Residents spend an estimated 25% of their time supervising, teaching, and evaluating medical students and their junior peers (1, 2), and residents have important functions in the lives of medical students as teachers and role models (3). Positive clerkship experiences in psychiatry have also been shown to influence student career choice (4). Developing the skills to become an effective teacher should be regarded as an essential aspect of postgraduate medical education.
According to a 2001 survey (5), 55% of U.S. residency programs offer teaching skills training to their residents. These training programs take place in a variety of settings, but the most commonly used formats are lectures and workshops (5, 6). Consistently, studies report that formal “residents-as-teachers” training programs improve teaching skills (7), as judged by self-teaching assessments, resident confidence in teaching, and student evaluations of resident teaching (8). Morrison et al. (9) reported that residents randomly assigned to receive a 13-hour longitudinal residents-as-teachers curriculum showed improved teaching effectiveness as evaluated by medical students. In another study by Morrison et al. (10), residents who participated in the 13-hour teacher training program expressed greater enthusiasm for teaching, used more learner-centered approaches, and showed more empathy toward learners than those who did not undergo the training program. Further, residents who received the training wanted to continue teaching in the future.
Teaching junior colleagues has been identified as a key aspect of resident education and training by both the Accreditation Council for Graduate Medical Education (ACGME) (11) and the Royal College of Physicians and Surgeons of Canada (RCPSC) (12). In fact, the RCPSC adopted a unique framework of education designed to foster the development of competent physician specialists, the Canadian Medical Education Directions for Specialists (CanMEDS) (12). CanMEDS describes several interconnected roles that a competent physician is expected to embody, including medical expert (central role), communicator, collaborator, health advocate, manager, scholar, and professional. This framework has set a standard for medical education in Canada.
As a scholar, the resident teacher facilitates medical student learning by selecting effective teaching strategies and content, evaluating and discussing teaching encounters, providing effective feedback, and describing principles of learning that are relevant to the curriculum (12). The incorporation of CanMEDS into residency evaluations has contributed to resident involvement in medical student teaching, and according to the RCPSC specialty training requirements in psychiatry, senior residents (defined as those in postgraduate years [PGY] 4 or 5) “will be provided with opportunities to consolidate the Roles of Communicator, Collaborator, Manager, Advocate, Professional, and Scholar.” As such, they are expected to assume “more leadership in the education and supervision of junior colleagues,” an expectation that is embodied by the role of scholar (13).
In order for residents to fulfill the scholar role, they must be familiar with both the course content they are expected to teach and the tools with which to become effective teachers. However, the tools needed in the development of a resident teacher are limited in both Canadian and U.S. postgraduate settings. A recent review of the resident-as-teacher literature (14) identified common barriers to teaching: lack of time, lack of training in teaching processes, and lack of confidence in teaching skills. However, when formal training on teaching skills is offered to residents (14–17), studies show that it has a positive effect on residents’ confidence in teaching and that the training results in improved student evaluations of teaching effectiveness (14, 16).
Although offering residents formal training in teaching has a number of described advantages, the evidence to support the effectiveness of these programs in psychiatry is scarce (18). With that in mind, residents in the Department of Psychiatry at the University of Alberta developed a teaching manual for residents to use to enhance the development of confident and competent psychiatric resident teachers. The goal of this article is to describe the first stage in the creation, implementation, and evaluation of this manual in the psychiatric residency program at the University of Alberta.
The need for a teaching manual to aid residents in teaching medical students was determined by two of the authors (JS, MM) who were second-year psychiatric residents at the time. At the University of Alberta, second-year residents complete a year in general adult psychiatry. During this time, they have significant interaction with medical students completing their core 6-week clinical rotations in general adult psychiatry (the equivalent of the psychiatry clerkship in the United States). Throughout this year, it became evident that the degree of resident involvement in teaching was variable. Informal discussion with fellow residents determined two reasons for this. First, several residents described difficulty in determining what to teach the students. Second, they were uncertain about how to teach the students. The Resident Teaching Manual was conceptualized to address these two issues.
We reviewed the local learning objectives for the medical student rotations and content of the didactic lecture series for medical students given by staff psychiatrists during the 6-week rotation. This review was discussed with the psychiatric residency program director and the undergraduate psychiatry clinical coordinator (clerkship director). We chose six core topics to be included in the manual and formed the basis for resident-led, small-group seminars. These seminars were designed to engage the students in an interactive discussion with a problem-based, bedside teaching approach, in contrast to the lecture-based series by the staff psychiatrists. For example, instead of preparing a seminar on suicide or depression, the “suicidal patient” seminar was designed to provide a practical approach to the assessment, evaluation, differential diagnosis, and treatment plan for a patient presenting with suicidal ideation. Other seminar topics included patient history and mental status exam, safety, the manic patient, the psychotic patient, and the anxious patient. Students continue to receive a lecture-based series (3 hours per week) given by staff psychiatrists. Where possible, resident teaching seminars are held over the lunch hour, but occasionally both students and residents are excused from clinical duties to participate in the seminars.
Manual content was developed from local medical student clerkship objectives and the authors’ own working knowledge of psychiatry (the manual is available online at http://www.psychiatry.ualberta.ca/Home/Clinical/Residency/Resources/MedicalStudent-ResidentTeachingManual.pdf). Information was supplemented as needed from general psychiatry textbooks such as Kaplan and Sadock’s Synopsis of Psychiatry (19). Seminars were prepared initially for content and then edited to be similar in organization and structure. Teaching tips (e.g., “People retain more information when they have not only heard it but also when they have seen it, written it down, and are able to review it with another person” and “Don’t be afraid to ask your students how they learn best”) were included at the beginning of the manual and with each seminar so that the manual would act as a guide for residents on how to teach. The manual was reviewed by the undergraduate psychiatry clinical coordinator, the psychiatric residency program director, and the psychiatric residency program committee. Response was overwhelmingly positive, and it was accepted for use with no further revisions. Copies were made for each resident, and the manual was introduced at a resident business meeting. Its use was then implemented, with a formalized seminar series for medical students occurring at each of the sites where students rotated. One resident volunteers for or is assigned responsibility for coordinating the seminars at each site, and all residents are expected to participate in teaching as a requirement of the psychiatric residency program. All resident preceptors were made aware of this requirement. The number of seminars given by any one resident over a 6-week period varies from zero to three and is based on distribution of residents and students at the various academic sites. Overall, this teaching initiative requires little time or preparation by residents.
After the manual was in place for 4 months (allowing the residents to use the manual with two groups of medical students [6-week rotations]), a quality control survey with a Likert-type scale was administered to residents to assess their opinions on the ease of use and utility of the teaching manual. In addition, the manual was uploaded to the University of Alberta Department of Psychiatry website and is available for others to use and adapt.
The teaching manual has been in use since September 2005. The response has been generally positive, both from residents and medical students. It was expected that all 29 residents in the psychiatric residency program had participated in giving seminars, and 22 residents (11 men, 11 women) responded to the quality control survey. It is unknown whether the seven nonrespondents had participated in the teaching seminars. Of those who responded, 13 were graduates of Canadian medical schools, eight were international medical graduates, and one did not identify this information. Most respondents were junior residents (nine from PGY-2 and eight from PGY-3). One PGY-4 resident and four PGY-5 residents responded. Fifteen of the 22 respondents had previous teaching experience. On the survey, the majority of respondents (71%) agreed or strongly agreed that the manual was easy to use, and a similar majority (76%) believed that the manual content was sufficient (Table 1). Qualitatively, residents commented that the best aspects of the manual were related to both its content and structure (Table 2).
The goal of this article was to discuss the creation, implementation, and initial evaluation of a teaching manual designed to enhance psychiatric residents’ skills as teachers. The quality control survey was intended as a preliminary evaluation of the manual. According to the survey, initial response is positive. However, further evaluation is necessary and should take the form of a controlled study. Limitations of the quality control survey include bias due to limited anonymity. Although “anonymous” surveys were collected by the residency program assistant, demographic information was provided (e.g., age and training year), thereby potentially unmasking the anonymity of respondents. It is possible that some residents were aware of this as they completed the survey and thus may have responded in an overly positive manner.
The overall response rate (22/29; 76%) reflected most of the residents in the psychiatry program; however, data from the seven nonresponders could have significantly changed the overall positive response pattern due to the small sample size. It is possible that residents who did not appreciate the use of the manual simply chose not to respond to the survey.
Future directions include medical students evaluating residents’ teaching, which is currently underway. Preliminary data from medical student evaluations indicate high satisfaction with the resident teaching seminars provided during the clerkship rotation. Ideally, a controlled study looking at medical student perceptions of psychiatric residents’ teaching performance pre- and postmanual implementation should have been undertaken; unfortunately, data were not collected prior to implementing the manual. Another area of interest would be to investigate the number of medical students from the University of Alberta choosing psychiatry as a career both before and after the teaching manual was implemented, because it has been previously documented that resident-student interaction can influence student career choice (3, 4).
Because the manual is not meant to be a textbook of information but a toolkit that residents can access to improve their teaching abilities, revision of the manual to further guide residents in teaching should prove beneficial in itself. Such revisions will be guided by results of the quality control survey, informal feedback from residents and medical students, as well as our own opinions.
Further evaluation is necessary to truly determine the effectiveness of this resident-as-teacher program. However, by emphasizing the role of resident-teachers, the implementation of this manual has contributed to important changes in the psychiatry program at the University of Alberta. Not only is the manual included in the orientation package for residents in PGY-2, but residents are also now offered adjunctive teaching skills seminars as part of their academic half day. These are planned by the psychiatric residency program. As such, development and implementation of a teaching manual for psychiatric residents has proved beneficial not only from the use of the manual itself but also from the new emphasis placed on resident teaching brought about by the existence of this manual.
To our knowledge, this is the first manual of its kind created and put into use in any residency program at the University of Alberta. On hearing about the manual, the postgraduate dean requested a copy and indicated that it could serve as a model for other residency programs. Certainly the concept would be feasible for other programs to adopt because it is easy to use, but a limitation is likely in the creation of such a manual for other programs. This psychiatry teaching manual was developed on the personal time of the residents involved, and it is estimated to have required 10–15 hours for production of the manual alone and another 10 hours to formalize the teaching program itself. Perhaps other programs could use incentives to encourage residents to produce such a manual, such as exempting residents from a grand rounds or journal club presentation in lieu of the work done for a teaching manual. The problems identified by psychiatric residents—not knowing what to teach or how to teach—are likely common barriers in other specialties as well. In particular, nearly half of the residents who responded to the quality control survey felt that the manual improved their confidence in teaching, and a majority of residents felt the manual’s use was helpful to the students. It is our opinion that confident teachers who feel they are providing an important function will be more motivated to continue teaching and further develop their own skills. We feel that the teaching manual does a good job of addressing content, and a reasonable job of addressing teaching method. Learning how to teach does require practical experience, and in addition to the teaching tips included in the manual, use of the manual itself helps to provide residents with this experience.
The authors wish to thank Dr. Mohammad Al-Ghamdi, Dr. Harris Lari, and Dr. Pravesh Vallabh, for their assistance in preparing the Resident Teaching Manual when they were first-year psychiatric residents. Thank you to Dr. Glen Baker for his review of this article.
At the time of submission, the authors reported no competing interests.