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REGULAR | September 01, 2008

Exposure to Child and Adolescent Psychiatry for Medical Students: Are There Optimal “Teaching Perspectives”?

Jeffrey Hunt; Rowland Barrett; W. Lex Grapentine; Gina Liguori; Harsh K. Trivedi

Academic Psychiatry 2008;32:357-361.

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Received April 15, 2007; revised September 9, 2007; accepted November 14, 2007. Drs. Hunt, Barrett, Grapentine, and Trivedi are affiliated with the Division of Child and Adolescent Psychiatry at Brown Medical School in Providence; Ms. Liguori is affiliated with Bradley Hospital in Providence. Address correspondence to Jeffrey Hunt, M.D., Division of Child and Adolescent Psychiatry, Brown Medical School, Bradley Hospital, 1011 Veteran’s Memorial Parkway, East Providence, RI 02915; Jeffrey_hunt@brown.edu (e-mail).

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Abstract

Objectives: The ability to develop quality medical student exposures in child and adolescent psychiatry is critical to the professional development of these future physicians and to the growth of recruitment efforts into the field. This study identifies teaching perspectives among child and adolescent psychiatry faculty to determine whether there are optimal perspectives that positively influence medical student satisfaction. Methods: Eighty-eight third- and fourth-year students at an allopathic U.S. medical school assessed teacher performance over a 1-year period using a standard internal teacher evaluation. Three experienced faculty members teaching the medical student seminars each completed a Teaching Perspective Inventory. The authors compared the different teaching perspectives with student satisfaction scores on the standard teacher evaluation instrument. Results: All teachers had two dominant perspectives and one recessive perspective. Each teacher had a predominant developmental perspective but they differed in other dominant and recessive perspectives. The transmission perspective was associated with significantly less favorable scores on the standard teacher evaluation compared to the apprenticeship and nurturing perspective. Conclusion: The authors discuss the value of teaching perspective identification among child and adolescent psychiatry faculty for medical student education.

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Methods

Abstract | Methods | Results | Discussion | References

The American Academy of Child and Adolescent Psychiatry (AACAP) has declared that its top priority for the next decade is to increase recruitment to address the significant workforce shortage (¹). It is believed, though not proven, that recruitment depends on adequate and optimal exposure during medical school. Stubbe (²) reported that mentorship by child psychiatrists during medical school was the most important reason for choosing child psychiatry as a career in surveyed trainees. Additionally, it is the opinion of the authors that all medical students need to learn the core knowledge in child psychiatry as they may be faced with having to care for youth with mental illness; it is also clear that most medical schools do not provide this educational experience. In introducing medical students to the field of child and adolescent psychiatry, the quality of these educational experiences is critical.

Surveys of medical schools in the United Kingdom, United States, Europe, and Canada have shown diversity in the teaching of child and adolescent psychiatry (³—⁵). There was agreement, however, that physicians need to understand children and their families from a developmental perspective as well as to understand early occurring psychopathology (⁶). This is particularly true for primary care practitioners, but is also true for any specialty that has direct or indirect interaction with children, including interactions through adult patients or through various medical procedures to which pediatric patients might be subject. When the decision has been made to expose medical students to child and adolescent psychiatry, significant variation remains in terms of what should be taught (⁵) and how it should be taught.

An important educational principle relating to how students are taught is "teaching perspectives." Pratt et al. (⁷) defined a series of well-validated teaching perspectives—an interrelated set of beliefs and intentions that give direction and justification to actions in teaching—which outline teacher values that can potentially impact the student’s learning experience. These authors described five teaching perspectives (Table 1 ).

Study Design

This study assessed the relative importance of the teaching perspectives of three experienced teachers in a 4-hour child and adolescent psychiatry seminar as part of a 6-week core psychiatry clerkship in a Northeastern allopathic U.S. medical school.

Three separate seminars led by three different teachers, each with differing teaching perspectives and frequencies of teacher-student interaction, were compared. Each seminar was videotaped once to provide documentation of teacher-student interaction. The level of student satisfaction with each of the seminars, as measured by a standard internal teacher assessment tool, was the defined outcome variable. We hypothesized that students would prefer more interactive teaching (⁸). Since teachers with a transmission perspective are less interactive with students, we thought that this perspective would be the least favored.

Participants

The study participants were medical students who attended child and adolescent psychiatry seminars during their core general psychiatry clerkship. Appropriate written consent was obtained from the participating students. The study period occurred over two academic years (2004—2006). A subset of 11 students from only one of the seminar dates completed the Kolb Learning Style Inventory (⁹). Previous studies of physicians and medical students using the Kolb Learning Style Inventory suggested that certain learning styles would predominate but that in most groups of students all four quadrants would be represented (¹⁰). These four styles of learning are within a complex continuum and are broadly defined as follows: diverging (learner is intuitive and uses emotions to learn); assimilating (learner prefers theories and uses reflection to learn); converging (learner prefers to gather information before solving a problem and prefers practical application of ideas to learn); and accommodating (learner prefers action and learns by doing). In this subset of students all four quadrants were represented with fairly even distribution of learning styles.

Teachers

The teachers were medical educators with 10—30 years of teaching experience in the medical school and in the general psychiatry residency and child and adolescent psychiatry fellowship. Each teacher completed a Teaching Perspective Inventory (¹¹). The Teaching Perspective Inventory is a well-validated instrument that is available online at www.teachingperspectives.com. It is a 45-item instrument with a 5-point Likert scale covering items such as educational beliefs, educational intentions, and educational actions. A predominant profile is determined from the responses given. A recessive profile, or least prominent teaching perspective, is also presented as a subscore. The majority of respondents hold one or two dominant perspectives (⁷).

The medical school’s standard internal teacher evaluation instrument was employed. While this instrument is broadly used within the medical school, formal reliability studies are not available. Respondents completed a series of 5-point Likert scale questions relating to the educational experience (1=poor, 2=fair, 3=satisfactory, 4=very good, 5=outstanding). The questions covered organization and preparation, whether the objectives were clearly defined, the clarity of presentation, whether the relevance to medicine was made clear, the degree to which it was a learning experience and enhanced the understanding of the subject, whether the material covered was appropriate to needs, and the instructor’s enthusiasm and ability to make the material interesting.

An assessment was completed immediately after each seminar. The responses were anonymous and specialty choice was not identified.

The Seminars

The child and adolescent psychiatry seminar was allotted for 4 hours out of 24 total core psychiatry clerkship didactics that are scheduled. The time was divided into four 1-hour blocks. The data for this report focused on 3 of the 4 hours. The four blocks were:

1. Overview of child and adolescent psychiatry (lecture)

2. Observed adolescent interview (not included in the analysis because it is observation only)

3. Phenomenology and treatment of Asperger’s disorder (lecture)

4. Developmentally informed management of common medical problems (case-based discussion).

Each seminar was videotaped once during the study period. The number of teacher-student interactions per hour was also recorded.

The three seminars were compared by analysis of variance (ANOVA) using SPSS with significance set at p<0.05 (SPSS for Windows, Chicago, 2005).

Results

Abstract | Methods | Results | Discussion | References

Eighty-eight students completed at least one teacher assessment. The average class size was 97 students. The students not completing the assessment tool were either absent for that day or chose not to participate in the teacher evaluation. Similar to the students who participated in the study, the female:male ratio for the 2006—2007 class was 1.6:1. The participants (n=88) were also asked about their prior exposure to child psychiatry and their preconceptions about the field. The majority (54%, n=48) had some prior exposure to child psychiatry during their training but 26% (n=23) had had none. The majority of the students had a preexisting favorable view of the field of child psychiatry. At the time of the seminar, the students’ career choices were as follows: 24% undecided (n=21); 17% pediatrics (n=15); 16% internal medicine or family practice (n=14); 12% psychiatry (n=11, with several already choosing child psychiatry); 7% surgery or surgical subspecialty (n=6); 9% dermatology, radiology or pathology (n=8); and 4% anesthesia, obstetrics/gynecology, or emergency medicine (n=4).

Differences among the three teachers are summarized in Table 2 . There were significantly more student-teacher interactions in the case-based discussion format compared with lecture. The teaching perspectives of the three faculty were similar in that all demonstrated a developmental point of view as one of their two dominant perspectives. The other dominant perspectives were apprenticeship, transmission, and nurturing. Each teacher had a unique constellation of dominant and recessive perspectives as defined by the Teaching Perspective Survey. Qualitatively, the three teachers studied expressed their styles in the following ways: Teacher 1 used clinical stories of actual patients to engage students; Teacher 2 used a structured outline to cover the material; Teacher 3 used question and answer with active discussion to engage students.

Table 3 highlights the significant differences among teacher satisfaction ratings on student-rated teacher evaluations. There was an overall preference for apprenticeship/developmental and developmental/nurturing perspectives compared to developmental/transmission perspective.

Discussion

Abstract | Methods | Results | Discussion | References

Pratt and colleagues (⁷) have stated that "teaching perspectives are neither good nor bad." Each perspective represents a legitimate view of teaching; however, there may be times when one perspective is more appropriate than at others. One possible conclusion from this study is that medical students, often being taught child and adolescent psychiatry for the first time in their medical school curriculum, prefer an apprenticeship or nurturing teaching perspective. It is not clear whether the transmission perspective is less favored or if these students preferred a higher level of nurturing or apprenticeship perspectives.

Most medical students in this school have not had substantial exposure to child and adolescent psychiatry. Optimal student-teacher engagement during the limited time that students have in child psychiatry is critical for learning and for interesting students in a career in child psychiatry. Knowledge of one’s teaching perspective can result in self-reflection about assumptions of learning and teaching. Through such a process teachers can expand their repertoire and adapt their teaching style based on the goals and objectives of the educational activity.

Limitations of this study include its relatively small number of teachers assessed and the difficulty in accounting for other possible variables that impacted the student-rated teacher evaluations, such as student learning styles (⁹, ¹⁰), the interaction of learning styles and teaching perspectives (⁸), teaching format (¹²), preference for the topic being taught compared to the others, and teacher charisma. Optimally, a larger number of teachers would complete a teaching perspective survey and would be rated by the same cohort of students over time. This would enable the possibility of determining optimal teaching perspectives for medical students learning psychiatry.

A critical area that would need to be accounted for in future studies is student learning styles. Kolb (⁹) has described four basic learning styles that are defined based on how the student perceives new information and then processes it into knowledge. The four styles are diverging, assimilating, converging, and accommodating, as described in the Methods section. Armstrong et al. (¹⁰) reported that the majority of medical students’ and physicians’ learning styles prefer active experimentation with newly acquired knowledge. Mann (⁸) outlined the principles of medical education that highlight the integration of teacher perspectives and learning styles of students and emphasizes that students should be exposed to authentic tasks by teachers and be encouraged to actively engage in the learning process. Opportunities for students to discuss what they have learned allow for critical conceptual connections to be made.

Given these conceptual constructs it is notable that the frequency of teacher-student interactions did not predict the most favored teaching perspective in this study. This leads to the conclusion that other variables are also important. One of these additional variables might be the importance of the process of teaching in a specific cycle. McCarthy (¹²) extended the experiential framework to define an optimal design for learning. The "4MAT system" of learning requires a progression through each of the learning quadrants starting from a concrete experience, then reflection of theories and concepts, and to actively experimenting with these new concepts. The student then uses the newly acquired knowledge in solving new problems. A new cycle is created by initiation of new experiences. It will be important in future studies to be able to reliably and validly identify whether or not teachers follow this cycle.

The interaction of the process of teaching with the content of what is being taught is an area that needs further exploration. It may be that a certain teaching perspective is optimal for some material. Finally, assessing teacher charisma, or the ability to naturally engage an audience, is of interest because the highest overall ratings for the studied seminar series were associated with the teacher with the least number of teacher-student interactions. The Pratt model (⁷) has been primarily validated by Pratt and colleagues. However, many of the concepts are confirmed in a study by Reid and Johnston (¹³), who address the interaction of teacher and student in higher education settings using a phenomenological approach. They found significant overlap between what teachers and students considered good teaching and the constructs identified in the study corresponding closely to Pratt’s conceptualizations.

Are there optimal teaching perspectives for medical students being exposed to child and adolescent psychiatry? It is not entirely clear from this study; however, the routine use of the Teaching Perspectives Inventory may lead to insights that allow for the optimal matching of teachers to the task of introducing medical students to the field of child psychiatry. Additionally, there is much promise in broadly introducing the principles of teaching perspectives and learning styles to medical school teachers as part of faculty development workshops (¹³, ¹⁴).

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TABLE 1. The Five Teaching Perspectives

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TABLE 2. Description of Teachers and Type of Educational Experience

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TABLE 3. Summary of Student-Rated Evaluations of Three Seminars Taught by Teachers With Differing Teaching Perspectives

References

Abstract | Methods | Results | Discussion | References

Kim WJ: Child and adolescent psychiatry workforce: a critical shortage and national challenge. Acad Psychiatry 2003; 27:277—282

Stubbe DE: Preparation for practice: child and adolescent psychiatry graduates’ assessment of training experiences. J Am Acad Child Adolesc Psychiatry 2002; 41:131—139

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Armstrong E, Parsa-Parsi R: How can physicians’ learning styles drive educational planning? Acad Med 2005; 80:27—31

Pratt D, Collins J: The Teaching Perspectives Inventory. Proceedings of the 41st Adult Education Research Conference. Vancouver, 2000

Guild P, Garger S: Curriculum: McCarthy’s 4MAT system, in Marching to Different Drummers, 2nd ed. Alexandria, Va, Association for supervision and Curriculum Development, 1998

Reid D, Johnston M: Improving teaching in higher education: student and teacher perspectives. Educ Stud 1995; 25:269—281

Hunt J, Shatkin J, Kelly K, et al: Principle Driven Medical Education: Applications for Child and Adolescent Psychiatry. Workshop presented at American Academy of Child and Adolescent Psychiatry Annual Meeting, San Diego, Calif., Oct 26, 2006