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Can Fam Physician
Vol. 55, No. 9, September 2009, pp.902 - 903.e5
Copyright © 2009 by The College of Family Physicians of Canada
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Research

Teaching-skills training programs for family medicine residents

Systematic review of formats, content, and effects of existing programs

Miriam Lacasse, MD MSc CCFP
Clinical Teacher at the Département de médecine familiale et de médecine d’urgence at Laval University in Quebec City, Que, and was an Academic Fellow in the Department of Family and Community Medicine at the University of Toronto in Ontario at the time of writing this article

Savithiri Ratnapalan, MB BS MEd MRCP FRCPC
Assistant Professor in the Department of Pediatrics and the Department of Public Health Sciences at the University of Toronto and a staff physician in the Department of Pediatric Emergency Medicine and the Department of Clinical Pharmacology and Toxicology at the Hospital for Sick Children in Toronto

Correspondence Dr Lacasse, Département de médecine familiale et de médecine d’urgence, Université Laval, Pavillon Ferdinand-Vandry, 1050 rue de la Médecine, local 1432, Quebec, QC G1V 0A6; telephone 418 656-2131, extension 7088; fax 418 656-5252; e-mailmiriam.lacasse{at}mfa.ulaval.ca

Medical residents are often involved in teaching undergraduate medical students or junior residents, in addition to teaching and caring for patients, during their postgraduate training period. Many medical schools and residency training programs offer teaching-skills training sessions to prepare residents to be better teachers. The format, content, and duration of these teaching programs, however, vary widely. Wamsley et al published a literature review of "resident-as-teacher" curricula, which included residents from different specialties. This review identified various formats of such courses and found that participants improved self-assessed teaching behaviour and teaching confidence, in addition to receiving improved evaluations from their students.1

Residents need to find balance between their own learning, patient care, and teaching. They also have to balance their needs for learning clinical knowledge with their needs for teaching-skills training.2–4 These barriers are especially obvious in family medicine residency.

Family medicine residency training programs differ from all other training programs in their shorter duration (usually 2 or 3 years in North America) and their broader scope of learning within this period. Teaching-skills training, however, is considered mandatory,5–8 as family medicine residents, and residents in other disciplines, are often expected to provide a considerable amount of formal and informal teaching to junior trainees. Most of them will also receive trainees when they begin practice. Family physicians are primary providers and are often the only providers of patient education and public education, which further stresses the importance of teaching-skills training for family medicine residents.

The College of Family Physicians of Canada’s Standards for Accreditation of Residency Training Programs states the following: "Residents must be given opportunities to develop effective teaching skills through organized activities focused on teaching techniques."5 The CanMEDS Physician Competency Framework also states that physicians should be scholars, "able to facilitate the learning of patients, families, students, residents, other health professionals, the public, and others, as appropriate, and to contribute to the creation, dissemination, application, and translation of new medical knowledge and practices."8 According to the Accreditation Council for Graduate Medical Education’s Common Program Requirements for practice-based learning and improvement, "residents/fellows are expected to develop skills and habits to be able to participate in the education of patients, families, students, residents and other health professionals, as documented by evaluations of a resident’s teaching abilities by faculty and/or learners."6 Moreover, the Liaison Committee on Medical Education’s Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree states that "[r]esidents who supervise or teach medical students, as well as graduate students and postdoctoral fellows in the biomedical sciences who serve as teachers or teaching assistants, must be familiar with the educational objectives of the course or clerkship and be prepared for their roles in teaching and evaluation."7 As prescribed by these organizations, teaching is not only a possibility, but also a responsibility for physicians in training.

Residents consider teaching medical students to be one of their primary responsibilities and they learn themselves in the process of teaching.4 Most learners feel that resident teachers, who are close to their own training level, facilitate their learning and have a good understanding of how they should be taught.9 Teaching also seems to enhance the teacher’s own knowledge acquisition.10 A literature review concluded that teaching also improved teachers’ perceived professional competency: physicians seen as competent were those who taught effectively and possessed a basic understanding of teaching and learning.11

This systematic review aims to evaluate the formats used and the content usually taught in existing teaching-skills training programs for family medicine residents, and will appraise the reported effects of such programs.


   DATA SOURCES
TOP
 DATA SOURCES
SYNTHESIS
 DISCUSSION
 Conclusion
 Footnotes
 Acknowledgments
 References
 
We searched Ovid MEDLINE (1950 to mid-July 2008) and the Education Resources Information Center (ERIC) database, which indexes education journals, (pre-1966 to mid-July 2008) using and combining the MeSH terms teaching, internship and residency, and family practice (MEDLINE) and teaching, graduate medical education, and family practice (medicine) (ERIC), and reviewed the bibliographies of identified articles. This search was specific to family medicine training. To make sure that we did not miss any relevant articles published since Wamsley and colleagues’ review,1 we also conducted a search using only the terms they used (internship and residency and teaching) for articles published after their review time frame (ie, June 2003 until mid-July 2008).

Study selection
The initial MEDLINE and ERIC searches identified 362 and 33 references, respectively. Titles and abstracts were reviewed to identify the articles relevant to our analysis. References were included if they described the format or the content of a teaching-skills program or if they presented the results of primary studies of the effects of a teaching-skills program for family medicine residents or which included residents in family medicine among other specialty trainees. Only articles published in English were selected. Three references were identified as relevant to this review. The bibliographies of these articles were reviewed, and 4 additional relevant articles were identified. The broader search extending Wamsley and colleagues’ review1 found 907 references, from which 1 additional article was identified. Therefore, we included a total of 8 articles in our systematic review.


   SYNTHESIS
TOP
 DATA SOURCES
 SYNTHESIS
DISCUSSION
 Conclusion
 Footnotes
 Acknowledgments
 References
 
Format and content of teaching-skills training
Teaching-skills training programs in which family medicine residents are involved have various formats: 1-hour weekly sessions over a few months,12–15 half-day courses,13,14,16 1-day intensive workshops,17 and on-line modules.18

Various teaching strategies are used, such as lectures,15 interactive discussions,13–15 role playing or simulated teaching activities,13–15,17 discussion of sample cases,15,17 videotaped vignettes,15 on-line teaching resources,15,18 one-on-one mentoring,15 and guidance by faculty supervisors.15

The content taught in teaching-skills curricula included the following skills.

Leadership skills
Program content covered leadership and role modeling,13,14 motivation,16 and directing attention.16

Effective clinical teaching skills
Specific areas of focus included general principles of clinical teaching and adult learning15,18; orienting learners13,14,17; objectives and planning12,16,17; the "teachable moment" concept13,14; delivery methods12; group teaching and inpatient work rounds13,14; discussion and questioning12,18; tips for effective teaching,15 such as the "five-step microskills" model of clinical teaching13,14,17; bedside teaching13,14; and audiovisual and presentation skills.12–14,18,19

Technical teaching skills
These included demonstration techniques,12 teaching with high-fidelity patient simulation,18 teaching procedures,13,14,16,18 and teaching charting.13,14

Feedback and evaluation skills
Residents learned to give feedback13–18 and to evaluate16–17 learners.

The description of format and content for each program is summarized in Table 1.12–20


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  		Table 1 Summary of format, content, and effects of teaching-skills training programs involving family medicine residents

 
Effects of teaching-skills programs
According to Kirkpatrick,20 4 levels of evaluation can be assessed: reactions, learning, behaviour, and results. His model for evaluating educational outcomes was modified by Freeth et al21 and was adopted by the Best Evidence in Medical Education Collaboration. This model was further adapted by Steinert et al22 to include students, residents, and colleagues (instead of patients). The results of studies on the effects of teaching-skills programs retrieved by this review are presented in Table 112–20 in terms of those 4 levels.

The evaluation of most programs was very positive in terms of curriculum appreciation (reactions),14,17 learning outcomes14,17 and teaching behaviour.12–14,16,17,19 None of the retrieved studies assessed the outcome on learners (results).


   DISCUSSION
TOP
 DATA SOURCES
 SYNTHESIS
 DISCUSSION
Conclusion
 Footnotes
 Acknowledgments
 References
 
This review demonstrates that teaching-skills programs for family medicine residents exist in many formats and shows what content is usually discussed. Specific data on the effects of teaching-skills curricula for family medicine residents are, however, lacking. Most studies involved "primary care residents," which usually included family medicine, internal medicine, and pediatrics residents.

When compared with studies aimed at various specialty programs, few data are available for family medicine residents on curriculum appreciation23–31 or learning outcomes of teaching-skills curricula.23,27,29,32 As for most studies involving residents from other programs,23–25,28,29,32–38 most studies for family medicine residents have assessed the effects of this training on residents’ teaching behaviour. Considerable gains were noted on several teaching skills in the various studies.

Not surprisingly, there are no data analyzing the highest evaluation level, which is outcome on learners (results). Such data are limited even when residents from all specialties are considered.24

The findings on primary care residents from Aiyer et al are of interest for family medicine training programs.17 When compared with non–primary care residents, primary care residents showed a greater increase in confidence in their teaching ability and in some teaching skills (improved perceptions of encouraging bedside teaching and providing daily feedback to their learners). This suggests a great potential for teaching in these residents.

After reviewing literature in 1990 on training residents as teachers, Chamberland and Boulé proposed 4 recommendations that still seem to be accurate and particularly relevant to family medicine residents: 1) because of residents’ time constraints, short (2 to 3 hours), periodic sessions are preferred to curricula presented over a few days in a row; 2) course content should be practical and relevant to the residents’ practices and should integrate basic education principles rather than teaching in a theoretical way; 3) educational strategies should encourage an active role for residents (workshops, role playing, videotapes, etc); and 4) teaching-skills training should be included in residency programs to establish and valorize residents’ teaching role and ensure evaluation of their teaching skills.39

Limitations
This review has some limitations. Publication bias is an important limitation, and some unpublished studies might have given a different view. Also, most articles that were retrieved targeted primary care residents, not specifically family medicine residents. This might have an effect because duration of training in internal medicine and pediatrics is longer than for family medicine.

Furthermore, applicability of these findings still needs to be carefully assessed, as the 8 studies that were included in this review were not conducted in Canadian settings. Most of the family medicine programs examined in the retrieved articles are 3 years in length, leaving more time for teaching-skills training. Canadian family medicine residency programs are very different from those of the other specialties owing to their 2-year duration. There is a paucity of papers on teaching skills for family medicine residents. This review is based on published literature and thus most of the papers on which the review is based have 3-year programs. Some of the findings, however, can be extrapolated to family medicine residents and should be considered during the development of teaching-skills curricula in the context of our shorter programs.


   Conclusion
TOP
 DATA SOURCES
 SYNTHESIS
 DISCUSSION
 Conclusion
Footnotes
 Acknowledgments
 References
 
Teaching-skills training programs for family medicine residents use many teaching strategies in curricula presented over a half-day to a few months. Their content includes leadership skills, effective clinical teaching skills, technical teaching skills, as well as feedback and evaluation skills. Program evaluation mainly targeted the effects of the programs on teaching behaviour, which was generally found to improve after completion of these programs.

Because family medicine training covers a broad scope of clinical content in the context of a short duration of training, further studies assessing the effects of teaching-skills training for family medicine residents are needed. Educators should, however, develop programs based on the available knowledge that would benefit family medicine residents in Canada and evaluate the effects of these programs. Future research should also concentrate on the learners’ outcomes to assess how residents’ teaching-skills training can affect their learners’ clinical training and eventually patient care.



   EDITOR’S KEY POINTS
 
  • This review focused on teaching-skills training programs designed for or including family medicine residents. It reviews the format and content and appraises the effects of such programs.
  • Teaching-skills programs for family medicine residents exist in many formats.
  • Few data are available on the effects of teaching-skills curricula for family medicine residents specifically.

 



   POINTS DE REPÈRE DU RÉDACTEUR
 
  • Cette synthèse porte sur les programmes de formation en enseignement concus pour les résidents, incluant ceux en médecine familiale. Elle examine la forme et le contenu de ces programmes ainsi que leurs effets.
  • Il existe plusieurs formes de programmes de formation en enseignement pour les résidents en médecine familiale.
  • Il y a peu de données portant sur les effets des programmes de formation en enseignement spécifiquement sur les résidents en médecine familiale.

 


   Acknowledgments
TOP
 DATA SOURCES
 SYNTHESIS
 DISCUSSION
 Conclusion
 Footnotes
 Acknowledgments
References
 
We thank Mrs Elizabeth M. Uleryk, Director of the Hospital for Sick Children’s library, Mrs Rita Shaughnessy, librarian for the Department of Family and Community Medicine at the University of Toronto, and Mrs Denise Paquet and Mrs Patricia Chamberland, library technicians at the Centre hospitalier de l’Université Laval, for helpful guidance with the literature search.


   Footnotes
TOP
 DATA SOURCES
 SYNTHESIS
 DISCUSSION
 Conclusion
 Footnotes
Acknowledgments
 References
 
Contributors

Dr Lacasse developed the concept and design of the study, conducted the literature review, selected and analyzed the studies, interpreted the analysis, and prepared the manuscript for submission. Dr Ratnapalan provided support for the development of the concept and design of the study and participated in the interpretation of the analysis and preparation of the manuscript for submission.

Competing interests

None declared

*Full text is available in English at www.cfp.ca.

This article has been peer reviewed.


   References
TOP
 DATA SOURCES
 SYNTHESIS
 DISCUSSION
 Conclusion
 Footnotes
 Acknowledgments
 References
 

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