Just Because I Am Teaching Doesn’t Mean They Are Learning: Improving Our Teaching for a New Generation of Learners

The first thing I noticed when I walked into our conference room was that half the residents who were supposed to be attending our small-group session were missing. “Anyone know where the rest of our group is?” I asked.

“Bridget and Tom had to work,” explained Micah, one of the second-year residents. (The names of all the residents have been changed.) “The schedule has changed and we need to start our shift at 2:00 instead of 3:00. Maria’s in the ICU and can’t leave for conference. Ed was on last night and had to go home to sleep; he wanted me to record the session. Is that okay?” I knew about the resident duty hours restrictions and supported the need for residents to get adequate sleep. And I agreed with taping our sessions to make them available for those who could not attend. Nonetheless, it was frustrating to prepare a session for the residents and then not have half of them attend. Although I had heard about the need for more resident coverage to improve our clinical services, I had thought that our conference time would be protected.

“Okay, sure, we can record the session. Has everyone read the article I sent out last week?” I got some awkward stares. “Did you all receive it?”

“Yes,” said Micah, “but I haven’t had time to read it yet.”

“How about the rest of you?” There was silence, which I interpreted as a negative response. “All right. Well, the article is not too long. Why don’t you pull it up now on your computers and read through it for the next 10 minutes? That way, we can all be on the same page when we’re discussing the case.” I had recently written an article about systems-based practice¹ with a resident case from our institution, and since that was the topic for today, I thought the residents would appreciate the timeliness of the article and how I had organized the literature around the case.

As I sat and watched the residents reading I began to feel my enthusiasm ebb. The small-group session was part of a course I had been teaching for many years. The course included many topics that I feel are critically important for a resident physician, topics often neglected in the resident curriculum, like professionalism, medical error, health policy, malpractice, wellness, and narrative medicine. All these areas now connect to various core competencies that all residents are expected to attain by graduation, but they are difficult to teach, assess, and test. A case-based discussion was one of the ways I could usually tell whether residents understood how to approach problems in the health care system. I had looked forward to the energy of an engaged and motivated group in the discussion. And yet … I sensed that they did not share my enthusiasm. I knew these residents well from working with them clinically. They were all excellent clinicians, motivated to learn and succeed. None of them was lazy or irresponsible. So what was the problem?

While the residents read my article, and also after the session was over, I scanned some of the medical literature to find out whether I needed a different educational approach and what the literature might tell me about current challenges to teaching. The first article I came across was by Pratt et al.² They described five alternative perspectives on good teaching: transmission, developmental, apprenticeship, nurturing, and social reform. Each perspective had a set of concepts about learning and methods for reaching the learning goals. For example, the transmission perspective, which I often use during lectures and is the most common perspective according to Pratt et al, involves presenting material accurately and efficiently so that learners can master the material. For this perspective, success depends on the teacher’s being prepared, having clear objectives, being enthusiastic, and providing answers to questions. In contrast, the developmental perspective has a more learner-centered focus and attempts to influence ways of problem solving and thinking through the presentation of cases and problems.

These two perspectives seemed most consistent with my usual approach to our class. I had followed the guidelines outlined by Pratt et al by reviewing previous literature and published materials and choosing a stimulating case. So what was wrong?

I came across an article by DaRosa et al³ that discussed the impediments to good teaching. The authors identified curricular, cultural, environmental, and financial barriers. I felt that several of the impediments they identified might be creating problems for our course. In particular, the time constraints and conflicts with clinical work seemed to be diverting the attention of the residents. There also might be a tension between providing problems that would encourage critical thinking and discussion versus providing content that the residents could use to pass their in-service exam. The residents in my course seemed acutely aware of the need to ultimately pass that exam and the later certification exam, and they valued any material that could help. And there may have been some confusion in the curriculum about what the goals for learning and what the assessment would be for the topic areas that I was supposed to teach. How important was attendance and participation at the session to the program director, and how could I demonstrate that the residents had improved their knowledge or behaviors because of our session? DaRosa et al suggested developing more clarity related to the goals and objectives and better support to faculty, including faculty development. Murnaghan et al,⁴ in a comprehensive review of graduate medical education pedagogy, identified the usefulness of case presentations such as the one I was using but also suggested shorter teaching segments and supplementary online materials to compensate for less time currently available for teaching.

Later, I also looked at articles that addressed how to recognize and support medical teachers and help them overcome the barriers identified by DaRosa et al. Sachdeva et al⁵ defined a continuum of skills and leadership for clinicians involved in surgical education, from the clinician–teacher who participates in educational activities for students and residents to the clinician–educator who develops scholarly skills and engages in scholarship and leadership in medical education in addition to teaching. The authors believed that by recognizing the distinctions between the various clinicians’ levels of commitment and expertise in education, incentives and rewards could be tailored to excellence in education, helping to build the field.

Varpio et al⁶ have further defined various roles in health professions education and scholarship in recognition of the growing field of medical education research. There are now many types of programs that can prepare students, residents, and faculty for educational roles that include PhD programs in medical education as well as one-year fellowships, master’s degrees in health professions education, and master’s degrees in education.

Sullivan et al⁷ in this issue of Academic Medicine describe a novel MD–master’s in education joint-degree program for medical students. There are also institution-based faculty development programs in medical education and specialty-based faculty development programs, some of which grant degrees while others offer certificates. Also in this issue, Baldwin et al⁸ describe a program sponsored by the Academic Pediatric Association that provides face-to-face and online education over three years and mentorship for a scholarly project in education. Finally, in this issue, Jordan et al⁹ analyze educational fellowship programs in emergency medicine that are institutionally supported.

While most faculty development in education focuses on full-time faculty, there has been an increasing recognition of the importance of community faculty in educating medical students. In this issue, Drowos et al¹⁰ report their survey of clerkship directors in family medicine about faculty development needs for community preceptors, and Beck Dallaghan et al¹¹ describe interviews with community pediatric preceptors. Their studies suggest that there are gaps in the preparation of community faculty as teachers as well as increased demands on the preceptors for patient care, and emphasize the importance of maintaining community preceptors’ motivation for teaching through payment or other incentives.

Faculty development programs for community physicians allow educators to diffuse the latest information about teaching and assessment to community physicians, recognizing that experience in clinical medicine does not necessarily equate to expertise in teaching and that changes in care delivery require continued education. In this issue, McMahon¹² emphasizes that continuing medical education (CME) and continuing professional development should be integrated into the career trajectories of all physicians so that training continues beyond residency. He notes the opportunities for integrating CME with quality improvement and institutional strategy to improve quality of care. This kind of integration is also likely to improve learners’ engagement in their CME.

Involvement of both community and academic physicians in the education of medical students and residents not only benefits the learners, it also benefits the teachers, who learn through the educational interchange and get exposure to new information being taught to the learners. If the learners and teachers can work together on quality improvement projects, the educational benefits can extend to improved patient care outcomes. In this issue, Wong et al¹³ describe educational situations where content is new to both the learners and the faculty, as is typical in quality and safety education. Such interactions are described as co-learning, as faculty and students work and learn together through solving quality improvement and patient safety problems. There is a great range of opportunities to improve teaching skills and educational scholarship in the continuum of medical education, and we need to encourage and support our next generation of faculty to avail themselves of these opportunities for continued growth and development.

When the residents finished reading my article, we discussed the case embedded in it, and they contributed examples from their own experiences to compare and contrast with what I had presented. One of the residents described a failure of the communications system with radiology that led to a misreading of a CT scan and the inappropriate discharge of a patient with a serious missed injury. Our discussion became increasingly lively and moved from intellectual concepts to a consideration of emotion as the resident shared his reaction to the error and how he had tried to cope with that reaction. We discussed the resources for residents and faculty who have had a stressful experience associated with an error and the possible legal consequences. We then discussed what the resident might do as an individual to avoid such a problem in the future as well as how we could build better systems of communication for everyone. These topics led to a difficult examination of the impediments to improving those systems, such as finance and power issues in the health system hierarchy. Several of the residents shared their frustration at their inability to fix problems at the hospital in spite of what they felt were obvious solutions, and how these examples represented vulnerabilities in our care system.

An outsider viewing our discussion might have pointed out that we wandered from the main point of the session and that we were somewhat unfocused in what we considered. But I suggest that our discussion was an example of what can happen when teachers and learners dissect authentic problems and pursue the implications, relentlessly following the threads wherever they lead and asking questions at every turn until we understand what we know about the problem and what questions remain for us to continue to investigate. In some ways we covered the entire year’s curriculum that day, although we did not resolve all our questions or concerns. We uncovered ethical problems, clinical problems, systems problems, and psychological problems that would all stimulate our thinking long after the class was over.

As we were leaving, several of the residents thanked me for listening and allowing them to share their stories. What had begun as a discouraging class had ignited our imaginations, curiosity, and emotions. In the end, we used many of Pratt and colleagues’² perspectives of medical education, including those of nurturing and social reform, as we searched for a deeper understanding of the case. I think that good education always has to be open to following the threads wherever they lead, and a good teacher needs to be able to help make the threads visible and, in the end, grasp them and try to weave them together so that the current chapter of the story can have an ending that the next meeting can build on.

While we should improve the skills of our teachers through various continuing professional development programs, and should continue to shape and evolve our teaching by using the findings and insights from the literature on innovations in medical education, we must also recognize the value of the unscripted journey of a teacher guiding a group of learners through the back alleys and dead ends of a case presentation, since that journey can sometimes contribute as much understanding as the straightforward trip along knowledge highways.

David P. Sklar, MD