This article describes the pilot year of a unique teaching rotation that was created in the Psychiatry Residency Training Program at the Mount Sinai School of Medicine. This teaching rotation was developed in response to several pressing educational needs. For junior residents (postgraduate year [PGY]-1 and PGY-2), an increase in inpatient ward attendings’ patient care responsibilities meant that the attendings were less available for teaching than they had been in past years. The junior residents were getting less practice with observed clinical interviews and fewer opportunities for learning connected to their clinical work. For senior residents (PGY-4), the required but mostly administrative rotations (i.e., inpatient chief resident, ER chief resident) were felt to have limited educational value. Senior residents needed an opportunity to review for the American Board of Psychiatry and Neurology (ABPN) Part 1 exam because they were taking the exam at the end of their PGY-4 year. In addition, senior residents needed opportunities to take on active teaching roles to prepare them for attending positions (1). We felt that with a teaching resident (TR) rotation, we could simultaneously address these educational needs. A TR rotation would fill the educational deficiencies on the inpatient psychiatry wards in addition to enhancing the senior residents’ consolidation of factual knowledge and obtaining a skill base in teaching and supervision.
There is literature documenting positive effects of various teaching methods such as workshops, one-on-one feedback sessions, role plays, and didactics (2–5); however there are few reports of intensive teaching rotations. In February 2009 we searched PubMed and the index of Academic Psychiatry with the search terms “teaching resident,” and “residents as teachers.” In addition, we reviewed the references on the UC Irvine’s Selected Bibliography of Residents as Teachers (available at http://www.ucimc.netouch.com/bibliography.shtml). One teaching rotation in an internal medicine residency program included instruction on teaching methods and literature search and appraisal as well as teaching in a case-analysis format (6). A radiology residency program in Philadelphia has a rotation in which the resident is instructed in design, execution, and analysis of a medical student rotation curriculum. The resident is responsible for conducting case conferences and lectures and for giving medical students feedback (7). There were no objective outcome measures in these reports. There is a recent report of an “Academic Chief Fellow” position in a Child and Adolescent Psychiatry Fellowship (8); it is similar to the rotation in our program in that this rotation exposed the senior trainee to teaching in a variety of formats and with learners at different levels of training. Outcome measures in that study included a postrotation survey of academic chief fellows and the junior trainees; in general, the fellows rated the rotation as worthwhile, and the medical students were very satisfied with the teaching. As far as we know, ours is the only teaching resident rotation in a general adult psychiatry residency training program, and it is the most teaching-intensive of the rotations described. We report here on our experiences during the pilot year of the teaching resident rotation to encourage other psychiatric residencies to consider implementing a similar program.
The teaching resident (TR) rotation is a 2-month block during which 60% of the TR’s time is dedicated to teaching pursuits; the remaining time is spent caring for outpatients and in didactic class time. The rotation is required for all PGY-4s except for the three administrative chief residents. It was decided to differentiate the TR from the chief resident positions. The chief residents have teaching responsibilities (namely planning and some teaching of the formal PGY-1 didactic curriculum) in addition to a primarily administrative role as the liaison between the residents and the program directors. Given the close ties between the chief residents and program directors, residents tend to be hesitant to reveal knowledge gaps or skill deficiencies to the chief residents; it was felt that their learning would be enhanced by having a more neutral TR who is not an extension of the administration. However, we also did not want to have a complete disconnect between the TR and administration, knowing that the TR’s close observations of the junior residents would provide important information. Thus the TR attends select administrative meetings with the training directors and chief residents. In this capacity, the TR advocates for the residents and helps the administration become aware of issues, such as uneven patient distribution on the wards, difficulties with attendings, or problems with morning rounds.
The exact role of the teaching resident has been evolving, and it was defined in large part by the first PGY-4 to take the rotation (CD-B). One major advantage to the intensity of the rotation has been that it provides experience with a variety of teaching techniques for a variety of different learners, including the one-on-one teaching and supervision experienced in an attending position.
The teaching resident provides both individual and group supervision. The TR meets weekly with each of the six PGY-1 residents on the inpatient psychiatry wards. Supervision is tailored to the needs of the individual PGY-1. Topics discussed in supervision include assessment of mental status, diagnostic considerations, and treatment planning according to the inpatient psychiatric rotation goals and objectives. The TR also guides the PGY-1s in other important aspects of their transition to psychiatric residency such as processing what it means to become a psychiatrist and dealing with difficult aspects of ward work (e.g., dealing with families and time management). In addition, the TR routinely observes the PGY-1 interviewing his or her patients on the ward and offers direct feedback on interview effectiveness.
The TR supervises the PGY-2s as a group, and the supervision takes a different form from PGY-1s. During group supervision, the residents discuss each other’s cases with the TR moderating the discussion, allowing the PGY-2s to learn from each other. Group supervision allows the PGY-2s to feel a sense of camaraderie around the difficult issues they confront, while having the benefit of a more senior resident to put their experiences into perspective.
The TR also leads group meetings with the fourth-year medical students rotating electively in psychiatry. This venue allows these medical students, who are seriously considering careers in psychiatry, unparalleled access to a senior resident with his or her perspective on residency, the application process, and psychiatry as a career. The supervisory experience is very useful for the TR; it offers an opportunity to revisit the inpatient wards with an advanced set of skills, to solidify knowledge regarding diagnosis and treatment, and to reflect on how far he or she has come in the course of training.
The teaching resident leads journal clubs for the PGY-2 residents and, separately, for fourth-year medical student rotators. We feel it is important for the residents to become versed in the latest sentinel papers in psychiatry, such as the CATIE study (9), STAR*D (10), and STEP-BD trials (11). We also feel that exposing the fourth-year medical students to these articles is a useful way for them to develop a deeper knowledge base in psychiatry and to build on the knowledge from their clerkships. Leading this discussion is helpful in consolidating the TR’s knowledge of these important recent contributions to the scientific literature in psychiatry.
The teaching resident also presents formal didactics to third-year medical students. Typically, the TR presents two to three lectures giving an overview of psychopharmacology. In preparing these lectures, the TR has to carefully consider the level of his or her listeners so that the lectures will meet the needs of the student audience. It also allows for the TR to develop a comfortable and effective lecture style.
The teaching resident administers and grades the final oral examination for the third-year medical students. The examination is an ABPN-style interview, presentation, and discussion. To evaluate the students on this test, the TR must be cognizant of the determinants of a successful interview, presentation, and formulation. The TR also helps to facilitate three to four weekly case conferences on the inpatient wards, and in these conferences has the opportunity to interview patients in front of the other residents and rotating medical students. Both of these experiences are valuable for the TR as preparation for his or her own oral board examination.
Another teaching resident role is as a teaching liaison to the internal medicine outpatient service. The TR is available by beeper to the internists for questions about psychiatric medication selection and management. In addition, the TR has the option to co-precept the mental health evaluation service in the internal medicine clinic. Together with the attending internist, the TR spends one afternoon per week supervising internal medicine residents on the diagnosis, workup, and treatment of patients with mental health complaints. In this capacity, the TR hones his or her skills in serving as a liaison and in communicating effectively as a consultant—an integral career skill.
The teaching resident is generally available to any of the inpatient residents or medical students for as-needed consultation and advice. The TR attends selected morning inpatient unit rounds. The purpose of this is twofold: to ensure that the rounds facilitate learning and accomplish clinical duties efficiently and to identify cases that offer unique learning opportunities. When such cases are identified, the TR organizes a case conference with expert discussants so that the other residents may learn from the case.
The teaching resident is supervised directly by the program director in weekly individual sessions. Sometimes supervision takes the form of “supervision of supervision” in which the program director observes the TR giving feedback to a junior resident and then gives the TR pointers on effectiveness in giving feedback. The program director provides a curriculum of journal articles and educational materials about teaching. He or she also emphasizes the goals and objectives of the inpatient ward months to help the TR focus on the most salient teaching topics. The TR also has the opportunity for supervision with the director of medical student education one to two times per month for more specific discussion of that population of learners.
Residents’ Perceptions of the Teaching Resident
Blind written surveys were administered in May of the first academic year that the teaching resident rotation existed to aid in curriculum planning for the next year. We surveyed the PGY-4 residents who had served as teaching resident during the year (all PGY-4s except the three chief residents), in addition to the PGY-1 and PGY-2 residents whom they taught. Because it was a survey in established educational settings, this study was exempt from review by the institutional review board at Mt Sinai Hospital. Formal statistical analyses were not run on the results; the descriptive results instead were used to inform curriculum changes. Logistical considerations precluded including the medical students in the surveys. The residents were asked to rate their agreement with statements on a 5-point Likert scale (1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree 5=strongly agree) and to provide written feedback on the teaching resident rotation. See Table 1 for exact survey items.
The PGY-1 residents indicated that useful aspects of the TR were adjusting to the role as a doctor, formulation of cases, and conduct of clinical interviews. They did not feel that the TR was particularly helpful in learning psychopharmacology, psychotherapeutic aspects of cases, evidence-based learning, or note writing. Written comments from the PGY-1s indicated that a tight schedule and high workload made it difficult to arrange for meeting times with the TR and that there was great variation in experience depending on the individual TR.
The PGY-2 residents identified the following three areas where the TR was most helpful: in understanding psychotherapeutic aspects of cases, improving conduct of clinical interviews, and in evidence-based learning. Residents in PGY-2 also indicated that their learning on the inpatient psychiatry wards was enhanced by having a teaching resident; these residents did not have a TR during PGY-1. They indicated that the TR did not seem to impact their note writing, and written comments from the PGY-2s indicated that more meetings with the TR would be useful.
Residents in PGY-4 responded very favorably to the rotation and indicated learning in every dimension that was queried. The most strongly positive responses were that PGY-4 residents learned a great deal about clinical interviewing, diagnosis, psychopharmacology, and teaching by being a teaching resident.
The survey results indicate that the teaching resident rotation was well-received by the PGY-1 residents—and especially by the PGY-2 and PGY-4 residents—and that the rotation met the goals of enhancing learning for the junior residents on the wards and for the senior residents in preparation for ABPN board exams and attending positions. Both levels of junior residents found the TR helpful in their learning about clinical interviewing, which was a major objective of the TR program. The survey results reflect that the PGY-1s and PGY-2s learned differently from the TR; with the PGY-1 residents, the TR focused on the more experiential and skill-based teaching, and with the PGY-2s, the TR focused more on evidence-based learning and the knowledge base in psychiatry. According to the survey results, the PGY-2s’ learning extended beyond the specific areas of the TR’s focus, but this was not the case with the PGY-1s. When designing the TR rotation, we thought that the PGY-1s’ explicit knowledge base would grow as a result of discussing cases with the TR even though the discussion was focused on the residents’ attitudes and bedside skills. Further discussion with the residents and program leadership will have to assess whether a primary focus on the psychiatric knowledge base would greater benefit PGY-1s or whether different instruction methods would allow greater generalization of knowledge.
The PGY-4s had a highly favorable experience with the teaching resident rotation, and the rotation met the objectives of helping PGY-4s prepare for the ABPN board exams and learn more about teaching. Obtaining feedback from the junior residents and medical students midway through the TR’s 2-month tenure (and using this feedback to guide skill-building) would likely further enhance the TR’s development during the rotation. As the direct supervisor of the TR, the program director plays a crucial, if behind-the-scenes, role in the experience. Suggestions to enhance the supervisory experience included role playing difficult situations and providing the TR with curriculum materials from the junior residents’ didactics to reinforce learning.
We feel that the Mount Sinai Psychiatry Teaching Resident Rotation uniquely addresses the educational needs of the trainees involved. During this year, one PGY-2 resident needed intensive instruction regarding interviewing skills, and this resident made substantial progress due to the focus from each TR. The extra observation and supervision of interviews by PGY-1s is both welcomed and necessary because now all residents will be examined for their ability to perform an initial clinical interview as part of the ABPN process. Inpatient psychiatry ward rotations, intense and arduous, are wonderful learning opportunities, especially if one has attentive supervision. The TR was able to step in and provide supervision which the ward attending had become too busy to provide. We feel that individual supervision of PGY-1s and group supervision of PGY-2s worked well. Given that the TR is a “near-peer” supervisor, PGY-2s might have had trouble becoming engaged with the TR in individual supervision (1). Providing the medical students with more teaching likely enriched their psychiatry clerkship, and involving the TR with the fourth-year medical students seems to have positively affected the attitudes of applicants to our residency program, as evidenced by informal verbal feedback we have received.
The PGY-4 residents who rotate as teaching resident benefitted from a rich opportunity to prepare for oral and written ABPN board exams. The rotation offers PGY-4s occasion to consolidate their knowledge and hone their interview skills, with a heightened awareness of what makes for an effective interview. Most important was the instruction in and experience with a variety of teaching methods afforded by the TR rotation. Supervision and direct observation of the TR giving feedback is especially valuable (12). Residents who undergo a residents-as-teachers curriculum go on to develop more enthusiasm for teaching and a more empathic approach to their learners (13); these attributes have important career implications even if the resident is not planning an academic career.
One concern while designing this experience was how the PGY-4 teaching residents would be differentiated from, but integrated with, the PGY-4 chief residents and with program administration. The outcome was that the TR did more teaching than the chief resident and became a part of the administrative team without becoming a “feared” administrator. The key problem-solving venue is the weekly meeting of the program director, associate director, nonphysician coordinator, and the three chief residents. The decision was made to have the TR attend this meeting for the duration of the 2-month TR rotation. This integrated the TR’s activities with other agenda issues and made the educational needs and progress of residents a constant concern. Another valuable aspect of this arrangement is that all PGY-4s have had some exposure to the administrative issues of a department of psychiatry, in addition to teaching experience, which prepares them for attending level positions in the near-future.
We believe that Mount Sinai’s Teaching Resident Rotation has been a success for all levels of trainees involved. It has given teaching itself a higher status—teaching now has its own rotation on par with research and clinical rotations. We believe it will enhance the esteem of the program and the success of its trainees. We hope our teaching resident rotation will serve as an example for other programs to use or adapt.
At the time of submission, the authors reported no competing interests.