Residents have been identified as key contributors in the education of medical students. Medical students attribute one-third of their knowledge to teaching from house staff (1). The residents’ proximity to students in the ward, ER, or consultation service and during extended hours provides for constant opportunities for observation and teaching (2, 3).

Not only does the structure of training present frequent opportunities for residents to take on the role of teacher, the training objectives for postgraduate education in the United States (4) and Canada (5) both state that these skills should be formally developed during training.

Resident teaching skills should be considered a priority by postgraduate and undergraduate training directors and department chairs. Not only do these skills represent essential competencies of a practicing psychiatrist, but competent resident teaching is an essential component of a successful undergraduate medical education program in psychiatry. Student experience with competent teachers, particularly during a clerkship experience, has an impact on attitudes toward a specialty, exam performance, and even future recruitment into the field (6–8).

This article will review the development of the Teaching-to-Teach program at the University of Toronto Department of Psychiatry over the past 15 years. We review the current curriculum and evaluate the program. We also highlight some of the challenges encountered and discuss ideas for implementation of similar programs in diverse training settings.

The University of Toronto psychiatric residency program is a 5-year program which currently accepts 29 first postgraduate year (PGY-1) residents per year. This comprises 50% of psychiatric residency positions in Ontario, and 18% of psychiatric residency positions in Canada. There are 14 clinical training sites and psychiatric residents rotate through a number of these sites through their residency.

In 1994, the faculty of medicine at the University of Toronto underwent a curricular reform in the undergraduate medical education program. The psychiatry clinical clerkship was moved from a 4-week fourth-year clerkship rotation to a 6-week rotation in the third year that incorporated both clinical and didactic teaching. Students began spending more time in the hospital settings at a more junior level, thus requiring more teaching and supervision from faculty and residents alike.

Residents provide the bulk of the onsite clinical teaching to our medical students, but there had been no formal program in the department of psychiatry to provide psychiatric residents with any particular teaching skills. The old adage of “see one, do one, teach one” was the prevailing ethos, without any provision in specifying how. With the advent of the new undergraduate curriculum, a small group of general psychiatrists created a course to provide the residents with an approach to developing the skill set necessary to become effective teachers.

The course was designed to familiarize residents with teaching modalities for undergraduate medical students. Topics included one-to-one teaching, seminars, role playing, problem-based learning, and evaluation/feedback. Sessions were delivered in an interactive and experiential way using techniques of brainstorming, simulations, and modeling while exposing the residents to common teaching moments encountered with clinical clerks in the ER and on the wards.

This course was held over the summer for five 2-hour sessions from 1994–2002. A cohort of five faculty members, including a medical educator (JL), delivered the course each summer prior to the arrival of the next year’s medical students. Initially the course was offered only to the residents at one site; eventually it was offered to all residents as an elective in Medical Education. Resident attendance ranged from 10–20 trainees out of approximately 125 during 1994–2002.

From 2003–2005, there was a hiatus in the Teaching-to-Teach course after a number of the staff participating in this program departed. Departmentally, there was a growing awareness of the need to provide core teaching skills to all residents in the training program and not just those at select settings. Residents began asking for a resurrection of the elective course given in earlier years. In 2005, a half-day session was created for second-year residents. Twenty-five residents attended this mandatory half-day Teaching-to-Teach workshop.

A small group of residents and faculty continued to work on a program that acknowledged the learning needs of junior and senior residents. By 2007, the current curriculum and syllabus were designed.

In 2005 a needs assessment was distributed to junior residents to survey them about their interest in an educational curriculum. We found that 73% of residents who responded wanted to devote at least 7 hours of their educational curriculum over the course of their residency (approximately 5% of structured educational time) to improving teaching skills.

In January 2007, we implemented a full-day curriculum/workshop for all 133 psychiatric residents called the “Teaching-to-Teach Day.” The morning was dedicated to junior residents (PGY-1 and PGY-2), and the afternoon was dedicated to senior residents (PGY-3, PGY-4, and PGY-5). Both groups of residents gathered together for a lunch session to share thoughts about teaching opportunities. This has since been split into a half day for junior residents and a separate half day for senior residents.

Junior Resident Program: PGY-1 and PGY-2

In the junior resident half-day (schedule available upon request), residents are oriented to the undergraduate curriculum, brainstorm qualities of strong and weak teachers, discuss anxieties about teaching medical students, and view a role play of a teaching encounter. Finally, the residents practice one-to-one teaching with a simulated medical student who is role-played by a senior resident. The role play scenarios have included the typical student, the disinterested student, and the sarcastic student (see Appendix 1).

Senior Resident Program: PGY-3, PGY-4, and PGY-5

In the senior resident half-day (schedule available upon request), residents have a review of basic teaching skills including knowing the learner, the one-minute clinical preceptor model (9) of teaching, and effective questioning techniques. Mandatory 1-hour sessions in a smaller group setting include giving effective feedback and advanced one-to-one teaching skills (e.g., challenging teaching scenarios).

Residents are also asked to rank their preferences for a selective workshop and topics have been offered based on resident feedback. These have included interdisciplinary teaching, small-group teaching, problem-based learning, providing supervision, and planning a teaching session. Residents are then slotted into one of three workshop tracks. With each track, the aim is to promote a supportive learning environment as residents move through 3 hours of workshops together.

The number of residents in attendance was not available. Twenty-eight residents at all levels of training submitted evaluations of the Teaching-to-Teach day when it was run in 2007. Thirteen residents submitted evaluations of the Teaching-to-Teach half day when it was run in 2008. All 13 residents were first- or second-year residents; evaluations from senior residents were not available.

Most residents who responded to the evaluation questionnaire in 2007 and 2008 felt that the topics were relevant to them (Table 1) and that they felt more prepared to teach medical students at the end of the program (Table 2). When asked about the perception about the amount of teaching to teach, one-half of the residents who answered in 2007 felt that this was the right amount of teaching to teach and one-half felt it was too little. However, in 2008, 46% of respondents felt that this was the right amount of teaching to teach, but 46% of respondents also felt that there was too much teaching to teach (Table 2).

The main findings of our evaluation are that the majority of respondents felt that the Teaching-to-Teach program was relevant to them, and the majority of residents who evaluated the Teaching-to-Teach program felt more prepared to teach medical students.

However, the challenge confronting this and other educational interventions is how to meaningfully assess the impact of the intervention. A recent review of residents-as-teachers curricula commented on the lack of controlled studies examining the impact of these interventions on future teaching (10). A systematic review of the evaluation of residents-as-teachers curricula revealed only one controlled study that included psychiatry trainees (11).

The evaluation of our program lacked both a control group and a pre/post assessment measure. Ideally, observed structured teaching encounters would be used as an objective determination of the effectiveness of our intervention (12, 13). The changes in requirements for postgraduate training over the preceding few years have led to mandatory teaching skills training in residency. This precludes the use of a standard intervention versus no intervention randomized controlled trial design. Given these limitations, it is still possible to assess in a pre/post intervention design the impact of the training on each trainee; however, without a control group, the findings would have to be interpreted with caution.

The low number of residents who responded to the evaluation questionnaire also limits the interpretation of the results. Given the size of the University of Toronto psychiatric residency program, it can be difficult to enforce attendance at teaching events. Residents are also required to split up into break-out groups and there is often attrition at the point of group formation. There may also be evaluation fatigue given the expectation of residents to complete evaluations of all of their core seminars and teachers. The postgraduate education department mandates that future evaluations will be performed online which may present further challenges to the response rate. Perhaps more encouragement in the curriculum with regards to filling out evaluations could increase the response rate in the future.

There may be some evidence of saturation as some residents did feel there was too much teaching to teach in the curriculum. The reason for this change is unclear as the residents who evaluated the 2008 Teaching-to-Teach half day were all junior residents and had not previously participated in this curriculum. There was a major restructuring of the postgraduate curriculum which has increased demands on residents’ time. This trend will need to be monitored longitudinally.

There are a number of factors in the University of Toronto department of psychiatry that make the Teaching-to-Teach program feasible. There is easy access to teaching facilities with auditoriums and break-out rooms. There is a large faculty that is interested in teaching and education and available to participate in the Teaching-to-Teach program. Also, the large size of the University of Toronto psychiatric residency program allows for a critical mass of residents to attend. As a result, this model may not be generalizable to other residency programs. On the basis of our evaluations, we can state that our curriculum is well-received by trainees and they feel better prepared to take on the role of teacher after participating. In addition, our curriculum fulfills the recommended content and time frame suggested in the recent review by Post et al. (10) for resident teaching skills programs.

Other potential models for smaller residency programs may include the use of online modules. This can reduce preparation time for faculty, and allows faculty to make use of expertise from other institutions. Collaboration between different psychiatry training programs, or collaboration with other clinical departments, may address physical plant limitations, faculty availability to teach, and increase the chance of a critical mass of residents attending. The identification of supervisors interested in teaching may also allow residents to be proactive in seeking electives in teaching to improve their skills.

The University of Toronto Teaching-to-Teach program has a 15-year history of development and implementation. The topics covered are based on resident feedback and the teaching methods are established interactive teaching methods. The program structure is consistent with the recommended intervention for effective residents-as-teachers curricula.

At the time of submission, the authors reported no competing interests.