The transformation of medical students into physicians requires the engagement of teachers who supervise students in their development of technical skills and applied knowledge and serve as role models of the values, attributes, and life of a professional.1 Residents play a critically important teaching role for medical students in the practice settings of the clinical workplace.2–4 In addition to being most directly involved in caring for hospitalized patients at academic medical centers, they arguably spend the most time in direct teaching contact with clerkship students. In a study by Barrow,5 medical students reported that up to a third of their education was provided by residents. Two subsequent studies confirmed this finding,6,7 and, more recently, medical students indicated that residents were their most important teachers on the wards.8 Residents, themselves, viewed teaching medical students as one of their primary responsibilities and estimated that they spent up to 25% of their time teaching.9 In turn, residents desired formal instruction in methods to improve their teaching skills.2
In recognition of the important role residents play as teachers, accrediting bodies, including the Liaison Committee on Medical Education10 and the Accreditation Council for Graduate Medical Education,11 have emphasized the need for programs to develop resident skills in teaching. Residents, however, face tremendous pressures in the current training environment. The rapid pace of clinical medicine, coupled with work hours regulations, result in residents struggling to balance their responsibilities. Therefore, it is critical that the limited time available for resident professional development be as high yield as possible.
“Resident-as-teacher” (RAT) programs were developed to address this critical need, and in 2001, 55% of U.S. residency programs provided some instruction on teaching for their residents.12 However, these courses vary considerably in instructional methods, length, format, and content.12–14 With respect to content, a review of the literature indicates that RAT programs predominantly emphasize15–17 the One-Minute Preceptor (OMP) model,18 the Stanford Faculty Development Program’s clinical teaching framework,19,20 or domains shown by Irby21 to be essential for clinical teaching excellence. Importantly, however, the teaching strategies included in these models are based on teaching behaviors of distinguished clinical faculty,21 derived from observations of faculty,21–24 or designed for use by faculty in encounters with residents.18 None of these models focus on the content students actually learn from resident teachers or include behaviors specifically identified by students as being effective teaching strategies used by excellent resident teachers.
In 1997, Skeff and colleagues25 argued that teaching improvement courses should have characteristics consistent with empirical studies on effective teaching methods and be designed to address features of the teaching role most commonly played by participants. Despite this call, and the central role of residents in the workplace education of medical students, to our knowledge no studies have explored in depth what third-year medical students learn from residents and which teaching strategies are used by the best resident teachers in their interactions with students. We sought to address these important questions, with the expectation that our findings could help focus the content and teaching strategies that should be emphasized in RAT programs.
We selected three U.S. medical schools with geographic and size diversity, but with similar curricular structures, including two preclinical and two clinical years: Icahn School of Medicine at Mount Sinai (R.K., D.M.), University of Chicago Pritzker School of Medicine (H.B.F.), and Johns Hopkins University School of Medicine (D.C.). We obtained institutional review board approval at each institution and at the University of Illinois, Chicago College of Medicine, because this was the site of two authors (A.S., I.H.) who assisted in study design and data analysis. The study was conducted between January and March 2012.
We conducted focus groups with medical students who were midway through their third year, to obtain the perspectives of students who had sufficient time to experience the clinical workplace environment and reflect on their learning in these venues. Specifically, we invited those who had completed their surgery clerkship, and either their internal medicine or pediatrics clerkships, to provide for purposeful sampling of students who had finished clerkships that were most dissimilar in terms of culture and tasks (procedural versus nonprocedural).
Several previous studies of learners’ perceptions about clinical teaching required them to respond to researcher-generated lists of hypothetically important qualities or skills of the clinical teacher.26,27 However, this use of lists to rank, rate, or select from may prevent the discovery of qualities and skills important to students but not on the lists28; hence, for this study we conducted focus groups to allow for open-ended questions, exploration of ideas, and clarification of statements.
We invited eligible students by e-mail to participate in the focus groups and selected on a first-come first-serve basis. Two one-hour-long focus groups of six to seven students, each, were conducted at each of the three sites. No compensation was provided. We obtained gender, age, and career plans in a deidentified manner at each focus group. Using a semistructured facilitator guide, investigators asked open-ended questions designed to explore students’ learning experiences with residents during the third year. Although focus groups were conducted independently at each site by the site investigator, in advance of the sessions we reviewed approaches to group facilitation to create as much consistency across sites as possible. The four focus group questions relevant to this study were developed by three authors (R.K., H.B.F., I.H.) through an iterative review of the literature and based on their experience as educators. They were:
* Describe the qualities and skills that make a great resident teacher for medical students in the clinical workplace environment.
* Describe the teaching approaches used by great resident teachers when teaching medical students in the clinical workplace environment.
* Describe the type of things you have learned from your residents during your clerkships.
* What do you view as the most important things you learned from your residents this year?
Focus groups were audio recorded and transcribed verbatim in a deidentified manner. Audio files were then destroyed. We analyzed qualitative data using the constant comparative method associated with grounded theory.29 Content units for analysis were words and phrases. Two coders (R.K., H.B.F) independently identified themes for the first three focus groups. The coders then estimated intercoder reliability and reached consensus on themes through discussion. Prior to discussion, intercoder reliability was 88%, and following discussion, agreement was 100%. Coding of the last three focus groups was then divided between the two authors. Focus group data were evaluated for trustworthiness using member checking, in which student participants were asked to review transcripts for accuracy and themes for effectiveness in capturing their perspectives. Following coding, themes were triangulated using available published literature on clinical teaching and RAT programs.
Thirty-seven students participated in the focus groups across all three sites. Nineteen (51%) were male and 18 (49%) were female, with a mean age of 26.6 years (range 24–33). Whereas 19 students (51%) were undecided about their career choice, 8 indicated internal medicine, 4 pediatrics, 2 anesthesiology, and 1 each emergency medicine, radiology, surgery, and plastic surgery.
Teaching methods used by excellent resident teachers
We categorized 228 comments into 20 themes representing the methods used by excellent residents to teach students in the clinical workplace environment (Table 1 and Supplemental Digital Table 1, http://links.lww.com/ACADMED/A184, which offers representative comments for each theme). These themes were then organized into seven domains: role-modeling, focusing on teaching, creating a safe learning environment, providing experiential learning opportunities, giving feedback, setting expectations, and stimulating learning.
Role-modeling, or learning through observation and reflection, accounted for 28% of all comments (63/228). The theme of role-modeling/by example–generally (47/63; 75%) included comments such as that residents taught “more by-example than by explicit stating,” “naming and identifying what they were doing,” and “[through] how they work.” Teaching “by-example” facilitated students’ learning of communication skills, adaptability, lifelong learning, and patient care. Residents’ admitting limitations (7/63; 11%) was another theme, with one student commenting that she learned by observing residents “[being] honest with students about what [they] know and what [they] don’t know.”
Focusing on teaching accounted for 21% of comments (49/228). Within this domain, comments were most frequently classified (24/49; 49%) as finding teachable moments—that is, the effective use of unplanned or informal opportunities to teach in the busy clinical environment. Students commented about residents’ abilities to teach “on the fly,” “even while they are working,” and “see opportunities as potential teaching moments.” Taking time to teach was also identified as a theme (16/49; 33%). Students commented that residents “set aside some time to teach,” even though they were busy. Showing interest in teaching was the third and final theme in this domain (9/49; 18%).
Creating a safe learning environment—that is, establishment of a supportive climate to facilitate learning—accounted for 19% of responses (44/228). The first theme in this domain, offering opportunities for safe practice, relates to experiences that students were afforded by residents to practice and make mistakes in a nonthreatening environment (14/44; 32%). For example, a student commented that “it felt safe … because practicing beforehand let us test stuff out,” and “[they] were given the freedom to be wrong.”
The second theme, establishing rapport with students, focused on efforts by residents to build relationships with students (10/44; 23%). For example, a student commented: “To me the best residents are those that are actually interested in your life. It’s not like they need to be your best friend, but they care, and they’re people.” Offering reassurance, another theme in this domain, focused on allaying students’ fears and concerns about their knowledge and confidence in functioning in the clinical workplace environment (8/44; 18%). Creating a sense of team through leadership and involvement (6/44; 14%) was another theme.
Providing experiential learning opportunities, or ways for students to learn by doing and becoming involved, accounted for 11% of student comments (26/228). Residents facilitated student participation in experiences such as doing procedures, examinations, or literature searches (12/26; 46%), thus helping them make meaning from these direct experiences. As one student stated: “I learned a lot more from being allowed to do something, by working it out by myself rather than just being told how it happens. Residents let me try and that learning really stuck.” Giving opportunities for ownership of patients and involving students in the team were additional themes within this domain.
The domain giving feedback accounted for 10% of student responses (23/228). Students commented that residents who “took the time to think about [their] work and performance” provided “feedback the way it should be.”
Setting expectations, comprising statements related to clarifying student roles and performance standards, accounted for 5% of comments (12/228). One theme, setting expectations for student performance (8/12; 67%), included student comments about “[getting] clear expectations” from residents. Explaining student role explicitly was the second theme in this domain (4/12; 33%). One student commented: “[Residents] know that if we learn how things work and what our role is then their life is easier. It helps us and it helps them.”
Stimulating learning—that is, encouraging students to take control of their own learning—was the final domain and accounted for 5% of comments (11/228). A theme in this domain, challenging students to learn (8/11; 73%), included comments such as “Residents “challenge[d] me to think not only about what’s going on … but what the next steps are and should be” and “pushed [me] toward the next level even if [I] didn’t know what to do.”
Knowledge and skills learned from residents
We categorized 197 comments into 33 themes representing the knowledge and skills students in our study learned from residents in the clinical workplace environment (Table 2 and Supplemental Digital Table 2, http://links.lww.com/ACADMED/A184, which offers representative comments for each theme). These themes were organized into nine domains: patient care, communication, navigating the system, adaptability, functioning as a student/resident, lifelong learning, general comments, career/professional development, and medical content.
Patient care—that is, the knowledge and skills pertaining to direct clinical practice and patients—accounted for 26% of comments (52/197). The first theme in this domain was linking knowledge to clinical care (16/52; 31%) which included comments focused on the application of knowledge to actual patient care. One student stated, “[Residents] taught me how to explain findings and link my formal knowledge of pathophysiology to the clinical case.” The theme of clinical reasoning—that is, how to discern the relevance of data and reason through cases and hypotheses—elicited the next greatest number of comments (9/52; 17%). Students learned how to “[be] rational about … why you go down certain paths with the information you are given.” Other themes in this domain were managing patients (8/52; 15%), physical exam skills (7/52; 13%) and prioritizing (7/52; 13%), or learning how to reorganize work on the basis of importance.
Communication was the second domain and accounted for 21% of comments (42/197). Interacting with others was the first theme (22/42; 52%), with students learning “how to interact with other professionals” and “what was socially appropriate to say and how to interact.” Presenting cases was another theme in this domain (9/42; 21%), and although most students learn case presentation skills prior to their clinical clerkships, our respondents emphasized that residents helped them focus their presentations on “what’s important” and “clinically relevant.” Calling for consults (5/42; 12%), writing patient notes (4/42; 10%), and giving sign-out (2/42; 5%) were additional themes in this domain.
Navigating the system—that is, the logistics, hierarchy, and division of labor in the clinical environment—accounted for 15% of student responses (30/197). The theme of getting things done on the floor relates to the practical steps involved in clinical care (14/30; 47%). One representative comment was “You take the patient into the OR and you have to be with them the whole time, and then … you put the Foley in and you put their compression boots on.” How the system works in the hospital was the next theme in this domain (7/30; 23%). Because students are new to the clinical environment, residents help them “get acclimated to working in the hospital.” Understanding the hierarchy—that is, knowledge related to the chain of command—was another theme in this domain (5/30; 17%), and students “look[ed] to residents just to understand that.”
Comments related to adaptability—that is, the ability to cope and adjust to changes or challenges—accounted for in 11% (22/197) of responses. Within this domain, students learned about balancing work and life (7/22; 32%). As one respondent commented, “You see … how they balance their lives during residency and you see that they still sometimes go out and have fun and things like that.” Responding to stress—that is, how residents cope with the many pressures they face—was another theme (6/22; 27%) in the domain of adaptability. Responding to criticism and feedback was also identified as a theme in this domain (4/22; 18%). Students commented that “the way [residents] respond to feedback [served] as a model for how you might be able to take it or respond to it.” Thinking and responding quickly (i.e., the process of reacting in the moment when necessary [3/22; 14%]) and developing and modifying a routine (i.e., the process of creating and adapting a work routine in the demanding clinical workplace [2/22; 9%]) were the final themes in this domain.
Functioning as a student/resident accounted for 10% of comments (19/197). Roles and expectations of students was the first theme in this domain (9/19; 47%); students commented that residents “explained what [the student’s] role should be” and “set expectations.” How to function as a resident, another theme in this domain, related to learning the expectations and responsibilities of residents (8/19; 42%).
Lifelong learning—that is, the knowledge and skills required to become continuous learners—accounted for 5% of comments (9/197). Self-directed learning—that is, taking control of one’s own learning—was the first theme in this domain (4/9; 44%). Students gained skills in “how to be professionally curious” and “how to learn new [topics].”
General comments accounted for 5% of comments (9/197), and career/professional development accounted for 4% (7/197). Within this latter domain, the career development theme focused on knowledge regarding the next steps in training (4/7; 57%). As one student commented: “The way I look at it, knowing what your eventual career is like is sort of like a stepwise process where it becomes gradually clearer. So the residents have one clearer step than us … like what our lives are actually going to be like when we finish school. So it’s good to get perspective from around the bend that you might not otherwise have.”
The final domain, medical content, also accounted for 4% of student comments (7/197).
This study is, to the best of our knowledge, the first to explore the perspectives of third-year medical students across multiple institutions regarding teaching strategies used by outstanding resident educators and knowledge and skills they learned from residents in the clinical workplace.
Lave and Wenger’s4 situated learning theory suggests that learning is inextricably tied to its context and to the social relations and practices therein. In education for the professions, learning in the practice settings of the workplace is perhaps the signature pedagogy.30 When applied to medical students, this theory suggests that clinical experiences, such as clerkships, provide for the beginning of entry into the professional community of medicine.31
Residents serve as essential teachers of medical students in the clinical environment and contribute in ways that are unique and complementary to the contributions of attending physicians.32 Despite this importance of residents in the clinical workplace and calls for a “more critical evaluation to define the high priority areas in resident teacher training,”32 RAT programs across the country vary considerably and focus on content and teaching strategies largely derived from studies of faculty educators.
Our study identifies teaching methods used by excellent resident educators that are unique from and underemphasized in previously known models of clinical teaching. In addition, our findings clarify what students learn from residents in the clinical workplace environment and challenge an assumption that the content students learn from faculty and residents is the same.
The teaching strategies we identified include some that have not been emphasized or identified previously in models including the OMP,18 Irby’s framework,21 and the Stanford Faculty Development Clinical Teaching Program (SFDP).19,20 The OMP model, designed for use by faculty preceptors with residents in ambulatory practices, includes teaching behaviors to understand and facilitate the learner’s decision-making process.18 The five micro-skills that comprise this model are encouraging the learner to make a commitment to a diagnosis or plan, asking for evidence to support the commitment, providing general information based on gaps or mistakes, offering positive feedback, and correcting errors through constructive feedback. Although this framework may facilitate teaching around a patient encounter, its applicability to the myriad learning interactions students have with residents is less clear. As a result, giving feedback is the one teaching strategy theme identified in our study that maps to the OMP model.
Irby’s21 model of clinical teaching excellence includes domains of knowledge used by distinguished faculty in the context of teaching rounds. Clinical knowledge of medicine, patients, and the context of practice, as well as educational knowledge of learners and general principles of teaching and case-based teaching scripts, make up the six domains of Irby’s model and allow faculty to target teaching to the needs of their learners. Although some of our teaching strategies, including showing interest in teaching, taking time to teach, giving feedback, and establishing rapport with students, can be classified under Irby’s general principles of teaching category, others do not appear to fit. Methods such as offering opportunities for safe practice and ownership of patients, providing experiential learning opportunities, and involving students in the team relate more to the longitudinal workplace-based experiences that students have with residents.
Although more of our teaching strategies can be placed under the SFDP general domains, many of these do not match the descriptive statements in the validated SFDP Clinical Teaching Instrument. Although the SFDP framework was based on theories of learning and empirical observations of clinical teaching,19,20 the SFDP Instrument statements relate more to formal teaching sessions. Themes from our study such as offering opportunities for safe practice, involving students in the team, finding teachable moments, and providing experiential learning opportunities, however, apply more to the workplace environment rather than to formal teaching sessions.
Role-modeling is the most frequently identified method of resident teaching in our study. This theme does not fit into any of the three popular RAT models. Although learning from role models involves a complex mix of conscious and unconscious activities,33 students offered numerous comments about learning through observation of and reflection on their residents’ behaviors. Three previous studies have identified the importance of role-modeling as a teaching strategy. One found resident behavior to be more instructive to medical students than mere provision of facts during work rounds,34 a second demonstrated that perceived teaching effectiveness for residents relates most strongly with being a role model,35 and a third suggested that resident role models are perceived by medical students to be as important as attending physician models to their education.36 Our findings highlight how critical role-modeling is in student clinical workplace learning. RAT programs should include strategies identified in the literature to actively prepare for such teaching through conscious recognition of the importance of role-modeling as a teaching strategy, making the implicit explicit by articulating what is being modeled, and facilitating reflection about the behaviors and attributes being demonstrated.33,37
We also identified other teaching strategies that warrant greater emphasis in RAT programs including finding teachable moments. Although residents consider teaching to be a critical component of their own experience and education,2 given the multiple competing demands they face, it is unrealistic to expect them to devote more time to student teaching. Therefore, offering training on how to adapt teaching to the clinical workplace environment by “thinking out loud” and “teaching while working” are critical in RAT programs.
Offering opportunities for safe practice was identified as another important teaching technique. For students to be absorbed into the professional culture, they must be afforded opportunities to observe, perform basic tasks, and learn the practices of the profession.38 At the same time, research has shown that the process of acculturation is a difficult one for students as they struggle to adjust to the clinical environment.31 Therefore, teaching residents how to offer students opportunities to practice their knowledge and skills in a nonthreatening environment is essential.
This study also identified the knowledge and skills students gained from their resident educators. Students turned to their residents to learn patient management and communication skills, ways to navigate the complex clinical workplace, how to adjust and adapt, and roles and responsibilities. Notably, these content areas do not feature prominently in the three popular RAT models. In the OMP model, the five “micro-skills” stimulate learners to commit to and defend a diagnosis or plan,18 while the SFDP framework and instrument19,20 appear to fit formal clinical content presentations better. Finally, Irby’s21 model emphasizes knowledge of medicine, patients, and the context of practice among the key domains of clinical teaching excellence.
Our findings about what students learn from residents are more consistent with research exploring students’ perceptions of the transition to clerkship years. O’Brien and colleagues31 demonstrated that logistics and adjusting to the culture of patient care (including how to manage patients and problems, how to communicate appropriate information, and what student roles and responsibilities are) were among the most prevalent struggles faced by students entering the clerkship years. Our findings indicate that residents are the teachers whom students turn to in the clinical workplace to address these important learning needs. Finally, student comments about what they learned from residents were least frequently classified as relating to medical content or general medical knowledge. Although knowledge is essential for outstanding clinical care, perhaps this student need is fulfilled by attending physicians or clerkship didactics rather than by residents.
In summary, in addition to stimulating content redesign, these findings offer an opportunity to introduce new methods of teaching and assessment into RAT programs, including having students or outstanding resident teachers as RAT cofacilitators39 and enhancing direct observation and feedback of resident teaching in the clinical workplace environment.
There are limitations to this study. Three investigators led the focus groups, and although we strove for consistency, there may have been differences that influenced students’ comments. We focused on students who had completed some of the most dissimilar inpatient clerkships. The generalizability to residents in other fields and to outpatient settings may, therefore, be limited. In addition, although none of the three institutions offered RAT courses specifically emphasizing the domains we found in this study, residents may have learned these techniques elsewhere, and this could impact students’ comments. We did not include residents in this study, and their perspectives may be a powerful way to capture the congruence between opinions on these important topics. Finally, our work focuses only on the perspectives of one stakeholder group (medical students). Because teaching skills programs should be developed for a participant’s lifelong needs in this area, additional RAT programming may be needed to prepare residents for teaching other learners. Next steps include investigating the perspectives of broader groups of students as well as residents themselves.
Programs developed to enhance the teaching skills of residents have focused on models derived largely from the teaching behaviors of faculty in formal teaching encounters. We propose that, together with teaching strategies used by excellent resident teachers, those content areas that have been identified by students as specific to what they learn from residents serve as a foundation for RAT program development in the future. Not only will this address students’ concerns about learning in the clinical workplace environment but it will also allow for more targeted and efficient teaching by busy residents.
Acknowledgments: The authors wish to thank the medical students who graciously gave of their time to participate in this study.
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