January 2020

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Residents as teachers



Objective assessment of resident teaching competency through a longitudinal, clinically integrated, Resident-as-Teacher curriculum.

Zackoff M, Real F, DeBlasio D, et al. Academic Pediatrics. 2019;19(6):698-702.  https://doi.org/10.1016/j.acap.2019.01.011

Reviewed by Molly Rideout

What was the study question? Is a Resident-as-Teacher curriculum effective at improving teaching efficacy in first-year pediatric residents as assessed through Observed Structured Teaching Encounters (OSTE)?

How was the study done? In a single-center study (Cincinnati), researchers provided a Resident-as-Teachers curriculum to all interns consisting of workshops with reinforcement through clinical teaching inherent to residency. Interns completed an OSTE prior to the program and prior to the start of their PGY-2 year. A historical control group took the same OSTE prior to the start of their PGY-2 year (this group had not taken the OSTE prior to their PGY-1 year). The workshops covered three education topics: brief didactic teaching, feedback, and precepting. OSTE’s involved clinical cases with a simulated clerkship student. Videos of the resident teacher were viewed and scored based on standardized rubrics by 2 separate viewers.

What were the results? Interns who participated in the program had a statistically significant improvement in performance in all three teaching areas: brief didactic, feedback, and precepting. Comparison of OSTE results prior to the PGY-2 year for participants and the control group showed higher scores for the brief didactic area only. Since the historical control group did not take the OSTE prior to their intern year, researchers were unable to compare the degree of improvement attributable to the experience of residency itself. The OSTEs demonstrated excellent agreement between reviewers.

What are the implications of these findings? Most, if not all, prior studies have relied on resident self-report of satisfaction and teaching performance. This study uses an objective assessment tool to measure teaching ability in residents. The use of their tool could prove useful to other programs in assessment of resident teaching skill and resident-as-teacher programs. (note- tools are available in a MedEdPORTAL publication from 2015 of which Amy Fleming is a co-author…)

Editor’s note: Wow, this is a very positive study showing there is an extant Resident-as-Teacher curriculum that objectively demonstrates positive results. Dissemination of both the curriculum and the OSTE (love it!) could be of great value for all residency programs. (RR)

 How to make the honor rol(e)…

Enhancement of role modelling in clinical educators:  A randomized controlled trial.

Mohammadi E, Mirzazadeh A, Sohrabpour AA, et al.  Medical Teacher (2019) https://doi.org/10.1080/0142159X.2019.1691720

Reviewed by Janet Meller

What was the study question? Does a longitudinal faculty development program enhance the effectiveness of faculty as role models?

How was the study done? Junior clinical faculty involved in teaching residents or medical students at the two hospitals affiliated with the Tehran University of Medical Sciences were invited by email to participate.  Thirty-five faculty members agreed to participate and were randomized into intervention and control groups.  The intervention group participated in a 3-month program with onsite and online activities.  Onsite activities included mini-lectures by highly regarded senior faculty, role play and group discussions.  Online activities included video clips and podcasts.  All faculty were required to reflect on their role modelling experiences.  The effectiveness of the program was then evaluated by the intervention group.   In addition, intervention and control groups completed a questionnaire designed to self-evaluate skills in role modeling before and after the program.  Finally, residents and students who had worked with faculty from either group for at least 2 weeks evaluated them before and one month after the program using the Role Model Apperception Tool (RoMAT), a previously validated tool to evaluate role modelling.  502 RoMATs were completed in all.

What were the results? The faculty who participated in the intervention rated the program highly using a 12-item questionnaire (overall mean 4.7 out of 5, SD 0.5).  The self-evaluation questionnaire showed a statistically significant increase in the skills of the intervention group (but not the control group).  The learner-completed RoMAT score, however, showed no difference between the two groups either before or after the intervention.

What are the implications of these findings?   Although the intervention group was not rated differently than the control group by the learners, the junior faculty members thought that their effectiveness as role models was improved by the program. It is important to help faculty become successful role models and an intervention such as the one described could be a useful faculty development tool.

Editor’s Note:  An interesting sidelight: the authors mention another study in which faculty improved their RoMAT scores simply by receiving their peer-normed results and having an opportunity to be tested again.    Perhaps a quality improvement model in which faculty receive ongoing feedback and make small changes could be combined with the intervention described in the study to bolster the results. (JG)

Navigating Hierarchy in Clinical Environments

Medical student strategies for actively negotiating hierarchy in the clinical environment.

Vanstone, M. and Grierson, L. (2019). Medical Education, 53(10), 1013-1024. doi:10.1111/medu.13945

Reviewed by Daniel Herchline

What was the study question? How do medical student clerks experience the clinical learning environment from their lowstatus positions in the social hierarchy?

How was the study done? The authors used a combination of ethnography followed by formal interviews in order to answer the research question. They data that was collected was analyzed using constructivist grounded theory.

What were the results? The authors conducted 88 hours of observations and 13 interviews with 9 clerkship students across 6 core rotations. Although recruitment was not based on any a priori criteria, the authors highlighted the diversity of the participants by asking them to describe themselves, focusing on unique qualities and traits. The authors describe a theory of how clerkship students navigate hierarchy in the clinical environment through a cycle of (1) appraising, (2) selecting, and (3) enacting strategies for interacting with supervisors and building strong personal relationships. In the appraisal phase, students aim to understand how they fit into a new clinical environment by appraising their supervisor, self and the environment. Strategy selection is based on the appraisal, and considers the circumstances of the rotation and the needs of the people they are working with. In the enacting phase three strategies commonly employed by the participants included (a) exhibiting deference to one’s place in the hierarchy, (b) contributing to team goals, and (c) demonstrating interest in learning and improvement. As students progress through clerkship, they monitor reactions and adjust their behavior.

What are the implications? Clerkship students devote a significant amount of time and effort toward navigating social hierarchies during clinical rotations. Making this process more explicit may assist learners in becoming more socially effective in the clinical environment. However, this study also reinforces the importance of setting clear expectations with learners and also highlights the need for more transparency in learner assessment.

Editor’s Comments: This study obtained rich data from a combination of extensive observations and follow up interviews. The findings emphasize the social and relational aspects of the clinical learning environment. Creating a supportive learning environment with clear expectations may go a long way in integrating junior learners and ease the burden of appraising, selecting and enacting strategies to negotiate the hierarchies in the clinical learning environment. (KFo)