Implementation and evaluation of a training program to

improve resident teaching skills

LeighAnn C. Frattarelli, MD, and Richard Kasuya, MD, MSEd

Honolulu, Hawaii

OBJECTIVE: This study was undertaken to develop, implement, and evaluate a program designed to improve

residents’ teaching skills.

STUDY DESIGN: A training program to improve the teaching skills of obstetrics and gynecology residents was

developed and implemented. All residents completed a survey of their teaching skills, participated in the

program, and then completed a follow-up survey. The surveys were compared using the Wilcoxon signed rank

test. Medical students also completed surveys about participating residents’ teaching skills either before or

after the intervention.

RESULTS: The training program was well received by the residents. Resident self-rating scores significantly

improved (P < .05) in a number of areas, such as ability to teach physical examination skills, and explaining

topics in a clear and concise manner. Interestingly, student ratings of resident teaching skills did not improve.

CONCLUSION: Although the training program improved resident self-ratings of teaching skills, this was not

reflected in student ratings of resident teaching skills. Possible explanations for this difference will be explored.

(Am J Obstet Gynecol 2003;189:670-3.)

Key words: Residents as teachers, teaching residents to teach, residents, teaching skills

The house officer in obstetrics and gynecology is

expected to assume a significant portion of the respon-

sibility for teaching medical students and junior level

residents. Barrow1 reported that medical students sur-

veyed indicated one fourth to one third of their clinical

education was from the teaching of house officers. A

resident spends 20% to 25% of the average work week

‘‘supervising,evaluatingor teachingothers.’’2Twothirdsof

residentscompletingonesurveybelievedthemajorbenefit

of teaching was to increase their ownmedical knowledge.3

The Liaison Committee for Medical Education has added

theneedtoprovide training to improveresidents’teaching

skills to their accreditation standards4 and demonstrating

that residents are able to teach others is included in the

AccreditationCouncil onGraduateMedical Education list

of general competencies.5

Although residents-as-teachers training programs have

been described in pediatrics,6,7 internal medicine,8-10

general surgery,11 family medicine,12 and psychiatry,13

From the Department of Obstetrics, Gynecology, and Women’s Healthand the Office of Medical Education, University of Hawaii John A.Burns School of Medicine.Developed as part of the 2002-2003 APGO/Solvay PharmaceuticalEducational Scholars Development Program.Presented at the Annual Meeting of CREOG/APGO, Anaheim, Calif,March 1-4, 2003.Reprint requests: LeighAnn C. Frattarelli, MD, 1319 Punahou St, Suite824, Honolulu, HI 96826. E-mail: leighann@hawaii.edu� 2003, Mosby, Inc. All rights reserved.0002-9378/2003 $30.00 + 0doi:10.1067/S0002-9378(03)00879-2

670

a national survey conducted in 2000 revealed only 38% of

obstetrics and gynecology residency programs reported

offering their residents any formal training in teaching.14

We developed, implemented, and evaluated a program to

educate obstetrics and gynecology residents to teachmore

effectively in the clinical setting. The project received an

exemption from the investigational review board of the

University of Hawaii.

Material and methods

A committee developed a training program to teach

residents how to teach. The committee consisted of the

clerkship director (L. F.), the residency program director,

a representative from the Office of Medical Education

(R. K.), and a resident representative. The representative

from the Office of Medical Education has experience in

setting up a resident-as-teacher program in other de-

partments. The committee chose topics that were based

on the educational philosophy of the medical school

(Problem-based Learning [PBL] centered), resident

suggestions, and weaknesses identified by student eval-

uations of residents. We selected the end of the academic

year for the program because residents are preparing

themselves for more responsibilities in the weeks to

come. An outside site was chosen for the training program

to minimize distractions. The program’s duration was

4.5 hours.

Five residents at the end of the first year, six at the end of

the second year, and six at the end of the third year

Volume 189, Number 3Am J Obstet Gynecol

Frattarelli and Kasuya 671

participated in the training program to help residents

improve their teaching skills. Sessions were interactive,

and residents were divided into small groups much of the

time. To begin the program, residents completed a self-

questionnaire about their teaching skills and listed

characteristics of their ideal resident teacher. After an

introduction and overview, the programdirector reviewed

teaching principles and adult learning styles. The clerk-

ship director discussed the PBL philosophy with the

residents and introduced them to the ‘‘PBL Microskills.’’

The ‘‘PBL Microskills’’ are a simple series of steps to help

teachers evaluate their students’ thinking, provide imme-

diate feedback, and facilitate additional independent

learning. The residents then practiced the ‘‘Microskills’’

in small groups. The residents also prepared and gave

‘‘Microlectures,’’ brief summaries of clinical topics that

residents can deliver to others with minimal preparation,

to their colleagues. They also taught college student

volunteers basic suturing and knot tying. The importance

of providing feedback was stressed. Residents gave each

other feedback and received feedback from their student

volunteers.

To evaluate the effectiveness of the program, the re-

sidents self-evaluated their teaching skills and confidence

in teaching in the clinical setting. They completed a

confidential self-evaluation questionnaire before the pro-

gram, and again 3 months after completing the training

program. The questionnaire focuses on the residents’

ability to create a positive learning environment, stimulate

students’ thinking about a subject, teach clinical skills,

incorporate the principles of PBL, and provide regular

and effective feedback. Self-evaluation questionnaires

were compared with the use of the Wilcoxon signed rank

test. Significance was set at 95% (P = .05).

Before implementation of the program three groups of

medical students completing their obstetrics and gyne-

cology clerkship completed a 20-question confidential

survey designed to evaluate the effectiveness of each

resident’s teaching skills. After the residents had com-

pleted the training program, the subsequent three groups

of students, most of these at the beginning of their third

year, completed the same questionnaire about the

residents. Given the design of our medical students’

clerkship model, it was not possible to have the same

group of students evaluate the residents before and after

the training program. We compared the student

evaluations from before and after the residents attended

the training program as well.

Results

Seventeen residents were involved in the intervention.

All residents’ evaluations of the training program were

favorable on verbal expression and on written exit surveys.

All residents reported that the training program should

be continued on a yearly or biyearly basis.

Results of the pretraining and posttraining program

surveys are seen in the Table. Significant improvements

(P < .05) after the intervention were seen in five of the

survey items. Resident self-evaluations did not worsen in

any category.

Medical students completed a mean of 16 ques-

tionnaires (range 7-22) about each resident’s teaching

skills before the retreat. In the 6 months after the retreat,

medical students completed a mean of 20 questionnaires

(range 16-25) on each resident.

Results of the preintervention survey (Cronbach

a = .9574) revealed the overall rating of the residents by

students was high at 4.2 (±0.9) on a scale of 1 to 5, with 5

being the best score. Residents scored highest in ‘‘showed

respect for me as a person’’ (4.6), ‘‘explained things in

a clear and concise manner’’ (4.4), and ‘‘asked questions

in a nonthreatening manner’’ (4.4). Residents’ scores

were lowest in ‘‘facilitated my use of PBL’’ (3.6).

In the postintervention survey results by students

(Cronbach a = .9532), the mean overall rating of the

residents was once again high at 4.2 (±1.0). The highest

score was in ‘‘showed respect for me as a person’’ (4.6)

with ‘‘asked questions in a nonthreatening manner’’

second (4.4). The lowest score for the residents was once

again, ‘‘facilitated my use of PBL’’ (3.3). The surveys did

not indicate a statistical improvement in resident teaching

skills in any category.

Comment

This resident-as-teacher training program was well

received by participating residents. Residents were very

receptive to learning to be better teachers and appreci-

ated the time to improve their teaching skills. After

exposure to an educational program on teaching, our

residents rated themselves as better teachers, probably

reflecting an increase in confidence.

The students rated our residents high both before and

after the training program, but we did not demonstrate

a significant improvement in our residents’ teaching skills

as viewed by students. The students evaluating our

residents were at different points in their third year of

medical education, and thus may have had different views

of how they should be treated by the residents. Many of

the students completing questionnaires after the educa-

tional program were in their first clinical rotation, and

thus had not had experience working with residents in the

past. Given their inexperience, it is possible they may have

had greater needs or higher expectations.

There are other possibilities for the lack of improve-

ment in the student evaluations that are worth investiga-

tion. Although simulation and active practice were used,

there may have been a lack of transfer of skills from the

workshop to real-life settings in which patients are

involved and stressors are high. Despite a needs assess-

ment based on national and local norms, a mismatch

September 2003Am J Obstet Gynecol

672 Frattarelli and Kasuya

between the workshop planners’ needs and the actual

true needs of the students may have occurred. It is also

possible that additional faculty reinforcement is necessary

to further shape the residents’ teaching skills. Prominent

residency program faculty were involved in the training

session, but the training session’s goals andmaterials were

not widely disseminated among other faculty.

Disappointing findings were also seen by Bing-You16

who reported that a weekend teaching skills retreat

for internal medicine residents did not improve most

teaching skills. A randomized study by Dunnington and

DaRosa11 also revealed few statistically significant dif-

ferences in teaching skills between residents randomly

assigned to receive a weekend retreat on teaching versus

a control group. Similar to our findings, Spickard et al.9

reported overall teaching skills were not significantly

Table. Resident’s self-evaluations

StatementPretestmean

PosttestMean P value

I show respect for thestudent as a person.

4.2 4.8 .039

I invite others’ thoughts inpatient care discussion.*

3.6 4.6 .004

I admit when I do not knowsomething.

4.5 4.8 .096

I enjoy teaching. 4.2 4.6 .083I am available to students. 3.9 4.2 .132I invited questions and

discussion.4.1 4.1 >.999

I ask questions in anonthreatening manner.

4.0 4.5 .053

I ask questions that stimulateproblem-solving.

3.7 4.1 .109

I support statements withevidence.*

2.2 2.1 .527

I provide guidance toappropriate readingmaterials.

3.5 3.9 .197

I am enthusiastic aboutobstetrics and gynecology.

4.3 4.3 1.00

I help others improve theirphysical examinationskills.

3.6 4.1 .020

I provide opportunity topractice technical skills.

3.8 4.4 .013

I give feedback on others’good work.*

4.1 4.4 .221

I provide constructivefeedback on areas othersneeded to improve.

3.2 3.6 .071

I facilitate the students’ useof PBL.

3.1 3.4 .109

I help the students identifyand resolve learning issueson the patients we care for.

3.6 4.1 .075

I explain things in a clearand concise manner.

3.8 4.2 .034

I make efforts to make othersfeel like part of the team.

4.1 4.5 .083

*Item negatively phrased in the survey given to students.Pre- versus posttraining program means: Wilcoxon signed

ranks test (n = 17).

changed after a 3-hour teaching skills workshop, but

internal medicine residents randomly assigned to partic-

ipation in the workshop gained more confidence in their

teaching compared with a control group.

Other authors have found improvements in residents’

teaching skills after a resident-as-teachers training pro-

gram.8,11 Roberts et al7 report that their program was

considered beneficial by residents, program faculty

members, medical students, and the program director

as demonstrated by an increase in residents being rated as

positive by students as opposed to neutral or negative.

Pediatric residents who received clinical teaching in-

struction received significantly more positive feedback on

their teaching and were judged by faculty members,

students, and peers to bemore effective clinical teachers.7

This study was randomized, but the finding was not

statistically significant.

We believe this resident-as-teachers training program

beneficial to our residents’ and students’ education. It was

also both inexpensive and logistically feasible. Our pro-

gram cost approximately $450 for 17 residents, workshop

staff, and volunteers, including room rental, materials,

and meals. Volunteer students were easily recruited.

Distractions were minimal and there was no disruption

in patient care.

Future topics suggested by residents and a needs

assessment from students included a more in-depth

session on feedback and evaluation and a review of the

students’ learning objectives. We have plans to create

more realistic learning simulations to facilitate transfer

of skills into the clinical setting and encourage faculty

reinforcement of desired teaching skills. We will continue

to try to understand the needs of the medical student.

Evaluation of resident teaching skills through the use of

standardized students and/or direct faculty observation

will also be explored.

In conclusion, this training program sends a strong

message to the residents that their development as

teachers and the education of medical students are

priorities for the residency program. With continued

commitment to these efforts, we are confident our

residents will realize their full potential as teachers,

ensuring that our students receive the best possible

educational experience.

We thank Lowel Arakaki, for his statistical support; Lisa

Kellett, for distributing and collecting the student

evaluations; and Virginia Steinmiller, RN, for assisting

with data entry. A special thanks to Tod Aeby, MD, for his

assistance with the Residents as Teachers Workshop and

Louis Vontver, MD, for his continued guidance through-

out the entire project.

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