual or simulated teaching encounters were used by 24 (59%) of these programs. Seventeen (41%) asked the medical students who completed the program to evaluate their own skills or attitudes using a pre/post or postcourse questionnaire. Fewer used faculty or residents to evaluate the students' teaching skills (11, or 26%). A majority of the programs (32, or 75%) provided grades for their course, mostly using a pass/fail/honors system. Seven programs (25%) did not provide grades.
Most of the 43 institutions (34, or 80%) conducted programmatic evaluations of their SAT programs (Figure 2). Twenty-three (68%) programs conducted satisfaction surveys of students who were taught by the program's student–teachers. Other programmatic evaluation methods included surveys of the student–teachers about their satisfaction with the training they received (20, or 59%) and surveys of faculty (8, or 23%) about perceived improvement of their students' teaching.
Responses to open-ended questions
Thirty-nine (91%) of the 43 institutions with formal SAT programs responded to the open-ended questions of the survey.
Benefits to implementation.
Six general themes were identified as benefits in having an SAT program:
* development of future physician–educators (9 programs, or 23%),
* enhancement of medical student learning (7, or 18%),
* providing teaching assistance for faculty (6, or 15%),
* contributing to curriculum development (4, or 10%),
* enhancing teaching effectiveness (3, or 8%), and
* strengthening student–teachers' clinical skills (3, or 8%).
Representative quotations appear in Table 2 for each theme.
Challenges or barriers to implementation.
Five themes were identified:
* competition with other educational demands (17 institutions, or 44%),
* difficulty in the recruitment and retention of faculty (10, or 26%),
* difficulty in convincing others of the program's value (8, or 21%),
* lack of commitment of medical students (6, or 15%), and
* inadequacies in the evaluation process of student–teachers (5, or 13%).
Nine (23%) respondent institutions saw no implementation barriers to their formal SAT program (Table 3).
The national survey of SAT programs that we conducted provides a current picture of students as teachers in U.S. medical schools. Use of students as teachers was universal: Each and every one of the 99 responding schools valued the teaching abilities of its students enough to give them teaching responsibilities, most often as peer tutors for students needing extra academic help. Only 43 schools (44%), however, offered formal, comprehensive programs to train their students to teach effectively. Evidence from graduate medical education indicates that the skills of untrained teachers are suboptimal and demonstrates that formal training creates better teachers. This evidence provides a strong rationale for formal training to be offered in every medical school that gives its students a teaching role.8–11
Our research was primarily concerned with the training approaches of the 43 schools with formal SAT teaching programs. Comparing our findings with data from the residency surveys, the similarities we found between SAT and residents-as-teachers programs were striking. Small-group facilitation, giving feedback, and principles of adult learning were the most common content areas for both types of programs.12 Both types of programs also used the same teaching formats: small-group work and lectures.12 For graduates of SAT programs, the similarity between these and residents-as-teachers programs poses a risk of redundancy—of experiencing “more of the same” in residency programs. Although the reinforcement of principles is desirable, vertical progression is necessary and coordination between undergraduate and graduate programs is clearly needed. One model in the literature introduced the teaching skills curriculum during Year 2 of medical school and then integrated it into programs for senior students and residents.13 This seems to be a step in the right direction, and additional models for vertical integration should be developed and tested. One potential direction is for residency programs to offer advanced teaching skills that will be of particular relevance to their specialties.
Most formal SAT programs evaluated their student–teachers as well as their programs, and, of note, the majority of programs went beyond sampling the satisfaction of their participants. Almost 70% of programs relied on student–learners' assessments of their student–teachers, a valid and reliable approach when done with appropriate rating scales and prepared learners.14,15 An impressive 59% used direct observation by faculty members. No program, however, reported long-term outcome evaluations such as assessment of the student–teachers' teaching competence as residents. Studies to evaluate such outcomes should be a priority for the future, as should studies to determine the need for and timing of reinforcement of skills. Ideally, outcomes evaluations should determine whether medical students who have completed a formal teaching skills program have become better teachers, better learners, and better physicians. Measuring these outcomes might be difficult, and a direct link to an SAT program would be difficult to prove. Surrogate measures, however, may be more feasible as described by DaRosa.16 For example, outcomes such as evidence that graduates of such SAT programs are likely to develop new educational initiatives, are awarded more teaching awards, or pursue careers involving medical education at a higher rate than those graduates without formal SAT training would support the positive impact of SAT programs.
Both free-text responses and our qualitative analysis of responses to the survey's three open-ended questions provided valuable complements to the numerical data. From the free-text responses, especially interesting were descriptions of innovative content areas and formats devised by several programs. A mechanism for sharing such innovations (and others that evolve) with a wider audience would be desirable. Morrison and colleagues have developed a residents-as-teachers Web site whose “What others are doing” section could be expanded to serve this function for undergraduate as well as graduate programs (http://www.residentteachers.com). MedEdPORTAL is another possible repository (http://www.aamc.org/medportal).
Our qualitative findings show useful information and some interesting differences regarding respondents' perceptions of the benefits and barriers relating to SAT programs. For example, one barrier theme that emerged was institutional resistance to accepting SAT programs, stemming from faculty doubts that students could be effective teachers. Though regarded as a barrier in some schools, student teaching was nonetheless considered a benefit in others. Endorsing their students' ability to teach effectively, these schools valued their students' abilities enough to rely on them to alleviate pressure on busy teaching faculty. Recent work sheds light on these conflicting views of students as teachers, demonstrating empirically that student–teachers can rival and in some instances exceed the regular faculty in teaching.17,18 Ten Cate and Durning19 highlight this and explore the theoretical foundations for SAT programs, referred to in this literature as peer-assisted learning programs. Lockspeiser and colleagues also discuss theoretical reasons for the special quality of peer-to-peer teaching, including cognitive and social congruence between peer teachers.20 This literature plus shared information from programs with successful experiences can be compelling resources for educators who meet institutional resistance to SAT program development.
In considering future directions for SAT programs, we have already pointed to the need for vertical integration of student and resident programs. If this integration were carried even further to the faculty level, the result could be an institution-wide culture of education with shared learner-centered values and skills. In this sort of culture, the playing field would be leveled and students, residents, and faculty would share the respected role of adult learner. Such a culture shift could significantly affect medical center interactions, raising important questions for future research. Would a universal culture of teaching improve persistent problems in the teacher–learner relationship? Mistreatment of learners by teachers is still reported by 17% of 13,102 students on the 2009 AAMC Graduation Questionnaire.21 Would a universal culture of education affect the clinician–patient relationship? A number of authors suggest the importance of exploring an association between teaching and health care outcomes.7,22
Another direction for the future is the establishment of competency goals for medical students who are learning how to teach. It has been suggested in a recent literature review of SAT programs that the general objectives of such programs should be threefold: providing medical students with knowledge about the basic principles of education and effective teaching; improving students' education skills and appropriate use of teaching strategies, as well as self-directed learning; and changing students' attitudes about the importance of the physician-as-teacher role and decreasing anxiety about early residency teaching responsibilities.5 A competency framework to operationally meet these objectives, however, has yet to be agreed on, though some authors have taken steps in that direction.5 A recently published article from Molenaar and colleagues23 in Holland describes a framework of competencies for medical teachers that could provide a common language to communicate about various aspects of teacher development and could serve as a foundation for the definition of teacher qualifications. Educators from the 43 schools identified by us with formal SAT programs, who among them have a wealth of experience, are ideally positioned to take on this challenge. Together, they could reach consensus on what teaching competencies a graduating medical student should bring to residency. Establishment of competencies is a natural next step in the educational evolution of a field—a step modeled in the area of graduate medical education by the ACGME.
Our study does have a number of limitations. First, in an effort to develop a manageable survey length for completion by potential respondents, we may have failed to capture additional rich program data of the sort presented in the free-text responses of the respondents. A follow-up focus group would have been a useful method to capture such data. Second, because this national SAT survey focused only on institutions that have formal teaching skills programs, it did not assess if and, more importantly, how schools without such formal programs trained their students. Our definition of “formal” teaching program is limited and possibly missed informal programs within the institutions that did not fulfill our definition. Lastly, the survey did not receive responses from 31 of the 130 schools surveyed. Responses from those schools may have altered our results.
Our national survey of SAT programs at U.S. medical schools provides an up-to-date picture of current practices. The survey documents a rich diversity of approaches that should prove useful in informing the future efforts of schools interested in developing SAT programs. Responses also show that every responding school used medical students for teaching, suggesting widespread support for medical school as an ideal time to prepare doctors-in-training for their teaching roles. The evidence supports the future implementation of a formal SAT program in every school where medical students teach. Also needed are models for integration of undergraduate and graduate programs and national teaching competencies. Finally, research is needed to determine which SAT curriculum methods work best, when and how to conduct skills reinforcement, and what long-term outcomes result from SAT programs. Outcomes of particular interest include the impact of SAT programs on patient care, on the selection decisions of residency directors, and on the teaching effectiveness of residents.
The authors wish to thank Christopher Akos Morriss for his invaluable literature review for the study.
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