The survey results indicate that progress is being made, but much work is left to be done to ensure that all residents are competent as physician-teachers. The field of education is, of course, quite broad, so what knowledge and which skills relating to teaching are requisite for this competency, and who shall decide this? To-date, the decision has been left up to program directors, and the survey of Crisp-Han et al. suggests that programs have come up with a variety of solutions. If teaching is to be given real “tread” as a core competency of physicians, it must be articulated as such in training objectives. For example, the CanMeds framework, the competency-based scaffolding that underpins the training objectives of all generalists and specialists in Canada, has the Scholar role as one of its core competencies. Within this role, residents are required to demonstrate competence in facilitating the learning of patients, students, families, and other health professionals (18). Furthermore, such a competency must be assessed if it is to be taken seriously. If it is seen as a core competency, reflected in objectives of training and accreditation standards, perhaps each program, then, taking into account its local setting, resources, and constraints, should develop a basic curriculum with required objectives that are most germane to teaching as it most commonly occurs in the practice of psychiatry—primarily, the teaching of patients, families, health professionals, and the community. Also, because residents provide much of the teaching on medical student clerkships, required objectives should also cover the clinical teaching of medical students on rotations. The impact of residents as role-models is another topic of importance, as are constructive approaches to helping residents support a positive training environment, rather than reacting to and amplifying the “hidden curriculum” of unprofessionalism present in some settings. Collaboration of the various national organizations in psychiatric education, including those that sponsor Academic Psychiatry, in drawing up an expert consensus on required objectives would be helpful. These should take into consideration the published objectives for psychiatry clerkships (19) and how these are being used (20). Elective objectives might be devised by each program for residents with career interests in medical education, such as objectives involving the design of medical school curricula, development of syllabi and examinations, or facilitation of problem-based and team-based learning groups. However it is delivered, if teaching is a core competency of physicians, it must be assessed—a task that requires observation by and feedback from faculty—a challenge, given that faculty already feel that time is an obstacle to integrating teaching.
How might one standardize the teaching by residents within training programs or even across programs? For the sake of discussion, a scenario for standardization will be proposed as follows: focusing on teaching residents to teach medical students on clerkships. Probably the most accessible and readily replicated teaching exercise during psychiatry clerkships involves observing and evaluating a medical student interviewing a patient and presenting the case. This might be standardized to resemble a less daunting version of the Clinical Skills Verification (CSV) (21) that residents undergo themselves. This type of exam is required for eligibility for board certification in psychiatry by the American Board of Psychiatry and Neurology and during residency training by the Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME). The CSV evaluates examinees’ abilities in forming a psychiatrist–patient relationship, executing a psychiatric interview and mental status exam, and presenting a case to the examiner. Modeling a teaching exercise for medical students after the CSV would promote continuity between training in medical school and residency in psychiatry.
If the above exercise were chosen for the purpose of standardization, then residents would be taught how to specifically teach, including providing feedback and evaluating clerkship students, in the context of this exercise. Coaching medical students through this exercise may even be useful to the residents as they learn to view the CSV process from the teacher’s perspective. One might require that each dyad of a resident assigned to a medical student have this exercise observed at least once by a respected faculty educator. A faculty member observing this exercise would be able to compare his or her independent ratings of the medical student’s interview with those of the resident teacher, and critique the resident’s feedback to the medical student. The above example has the advantages of being clinical and practical, supportive of active learning, and consistent with adult-learning models. Such an exercise may be videotaped with appropriate consents, providing additional time to look carefully at the interaction between the resident and medical student.