Reports on the role of residents as teachers have appeared in
the medical literature for over thirty years, citing, in addition
to the benefits to students, improvement in the knowledge and interactive
skills of the residents1. It has
been estimated that, at any given moment in this country, some 100,000
residents on hospital wards are working alongside half of the nation’s medical
students, and that these students will receive 20% to 70% of
their clinical instruction from residents2-4.
Traditionally, the role of residents is complementary to that
of attending physicians: principles taught by faculty in
lecture format are applied to patient care in the clinical setting,
where interaction between residents and students is common. Residents
are effective teachers in these settings because they emphasize
the practical aspects of care and understand the needs of students. Residents
are often better suited, for example, to the teaching of basic technical
skills than are staff members who have become less conscious of
the individual steps that a novice must take to master a given procedure.
Being less threatening gradewise, residents are also more approachable
for answers to "stupid questions" than are members
of the faculty.
Since teaching by residents is crucial to the education of both students
and residents, the issue is not whether residents should teach but
how they can be enabled to do it most proficiently.
There are at least six impediments to more proficient teaching
by residents.
(1) Insufficient role-modeling. Lack of faculty commitment to the
teaching enterprise is perhaps the major obstacle to improving the
enthusiasm, effort, and teaching skills of the residents.
In too many institutions, teaching, especially of medical students, has
become an elective, rather than a required, faculty responsibility.
(2) Time constraints. As the influence of the marketplace on health
care has increased, teaching hospitals, whose mission includes a
major educational component, have become disadvantaged. With 50% of
an average medical school’s budget derived from clinical
revenue and with reimbursement decreasing for each unit of service,
clinical faculty have been compelled to spend more time providing patient
care, often at the expense of teaching time5.
(3) Little instruction in the principles of adult education and
the techniques of teaching. Because teaching defines us as professionals
and as individuals, it is too important a responsibility to be delegated
to residents without guidance.
(4) Limited awareness of service-specific learning objectives for
clinical clerks, if, in fact, such objectives have been developed.
(5) Minimal institutional and/or departmental recognition
of either the quality or quantity of teaching performed
by residents. Teaching by residents is seldom monitored, supervised,
or evaluated, which does not encourage residents to exert effort
in this area.
(6) Lack of interest in teaching.
Each of the above impediments can be addressed to improve the teaching
skills of residents.
(1) The teaching of medical students must be required by the school
for faculty promotion, and all members of the department must participate.
A strong argument can be made that teaching students is the most important
obligation of a medical school faculty; if faculty members do not
serve as enthusiastic, competent, and accessible teachers of medical
students, it is unrealistic to expect or require those qualities
in residents. Quantifiable means of measuring teaching effectiveness,
such as those developed by the Association of American Medical Colleges6, should be made available to promotions
committees, and predefined salary adjustments should be made for
those who demonstrate exceptional teaching skills.
(2) The compression of teaching time as a result of expanding patient-care
responsibilities has made separate work-related and teaching rounds
less feasible; however, by simply thinking aloud as decisions are
made during work rounds, residents can make the education of students
a valuable by-product. Additional time for teaching may be found during
night and weekend call activities when residents are working one-on-one
with students. Other "teachable moments" that
are often overlooked are coffee breaks and downtime between patients
or operating-room procedures, which can be particularly useful occasions
for providing feedback to students out of the earshot of patients.
In short, every encounter that involves a resident and a student should
be viewed as an opportunity to teach, both by delivering information
and by demonstrating nonverbal professional attitudes and behaviors.
(3) Most residents have not received formal instruction in the principles
and techniques of education. For motivated adults, the principal
determinants of learning are active involvement of the learner and
problem-centered teaching; nonjudgmental feedback and the opportunity
for repetition are critical adjuncts7.
Surgical residents, whose time for patient interaction is limited by
the demands of the operating room, are understandably prone to a
direct approach that emphasizes recall and delivery of facts and
sometimes forget that knowledge can be drowned in information and
wisdom can be missing in knowledge. While an assertive style is
useful at times, teaching only by force-feeding information, whether
by faculty or by residents, produces—like the proverbial
Strasbourg goose—a pâté that contains
too much of the formalism and too little of the ethos of medicine. Why
do we persist in teaching facts, when learning based on understanding
and reflection is more likely to be stored in long-term memory?
Because it is easier to impart information than it is to teach students
how to think.
Even experienced instructors sometimes forget that teaching does
not ensure learning. It is a mistake to consider teachers the active
and students the passive participants in education. Students must
realize that the primary responsibility for their education rests
with them. Both parties must be active for learning to occur, although
the emphasis on independent learning should increase as the trainee moves
along the educational continuum.
Teaching techniques vary with venue, content, and group size. Small-group
teaching differs from the lecture format in that, in the former,
content is delivered in small bites on the basis of data generated
from the patient, and opportunities to display interactive, motor,
and attitudinal behaviors are more frequent. In the outpatient setting,
where more time may be available, residents should arrange for students to
examine patients on their own so that they can formulate a diagnosis
and a treatment plan independently before the resident and student
see the patient together.
Clinical and bedside teaching are important because
they enable students to perceive the role of the human dimension
in increasingly technological methods of care. One cannot overemphasize
the importance of role-modeling in these settings, not only in the
provision of competent medical care but also in the demonstration
of an attitude that reflects caring and concern. Moreover,
by getting quickly to the essence of a problem, the resident can
demonstrate how efficient time management can coexist with respect
and empathy. In their preoccupation with knowing and doing, inexperienced
instructors often do not understand the importance of these attitudes.
It is heart and character that drive the head and hands.
In general, presentations made on rounds should be brief
(three minutes or less) and should include the diagnosis, an update on
the patient’s condition, a demonstration of pertinent physical
findings, and a description of what is planned and why. When the
diagnosis is known, discussion should center on management and supporting
data. Resident comment should be limited to one or two key points, with
an emphasis on relevance rather than completeness.
Teaching in the operating room is focused on applied
anatomy and provides students with a unique opportunity for the
correlation of gross pathology with clinical, laboratory, and radiographic
findings.
Most opportunities for teaching by residents occur in the informal
settings described above. Occasionally, however, residents are called
upon to present a classroom lecture, in which case the educational
objectives should be clearly stated, comment limited to thirty minutes
or less, and time allowed for a summary and questions. Clarity,
conciseness, and awareness of the students’ levels and
needs are ever essential, as is eye contact, variation in pace and
volume, and, above all, a manifest enthusiasm for the subject and
its teaching.
Open-ended questions, such as the significance of a
particular finding, the options and rationale for management of
a given problem, and the correlation of clinical and laboratory
findings, are useful means of encouraging deeper discussion in all
venues.
(4) Prior to their appearance on the floors or in the clinics,
students and residents must be made aware of the learning objectives
for that rotation. When stated in behavioral and measurable terms,
learning objectives serve as guides for both teaching and
evaluation. In addition to the requirements for acquisition, comprehension,
and application of requisite knowledge, objectives should include the
development of skills (motor and interactive) and attitudes. The
latter are more difficult to formulate—and to achieve—but they
are ultimately of greater importance.
(5) The departmental commitment to teaching by residents can be
demonstrated by holding periodic workshops to improve the teaching
skills and confidence of residents. Staffed by an appropriate faculty
member and an education specialist, sessions should include the
principles of adult learning, teaching strategies, and curriculum
content8. Videotapes that demonstrate
the strengths and weaknesses of different teaching styles may be useful
in this undertaking.
The value placed on teaching can be further emphasized by the inclusion
of a category on resident evaluation forms that rates the resident’s
effectiveness as a teacher, with special recognition for those who
achieve high ratings.
(6) The extent to which an interest in teaching is innate, as opposed
to acquired, is unclear. Nevertheless, most people enjoy doing what
they do well, which, even for uninterested residents, justifies
our efforts to make them better teachers—as we continue to
search for ways to identify applicants with a genuine desire to
teach. House officers who relish working with students will be more
likely to involve them and to make themselves accessible, attributes
that garner high marks from learners9.
There is perhaps no better conclusion to this topic than the statement
of Sir William Osler who, almost 100 years ago, said: "I
desire no other epitaph . . . than the statement that I taught medical
students in the wards, as I regard this as by far the most useful
and important work I have been called upon to do."10
Note: It is difficult to write, or even think, about residents as teachers
without acknowledging Neal Whitman and his colleagues at the University
of Utah for their pioneering work in this field, which
has informed and inspired so many for so long.