The Liaison Committee on Medical Education (LCME) (1) and Residency Review Committees (2) expect residents to teach medical students and mandate instruction on teaching, but many articles on chief residency positions do not mention teaching medical students as a responsibility (3–9). Certainly, a focus on resident leadership and administrative skills contributes to a chief resident’s professional development and overall resident morale, but it appears that the traditional chief resident position does not explicitly prioritize teaching medical students. Furthermore, the Association of American Medical Colleges 2008 Graduation Questionnaire (10) found that nearly 27% of students did not feel that teaching by psychiatric residents was adequate.
Without explicit teaching roles, it is not surprising that competing responsibilities, including caring for patients, making rotation and call schedules, liaising between residents and staff, and resolving resident conflicts, are emphasized for psychiatry chief residents (5, 7). Likewise, chief resident mentorship may not include development of teaching skills (6). As part of our effort to revitalize medical student teaching by residents in our department, we developed the position of Education Chief Resident in Medical Student Education.
A review of the literature found one position similar to ours—an academic chief fellow (11). This position was held for 4 months by a fellow in child and adolescent psychiatry, with 1 day a week devoted to enhancing academic skills through teaching and supervising junior colleagues. Although five medical students participated in the didactic teaching sessions focused on child and adolescent psychiatry, the position itself did not specifically target teaching students. The students reported high satisfaction with the academic chief fellow (11).
Ning et al. (12, 13) describe a chief resident for education as part of the Teaching Residents to Teach program at Temple University. In this position, the education chief is responsible for the residents-as-educators program, assists in enhancing both medical student and resident education, and pursues educational scholarship. The professional development of this resident is a top priority, and feedback from the residents revealed that they felt the position was valuable. Student evaluation data were not reported.
At our institution, the director of medical student education, with the support of the department chair and the director of residency training, created the position of Education Chief Resident in Medical Student Education to increase resident teaching time for students while emphasizing skill development and knowledge, to better identify and assist “at-risk” students, to liaise between students and junior residents in teaching, and to develop personal academic skills. This article describes the education chief role in more detail than previous literature (12, 13), with examples of how the education chiefs facilitate the educational mission.
Selection of Education Chiefs
Our program has approximately 35 residents in general residency training, with up to eight fourth-year residents. About 60% of the fourth year is elective time. Because of this, the director of medical student education and the residency training director agreed that the education chief could devote about 20%–25% of that year to the medical student education program.
The proposed responsibility list of the position is sent to third-year residents midway through the year, and interested residents submit an application that describes their qualifications and teaching goals and proposes an educational research project. The director of medical student education and the residency training director select one or two residents for this position each year. The other two chief resident positions in the department are elected by residents, but neither of those positions focuses on medical student education.
In the first year (2007–2008), two residents were selected. One resident was selected in 2008–2009, and two residents were selected in 2009–2010. To date, all applicants have ultimately been selected. However, if applicants did not possess the necessary skills and ambition, the position would not be filled; an unqualified or unmotivated resident would detract from the medical student education program.
The education chiefs are involved in all aspects of the medical student education program in psychiatry under the direction and supervision of the director of medical student education. The preclinical curriculum consists of 1.5 weeks for the first-year human development course and 3 weeks for the second-year psychopathology course. The time requirements intensify during those weeks for the education chiefs, as they do much for the faculty who direct and teach those courses. The education chiefs spend up to 20 hours a week assisting in the medical education program; however, the average throughout the year is 10–12 hours a week. The psychiatry clerkship repeats throughout the academic year. Having two education chiefs the first year was helpful to define roles and to establish the position as an important educational component of the department.
The education chiefs have weekly supervision with the director of medical student education to develop their teaching and administrative skills and to discuss topics for their work with the junior residents, such as giving feedback to students, managing disruptive students, and addressing appropriate attire and boundaries. Because of increased attention on the medical students, individual students’ concerns are often more quickly identified, with corrective plans developed early in the rotation.
The education chiefs spend most of their time in the psychiatry clerkship, devoting 1 day a week to clerkship activities. They participate in the clerkship orientation by presenting the psychiatric assessment and mental status exam in an interactive didactic module with videos and an audience response system (14). They spend 3–4 hours a week on inpatient units with the students, discussing cases, giving students opportunities to practice presentation skills, providing formative feedback, and discussing ethical issues such as treatment over objection and informed consent.
Three or four times during each rotation, the education chiefs observe students interviewing a patient and provide formative feedback on the interview and a grade using a standard evaluation sheet. They also participate with faculty in oral examinations. Before working independently as examiners, they are trained by faculty on the measures and on what constitutes specific scores. They grade the required psychiatric assessments, and the director of medical student education reviews their work and provides feedback on the effectiveness of their grading and written comments.
The education chiefs coordinate the teaching didactics given by the junior residents at each site and mentor and teach junior residents, providing them with feedback on their teaching and liaising between the medical students and junior residents.
In the first year of the program, the education chiefs also developed a “411” psychiatry handbook with tips for students on the inpatient services. Currently, the education chiefs are working on web-based learning modules for students.
An additional clerkship responsibility is tutoring “at-risk” students. For example, a medical student was having difficulty learning to gather a history and present the case to the team. The education chief spent extra time with this student, observing interviews and listening to patient presentations, and thus was able to help the student prepare to pass the observed interview. The treatment team noted improvement in the student’s performance.
In the preclinical courses, the education chiefs develop exam questions, lead small groups, conduct review sessions, grade examinations, and tutor individual students on request. The first two education chiefs also delivered one large classroom lecture because both wanted to develop that skill. Although the education chiefs could access previous lecture materials, the electronic presentation and lecture materials were completely revamped with the assistance of the director of medical student education and an education specialist who is available to all faculty at the School of Medicine. The specialist worked with the residents on presentation skills and gave feedback on the materials and delivery. The education chiefs’ direct teaching time averaged about 2 hours a week in these courses, with several more hours devoted to developing exam questions and grading essays. Depending on the interests of the education chiefs, time could also be spent teaching in the preclinical Introduction to Clinical Medicine course, in which the education chiefs can assist with interviewing skills for 2 hours a week in the fall. At the end of that portion of the course, the education chiefs can observe the first-year medical students perform live patient interviews and offer both formative and written feedback.
The education chiefs assist the director of medical student education in grading the psychiatry cases of the required fourth-year objective structured clinical examinations; grading these cases consumes several hours in the fall. The education chief also has mentored junior residents in medical student teaching even though that was not originally conceptualized as a responsibility for the position. As the role has evolved, the education chief has become increasingly active in directly supervising junior residents in their teaching roles, providing feedback about their effectiveness as educators. Liaising between the junior residents and medical students is another role that is not specifically listed as a responsibility but has benefited both residents and students.
Qualitative data from medical students and the education chief residents about the position were collected and analyzed at the end of the psychiatry clerkship in the 2007–2008 academic year. Students completed a seven-item survey with responses scaled from 1 (strongly disagree) to 5 (strongly agree). The education chief residents rated eight items about the position on the same 1–5 scale. This study was approved by the university’s institutional review board.
Seventy-six of 85 students completed the survey for a response rate of 89%. Mean student responses to the statements “I feel comfortable coming to the Education Chiefs with any difficulty on my rotation,” “The Education Chiefs made time available for individual help,” and “I feel the Education Chiefs are a beneficial addition” were 4.25, 4.16, and 4.32, respectively (5=strongly agree).
The psychiatry clerkship evaluations in general continue to be very positive, with resident teaching improving from 3.67 and 3.95 in the two academic years before changes in the medical student teaching program to 4.20 in the last academic year and 4.37 this year (5=highly satisfied). Narrative comments on evaluations included “other departments should do what psychiatry has done with the emphasis on medical student education and the use of education chiefs” and “[education chiefs] are not focused on the work requirements of taking care of patients, but rather on students learning as much as they can about psychiatric illness and the core skills of interviewing and presenting patients effectively.”
The education chiefs all reported a positive effect of the role on the their educational development, most specifically on their teaching and liaising skills, with average scores ranging from 4.6 to 5 (5=strongly agree) on “positive impact on educational development,” “improved leadership skills,” “improved administrative skills,” “better understanding of the LCME requirements,” “improved teaching skills,” “improved supervisory skills,” and “improved ability to act as a liaison between groups.” Additionally, each chief felt that the position helped prepare for a career in academic psychiatry. Appendix 1 gives examples of additional roles of the education chiefs.
Although we cannot establish a definitive causal relationship, the overall resident teaching evaluations in the psychiatry clerkship have improved since the education chief position was introduced in 2007. Medical students clearly felt that the addition of education chief residents was beneficial. Ning et al. (13) wondered if having residents be highly responsible for educating medical students might be problematic given their lack of experience and desire to be liked. Our findings suggest that senior residents can be effective teachers of medical students. Informal feedback was that students highly appreciated the time and energy devoted to teaching. Students also expressed that their clinical skills improved because of the additional time spent on interviewing skills and case presentations. The medical students thought that the education chief enhanced not only the overall educational program but also the role of the director of medical student education by providing additional means to bring up concerns or questions. The education chiefs occasionally filled in for the director of medical student education for didactic sessions when scheduling conflicts arose, but in most circumstances the teaching done by the education chiefs was additional. Lastly, the department was better able to identify and work with “at-risk” students.
The education chiefs appreciated the challenges of administering a good medical student education program. They felt that their supervisory skills improved as they oversaw junior residents in teaching. Furthermore, they gained experience working with “at-risk” students. The first two education chiefs reported an increased understanding of LCME requirements, likely due to their involvement with institutional self-study subcommittees as the medical school was preparing for an LCME site visit. The education chief residents have presented at national and regional education meetings, and all have worked on educational research projects under the supervision of the director of medical student education. The first two plan to enter academia following completion of their child and adolescent fellowships. The most recent education chief plans to enter academia in the future. With just 2 years of experience with this position, it is unclear if having two education chiefs is ideal or if having one is sufficient. Students are eager for teaching by residents, so it is doubtful that they would see two education chiefs as a problem. As a result of feedback from the students, the education chiefs no longer give didactic lectures at each site; rather, they utilize case-based formats to illustrate the main teaching points. Students crave feedback, stating that they often do not get enough formative feedback from their attendings, so this has become a priority of the education chiefs in all areas of teaching.
Limitations of this study include the small number of education chiefs and the lack of anonymity in their responses about perceptions. Although the medical student response rate was high in the first year, continuing to evaluate the position specifically for another year could have strengthened our findings. Early results are promising, but clearly several more years of experience are needed with this program before more definitive conclusions can be drawn.
Future considerations include expanding the concept of an Education Chief Resident in Medical Student Education to other core clerkship specialties, helping to transform “resident as teachers” programs. With clinical workload expectations generally taking priority for residents, medical student teaching often becomes a responsibility that is executed only if time permits. Just as faculty face competing demands and often have little external incentive for medical student teaching, residents feel the same pressures and lack of reinforcement for their teaching efforts. If each department creates such positions, the priority of educating medical students becomes evident to faculty, residents, and students alike. It is our hope that the focus on resident teaching will be evident in the 2009 American Association of Medical Colleges Graduation Questionnaire results. If there were education chief residents in several departments, greater opportunities would exist for collaboration across the disciplines of medical student education. Finally, the education chief resident position could be especially desirable to residents seeking careers in academic psychiatry, with its introduction to administration and management as in other chief resident positions (15).