Residents are entrusted with extensive teaching duties in medical schools across the country, and the educational experience of medical students during clinical training is greatly shaped by resident-teachers. We know this to be true in relation to our own learning as students and our observations in our current academic roles. We also know this to be true on the basis of the findings of the AAMC Graduate Questionnaire documenting that residents are important teachers, yet may also belittle, diminish, or unfairly treat their medical students (1). In addition to this critical role, residents are often responsible for teaching junior residents and interns. Chief residents in many programs are handed this responsibility along with their administrative duties. Residents are also in positions of teaching a wide range of others, including members of the multidisciplinary team, residents in other specialties during Consultation Rotations, family members of patients in the context of care, and, finally, teaching in community settings, including mental health awareness programs and school- or forensic-based educational programs.

Capable, and, especially, gifted teachers possess specific skills and also have a capacity for understanding their formative influence upon others. Few residents will come to postgraduate training with well-developed teaching skills or the sense of their salience in student education. Few residents (as well as few faculty) are informed about principles of adult education and its theory or practice. Moreover, residents are busy—very busy! —mastering the many clinically-based competencies that constitute their field of medicine. For these reasons, intentional efforts to enhance the strengths of residents as teachers are, in our view, not only valuable, but necessary.

Assessing the extent to which psychiatry programs across the nation teach their residents to teach is the aim of the article by Crisp-Han et al. published in this issue of Academic Psychiatry (2). In recent years our journal has featured many articles offering guidance and perspectives on the role of resident-teachers (3–17), although this survey is the first to assess what psychiatric residency training programs are actually doing in this regard. Remarkably, formal curricular attention to help residents acquire and strengthen teaching skills was reported by 73% of the program directors who participated in the study, and 79% viewed this effort as “very important.”

Although these high percentages suggested relative consensus about having a curriculum on pedagogy, the topics chosen for each program’s curriculum were less consistent. For instance, the topic of “evaluation and feedback” was included in only 60% of the programs. Sixty percent seems low, given the fact that one would assume that all residents are involved in evaluation and feedback for medical students on psychiatry clerkships. In contrast, teaching about “lecturing skills” and “small-group skills” occurred in 45% and 42% of programs, respectively, which are skills that residents generally perform infrequently during their residencies. The manner in which topics were taught similarly varied, with “group discussion” (65%) and “lecturing” (62%) as the most common. With regard to evaluation of residents’ teaching performances, most programs used ratings by medical students (91%) and/or faculty members (76%). Attempts to standardize evaluation of residents’ teaching abilities were generally lacking, and only seven programs employed validated instruments to this end. Last, of note, left unclear by the survey is whether most of the instruction and evaluation focused on the teaching of medical students. If this is the case, the teaching of patients, families, nonpsychiatry members of the profession, and members of the general public merits more attention, because many physicians will only teach medical students during their residencies, but will teach others for the rest of their careers.

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.

Certainly, teaching as a skill is in itself valuable for physicians. Teaching, however, also has importance in the broader framework of the six Physician Competencies endorsed by the ACGME. It is included in the “practice-based learning and improvement” competency with regard to teaching colleagues and patients. In the context of this competency, physicians learn and improve their practices in part through peer-to-peer interactions and comparing best practices—learning from each other and teaching each other. This is a way of learning that, it is hoped, will become a career-long habit. This implies value in having peer-to-peer learning and teaching between residents. To the contrary, in the past, residency didactics have consisted of residents sitting in classrooms and passively listening to a parade of experts from one session to another, with a disjointed, uncoordinated, and unarticulated curriculum. More recently, faculty members have embraced active learning techniques to draw out discussion among residents. At times, a resident will actually be the teacher when assigned a topic to prepare and present to his or her fellow residents. This can be limited by having only one resident at a time preparing the lesson and teaching the other residents, which might constitute a form of passive learning for the other residents. This does not achieve peer-to-peer teaching, in which all residents are learning and teaching simultaneously, as should occur in team-based learning settings.

Recently, great interest has been generated in the education world by the peer-to-peer learning and teaching promulgated by the so-called “flipped classroom.” This model involves “flipping” the traditional sequence of students attending a lecture, followed by doing associated problems for homework. In the “flipped” version, the students first learn the lecture material on their own, from textbooks or online modules, and then attend class to work on problems, usually in groups. In these groups, the students learn from each other, with the instructor only serving as a facilitator. This model emphasizes active learning in groups and self-discovery of knowledge. Another form of peer-to-peer learning occurs when small break-out groups of residents respond to clinical problems, cases, or assigned tasks after a brief didactic piece and then join the larger group, with summaries of their group’s processing of the material. Medical schools have previously embraced to varying degrees such group learning through problem-based learning and case-based learning. Residents actively participate in clinical rounds and case conferences, but any peer-to-peer learning and teaching are usually not intentional. More often, the assembled learners hold out for the attending or expert discussant to deliver the awaited clinical wisdom. This wisdom may come in the form of “In my clinical experience…” Although this approach still has its place, it leaves self-discovery by the learners out of the picture. Residents may complain that residents-teaching-residents is akin to “the blind leading the blind” and that they are in residency to learn from attending physicians. Residents, however, will become attending physicians all too soon.

If residency didactics are to keep up with current educational methodologies, including ones already applied in undergraduate medical education, residencies will need to stimulate more active and peer-to-peer learning and teach principles of adult learning. This will involve teaching residents how to teach each other and stimulating enthusiasm for this type of learning. Residents who are used to passive lecturing will have to adjust to a new educational culture that includes peer-to-peer learning and teaching, which requires preparation and reading outside of class and full attention during class—or, as in the team-based model, actively interacting and negotiating solutions together in ways that not only draw upon the ideas of others but add components of negotiating the “best” solution to a problem. The team-based approach (22) not only involves peer-to-peer learning but incorporates group interaction, which simulates what may be done in actual team-based practice on the wards. The necessary investment and energy of peer-to-peer approaches with outside time demands may not be welcomed at first by residents, who may already feel fatigued by their clinical duties, but the reward of renewed curiosity and interest in learning will, it is hoped, win out in the end. One way to simultaneously assess participation in such peer learning and also provide value for such effort is to build in reflective practice, where residents as teachers, with guidance, reflect on the triumphs and challenges of teaching. Whether this is done in written or verbal form, it provides an opportunity to reflect on critical teaching moments and identify learning needs. This reflective practice is crucial for such correlates as life-long learning and professionalism.

Going one step further, much might be said for having all residents involved in designing their own didactic curriculum and lesson plans with the training directors or other interested faculty. Some programs have piloted this quite successfully in journal clubs, for example. This may include residents’ selecting faculty members and inviting them to participate in their didactics, as primary teacher or as an expert consultant. This, in turn, may be more gratifying for the faculty member than having the invitation come from a departmental educational leader. Moreover, beyond selecting the faculty members, residents may be asked to create the format of the teaching session (e.g., large-group lecture, small-group, peer-to-peer, or team-based format, or even use of simulation); and they might also be asked to provide the syllabus, outlines, electronic slide introductions, or reading lists. In the context of the ACGME competencies, residents should be learning how they will learn for the rest of their careers. If residents learn how to design their own curricula, they will be more prepared to continue to design curricula after graduation. In fact, future graduates may have to create their own venues for peer-to-peer learning and teaching, like study groups of private practitioners, quality-assurance committees in hospitals, and grand rounds in their department, and they should be taught how to do this.

We also need to consider that as such curricula are developed and residents are taught the necessary knowledge and skills of teaching, the current climate of clinical practice in academic medical centers sets up major obstacles and challenges for teaching. We all know that teaching requires considerable additional time in an already-overburdened day. Managed-care, with shorter lengths of stay and increased administrative demands for many, makes teaching more of a burden than a pleasure. Although many have gone to academic medical centers with explicit interests in teaching, attending physicians as well as residents find themselves resisting teaching obligations or, at worst, finding that teaching adds to stress and burnout. Having teaching as a core competency of physicians, reflected in training objectives and accreditation standards, is an important first step to backing-up department chairs providing resources. Hence, not only must we find the time to include teaching in already-overloaded schedules, we must consider innovative ways of seamlessly including teaching along with feedback and evaluation into our schedules, while improving efficiency without compromising quality. Ultimately, teaching must not only be said to be valued but must be shown to be valued. Ensuring this is so will also require ongoing efforts to examine and address the impact of the hidden curriculum, where the very faculty we are asking to assess residents’ teaching may not tell a favorable narrative, whether routed in competing demands or otherwise. Furthermore, if teaching, and, more broadly, education, is going to have its cultural capital increased in a real way, so that it can rival research and clinical work, rewards must be in place from the senior-resident level all the way to early-career faculty. This could be from support to presentation at an education meeting, to awards, and to seeing a clear and credible career-track ahead reflected in remuneration, time, and promotion platforms and pathways.

At a more “meta” level, it is important that departments have a vice-chair of education, or equivalent, to ensure a voice at the executive table, where priorities are set and resources are allocated (23). Visible recognition of the importance of teaching by residents within the departmental culture, and particularly as expressed by department leaders, is essential; one possible example is the creation of an annual award for the best resident-teacher as selected by medical students and other learners. More broadly, chairs and education leaders must advocate on a national level so that this is an identified priority. One such powerful example is this year’s Future of Medical Education in Canada (FMEC) Report, commissioned by the Association for Faculties of Medicine of Canada, to review postgraduate education nationally and formulate recommendations that will be taken up by medical schools. It is encouraging that one of the recommendations is to develop a national strategy to develop, support, and recognize clinical teachers. Another recommendation important for education relates to leadership development in postgraduate trainees (24). An important part of creating a community of resident teachers, and eventually faculty teachers, is having a community of practice and opportunities for mentorship, which may not always revolve around one’s local setting, especially for those from smaller departments. For psychiatrists, for example, the annual meetings of our journal's sponsoring organizations can help resident-teachers to meet and interact with academically-committed faculty from other institutions and gain invaluable mentoring. This can be a potent counterpoint to the sometimes-local hidden curriculum messages with which one struggles.

Finally, we need to identify and nurture those with the potential to take up medical education’s torch. This means recognizing the subset of residents who are not only teachers, but emerging clinician educators. These people need support developing all tenets of the clinician-educator career track, including not only teaching, but research, scholarship, and leadership. These are the very people who, at the same time, can support their peer teachers and identify opportunities for research and innovation in teaching. Martimianakis et al. (25) detail the development of a program designed to support this career focus, from residents to faculty, in North America’s largest department of psychiatry.

The word “doctor” has its origin from the Latin for “teacher” (docere). Although graduate medical education has come a long way in terms of defining the core competencies required for practicing physicians and has been dutiful in setting national standards for knowledge, skills, and attitudes, with specific goals and objectives, we have fallen short in one of the most critical areas, namely, our ability to serve as teachers. Residents as clinical educators are the primary role-models for medical students and a range of professionals in and out of medicine, and, particularly, for their patients and families. After graduation, they have the responsibility of developing and refining these roles, teaching the residents themselves, and educating the public in community settings and through the media. Patient and public education will be even more important in the future era of medical homes and in patient-centered care.

It is therefore incumbent upon us all in academic medicine to pay more serious attention to establishing core and elective graduate medical curricula on teaching residents to teach. These should incorporate principles of adult learning and the broad range of educational modalities and information-technology and use effective methods for feedback and evaluation. Moreover, we need to encourage educational research to inform best practices and evidence-based methods in this work. We also need high-quality educational randomized, controlled trials (26) that can contribute to our knowledge of evidence-based methods for national dissemination and replication. Developing residents as teachers is a necessary professional obligation and a national priority.