Teaching residents to teach is a well-recognized national priority. Residents spend around 20% of their time teaching, and they are a major source of a medical student’s knowledge base and practical clinical skills (1). Academic Psychiatry has recently published a special edition on residents as teachers, demonstrating the great range and variation of current efforts to raise the quality of teaching by psychiatric residents (2–15). With the general changes in graduate medical education and a necessity to balance service and education, there is an increasing reliance on the development of residents as teachers. The ACGME requires that residents “participate in the education of patients, families, students, residents, and other health professionals,” and also stipulates that senior residents supervise more junior residents (16).

Despite this attention, there have been no previously published national surveys concerning what and how psychiatry residents are taught in order to improve their teaching skills. One previously-conducted study surveyed a number of specialties, including psychiatry, but did not separate out information on the teaching of psychiatry residents from the other specialties (17). Another recent study reviewed all “Residents-as-Teachers” curricula that included assessments of their efficacy. However, no psychiatry studies were assessed, since none met inclusion criteria for the analysis. Hence, we cannot look at psychiatry curricula in that comparison (18). Given the need to learn about what and how program directors teach residents to teach and given this dearth of information, we set out to survey all program directors across the United States on this topic. Our main goal was to identify what programs taught, if anything, and how residents were taught in order to improve their teaching skills. We therefore hope to provide information for program directors on what teaching methods and content are included in various programs around the country.

An anonymous survey was distributed to 181 psychiatry training programs across the United States in late 2009 and early 2010. The list of programs was obtained from the ACGME website. The program directors were asked to fill out a two-page questionnaire. The IRB approved the research project, and completion of the survey was indicative of consent. There were two mailings; program directors who did not respond the first time were sent a second survey.

The questionnaire was developed from previous descriptive studies on residents as teachers (17, 18). The survey consisted of seven main questions, with subquestions, including Yes/No/Don’t Know, open-ended, and Likert-type scale answers. (The questionnaire is available to readers on request.) The content of the survey included questions on teaching psychiatry residents about how to teach; whether the program offered formal instruction to residents about how to teach; the number of seminars offered each year; and what texts, materials, topics, methods, and evaluation tools were used. Also, we asked how residents were evaluated for their teaching skills, whether any formal assessment tools were used, barriers to developing residents’ teaching skills, and asked about suggestions for improving the teaching of residents.

Of 181 program directors mailed the questionnaire, 95 responded (response rate: 53%). All of the questionnaires returned were usable. Of the 95 respondents, 75 (79%) thought that it was very important to teach psychiatry residents to teach. Only one thought it was not at all important, whereas the remainder (N=19; 20%) thought the topic was somewhat important.

Of all programs, 69 (73%) provided formal instruction to residents about how to teach, such as in a course, lecture series, or by planned discussion, as opposed to bedside discussion. The remainder (N=25; 27%) did not provide formal instruction to residents on how to teach. Of the 69 programs that formally taught, teaching occurred at all PGY levels. Some programs taught in all 4 years, whereas others concentrated the teaching into 1 or 2 years.

The numbers of seminars taught per year ranged between 0 and 12 seminars per year; two programs provided as many as 26 or 30 per year. Topics most commonly taught included evaluation and feedback (N=57; 60%), lecturing skills (N=43; 45%), small-group skills (N=40; 42%), learning-theory (N=37; 39%), and problem-based learning (N=36; 38%). Other topics commonly taught included audiovisual techniques (N=23; 35%), team-based learning (N=29; 31%), use of assessment tools (N=27; 28%), evidence regarding teaching skills (N=24; 25%), and curriculum design (N=21; 22%).

The instructional methods used for teaching residents how to teach were predominantly group discussion (N=62; 65%), lecturing (N=59; 62%), reading of relevant literature (N=35; 37%), role-playing (N=33; 35%), and audiovisual instruction (N=32; 34%). Most programs evaluated their seminar or course through resident feedback. Only 24 of the 69 programs that taught (35%) used a formal assessment of teaching as a way of evaluating the skills taught in the seminar. When asked to describe texts and materials used, a number of specific text recommendations were provided (19–23).

We also asked all program directors how residents were evaluated for their teaching skills, if at all. Most commonly, residents were evaluated by medical students in clinical settings (N=86; 91%), and by faculty in clinical settings (N=72; 76%). Other common methods of evaluation were by self-assessment (N=48), formal evaluation of a teaching intervention (N=47), and evaluation by other residents in clinical settings (N=38). Only six programs provided an observed structured teaching examination (OSTE), and only one used the LISAM (low-interference self-assessment measure). Some program directors referred to using evaluation forms with anchored items or checklists of skills, or “e-value” observations by faculty supervisors or medical students. Few of the programs identified a formally validated tool. Those tools that were identified included only the OSTE and the LISAM.

Many of the programs identified barriers to developing resident teaching skills. These were most commonly a lack of time in the curriculum (N=53; 56%) and a lack of faculty teachers (N=33; 35%). Other barriers included a lack of interest by the faculty, perceived lack of interest by residents, limited teaching opportunities by residents, and a need for curriculum resources. Some program directors suggested that, because residents’ teaching skills were already adequate, there was no need for any formal instruction.

Program directors were asked to make any suggestions for teaching residents about how to teach. Many suggested that existing curricula should be expanded. Other suggestions included provision of observation and feedback by a master teacher, faculty training on how to teach to improve role-modeling by faculty, and starting resident-run residents-as-teachers committees or clinician-educator tracks, which are learner-driven forums for learning how to teach. Some indicated that it would be helpful to provide more resources in the way of faculty and time, to develop a portfolio for teaching activities, and to include more opportunities for videotaping and assessments.

We found that that the majority of training programs (73%) were providing formal teaching for residents about how to teach. Heterogeneous teaching methods were being used, and some programs taught across all 4 years. These findings reflected the high importance that program directors attributed to this subject area.

Interestingly, few of the programs provided a formal evaluation of residents’ teaching skills. In particular, few programs used observed structured teaching examinations or video and audiotape observations, which are some of the most valid and reliable measures of residents’ clinical teaching skills. Instead, residents were most commonly evaluated by medical students and attending physicians in clinical settings or by self-assessment. Valid and reliable tools may be helpful in assessing resident teaching, although we realize that the barriers of time, faculty training, and access may challenge their use and limit practicality. Moreover, rigorous model studies concerning the efficacy of teaching residents about how to teach might be a future asset to the development of curricula. In one recently published systematic review, only one randomized, controlled trial was found evaluating teaching psychiatry residents to teach (24). In a recent nationwide survey of pediatric resident-as-teacher curricula, over 60% of those curricula were evaluated for their efficacy and were modified on the basis of those evaluations (25).

Of note, an important minority of programs were not providing formal teaching to residents on how to teach. Common curriculum barriers were a lack of curriculum time and a lack of faculty expertise. Individual programmatic barriers should be identified and addressed. Our data provide a picture of curriculum resources and teaching methods used at programs across the country. This information might reasonably be used by individual programs to shape their own curricula.

There are several limitations to our data. First, nearly 50% of program directors did not respond to the study, limiting the generalizability of the data. Second, program directors may not have been fully knowledgeable of the methods or content of the educational programs regarding teaching. Allowing program directors to respond “Don’t Know” on some questions could possibly have led to an underestimation of the amount that was taught. Nevertheless, and in conclusion, although many programs formally taught residents to teach, there is clearly a need to build on these programs and to extend teaching to programs that are not teaching. We also need to design and rigorously evaluate model programs in order to promote the development of psychiatry residents as excellent teachers.