NewIdeas

Teaching Psychiatrie Residents to Teach

DavidJ. Katzelnick, M.D.,JuniusJ. Gonzales, M.D.Mary C. Conley, M.D.,John L Shuster, M.D.

Jonathan F. Borns, M.D.

Teaching other residents andmedicalstudents isone oftheprimary activities of psychi­atrie residents, yet mostreceive minimal ornoformal training orsupervision onhow toteach. This report describes a Teaching Day Workshop, designed andimplemented by res­idents at theM1lssachusetts General Hospital with thesupport of their faculty andan ed­ucational consultant, asone model to introduce theconcepts andtechniques 0/ teachingtopsychiatrie residents. The participating residents were unanimous in their positive ap­praisal oftheworkshop, andtheyrecommended that additional seminars on teaching beintegrated intotheresidency'5 core curriculum. Ways thattheTeaching DayWorkshopcan be adapted for use by other residency training programs are discussed. The authorsbelieve that teaching residents tobebetter teachers can have an impact on recruitment ofmedical students intopsychiatry andpsychiatrie residents intocareers in academicpsychiatry.

Many studies of medical education havedemonstrated that resident physicians

are important teachers and role models formedical students and less experienced res­idents. A 19705 cross-sectional survey ofinternal medicine residents estimated thatthey received, on average, 45% of their edu­cation from fellow residents (1). A 1980sur­vey found that psychiatrie residents spendon average 1-2 hours a day teaching and feItthey should do more (2). In addition, a sig­nificant percentage of medical studentteaching in psychiatry is done by residents.This is especially important because psychi­atry has had difficulty recruiting the bestmedical students, perhaps in part due to theway that psychiatry is taught to medicalstudents (3). Despite this major teachingcommitment, most psychiatrie residencyprograms lack formal programs to improvethe teaching skills of their residents. A recentsurvey by Painter et al. (3) of psychiatrie

residency programs found that only 13% ofpsychiatrie residents receive any training toimprove their teaching.

Educational research on how to bestteach psychiatrie residents to become hetter

From the Massachusetts General Hospital Depart­rnent of Psychiatry, where DIs. Katzelnick, Gonzales,Conley, and Shuster were residents and Dr. Borus wasdirector of residency training. Dr. Katzelnick is nowassistant professor of psychiatry at the University ofWisconsin, Madison. Dr. Gonzales is now ADMHAFellow at the National Institute ofMental Health, Rock­ville, MD. Dr. Conley is now staff psychiatrist at theBrigharn and Wornen's Hospital and instnJctor in psy­chiatry at Harvard Medical School, Boston. Dr. Shusteris now assistant professor of psychiatry at the Univer­sity of Alabama, Birmingham. Dr. Borus is now directorof psychiatryat the Brigharnand Wornen's Hospital andassociate professor of psychiatry at Harvard MedicalSchool, Boston. Address reprint requests to Dr. Katzel­nick. Center for Affective Disorders. University of Wis­consin Department of Psychiatry, Room 86/276, 600Highland Avenue, Madison WI 53792.

Copyright Cl1991 Academic Psychiatry.

teachers is limited . Courses about teachinghave been developed for residents in inter­nal medicine (4,5), obstetrics-gynecology (5),neurology (6), and pediatrics (7) . Prelimi­nary research in other specialties has shownthat resident teaching can be improved byformal teaching skills workshops (5,7).Although teaching psychiatry to medicalstudents presents unique challenges not en­countered in other specialties, especially inthe areas of supervisionand evaluation, onlytwo reports have been published on teach­ing programs designed for psychiatrie resi­dents (8,9).

The importance of improving residentteaching skills was emphasized in the 1984General Professional Education of the Phy­sician report (0), and the need to teach psy­chiatry residents to be good teachers hasbeen the focus of two recent articles 01, 12)and an excellent pamphlet prepared by theAmerican Psychiatrie Association Commit­tee on Medical Student Education (3) . Inaddition, today's residents are tomorrow'sfaculty . The Painter et a1. (3) survey foundthat only 24%of the nation's psychiatry de­partments offer any education skills devel­opment programs for their full-time faculty.Thus it is clear that improving residents'teaching skills now can have an importantlong-term effect on the quality of facultyteaching in the future.

This article will first describe a TeachingDay Workshop, designed and implementedat the Massachusetts General Hospital(MGH)by psychiatry residents with the sup­port of their faculty and an educational con­sultant, as one model to introduce theeoneepts and techniques of teaching to psy­chiatrie residents. It will review TeachingDay Workshop activities, including theteaehing format, objectives, and materialsutilized for each activity. Both formal andinformal course evaluations are discussed inrelation to why we believe the workshopwas a suceess, what variables need to bestudied in designing psychiatry residentteaching programs, and what the im-

plications are for psychiatry of formallyteaching residents how to teach.

STIMULUS FORDEVELOPINGTHE WORKSHOP

Six months prior to the workshop, we sur­veyed 11 of the 12 PGY-2 MGH psychiatryresidents to assess their interest in improv­ing their teaching skills and to determine thespecificareas that they feItneeded improve­ment. We found that although 10 of 11 hadtaught medical students during their intem­ship, none had had any formal courses orseminars on how to teach. None of the 11responded that they feIt adequately pre­pared to teach medical students now, and allbut one were interested in participating in aseminar focused on improving their clinicalteaching skills. The areas they were mostinterested in leaming about were fair evalu­ation of students, educational theory, andteaehing the art of psychiatrie interviewing.The results of this survey are consistent witha survey of pediatric residents that foundthat only 18%feIt confident in their roles asteachers (7). We then reviewed the medicaledueation literature searching for materialsfrom prior resident teaching skills programsthat could be adapted for our Teaching DayWorkshop (4-9, 1~16).

THE TEACHING DAYWORKSHOP

The workshop took place at an off-eampussite on a Saturday and was led by the fourPGY-2and PGY-3psychiatric residents fromthe planning group. Sixteenof the program's32 residents, representing aIl three (PGY-2­4)residency classes,voluntarily attended theworkshop. Several residents who had statedadesire to participate in Teaching Day didnot attend due to vacations , illness, or reli­gious prohibitions to participation on a Sat­urday. Staff eoverage was provided so thatthe residents on call could participate.Twelve faculty members also participated assmall-group leaders, lecturers, and panel

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discussants. The chief of psychiatry, directorand associate director of residency training,and director of medical student education asweIl as the director of faculty developmentat the medical school all had active teachingroles in the workshop and provided supportat all phases of the project. The schedule forthe day is shown in Table 1. Attention wasgiven to designing the day so that four differ­ent teaching formats (lectures, small-groupdiscussions, tutorials, and supervision) wereall appropriately modeled in at least oneactivity.

The workshop began with a welcomeand introduction to Teaching Day by theresident organizers. The director of medicalstudent education then gave brief reflections

TADLE1. Teaching Day Workshop

1. Introduction (8:30-9:30,coffee and donuts)

a . "Reflections on the resident's role as ateacher in the Massachusetts General Hospi­tal Department of Psychiatry: Past, present,and future" Gerald Adler, M.D., director,medical student education

b. Lecture: "Teaching and Leaming in Psy­chiatry" Jonathan Borus, M.D., director ofresidency training

2. A Closer Look at Leaming and Teaching:Panel Discussion (9:30-10:15)Distinguished MGH faculty give personal corn­mentary on teaching, followed by question andanswer period, then open discussion.

Ned Cassem, M.D., chairman, Department ofPsychiatry

Anne Fishel. Ph.D., family therapy teacherSteve Hyrnan, M.D., neuroscience teacher

Nicholas Kouretas, M.D., psychotherapyteacher

Dreak-Coffee and donuts (10:15-10:30)3. Experlences with Leaming and Teaching:

Task Groups (10'.30-11:30)

To assess effective and ineffective leaming andteaching through small-group participation.

i, List powerful (both positive and negative)experiences we have had in leaming andteaching.

ii. List five characteristics of powerfulleam­ing and teaching.

iii, Reconvene and share lists in group discus­sion .

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on the importance of residents as teachers inboth clinical and didactic areas. The nextactivity was a lecture by the director of resi­dency training on basic concepts of learningand the roles of teaching in psychiatry. Thislectureemployed a logical structure and wassupplemented by slides and cartoons to notonly convey content but also demonstratethe teaching skills utilized in organizing andpresenting an effective lecture.

This lecture was followed by a paneldiscussion featuring four teachers from thedepartment. Each 100off with a brief state­ment of his/her personal approach to teach­ing, described past experiences as a studentor teacher that indelibly marked his/herteaching style, and shared teaching "pearls"

Facilitators included Drs. Adler, Borus, Fishel.Hyrnan, and Kouretas

4. Understanding the New Pathway and Problem­based Leaming: Lecture (11:30-12:15)

LuAnn Wilkerson, Ed.D., director of facultydevelopment, Harvard Medical School

Lunch (12:15-1:00)

5. Implications for Teaching: Workshops(1:00-4:00)

a. PGY-3 and PGY-4 Residents : LecturingIn small groups with facilitators, residentswill give a lecture on a preassigned topic(through mailing), Others will review, cri­tique, and give feedback. Highlights on lec­turing will be reviewed.

b . PGY-2Residents: Supervising Students onthePsychiJItric InterviewResidents will watch a videotape of a stu­dent interviewing a patient and thendiscuss supervising the student and teach­ing the interview.

c. All Residents : GivingFeedback and Evaluat­ingStudentsDiscussion on general principles ofevaluation followed by aseries of role playsof difficult situations. Abrief lecture high­Iighting principles and methods of evalua­tion for medical students.

6. Convocation (4:00-4:30)

PIenary discussionFeedback: evaluation formsDiscussion of possible follow-up interviews

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that he/she rarely has a forum to discusswith residents. One panel discussant de­scribed how he has maintained his originalenthusiasm for teaching by viewing eachteaching experience as a new opportunity toleam from his students. "Once one views theroles of teacher and student rigidly, teachingrapidly becomes repetitive and loses its ex­citement." Another discussant emphasizedthe importance of preparation. "Qualityteaching takes time just like quality researchand quality patient care ." These presenta­tions generated many questions and a livelydiscussion with the workshop participants.

The next activity divided the partici­pants into four task groups with the goals ofstimulating participants to identify import­ant characteristics of effective leaming andteaching, understand how the teaching mo­dality is a variable in effective leaming, andexperience the use of the task-orientedsmall-group modality as a leaming format.Faculty facilitators 100each group of five tosix residents. The groups were asked tobrainstorm and share positive and negativelearning experiences and to develop lists ofsix important qualities for both powerfulleaming and teaching. At the end of the ex­ercise the small groups reconvened to de­velop a common list of effective teachingand learning characteristics.

A group lunch was followed by a mini­lecture on the principles of problem-basedleaming by the educational consultant, whothen acted as faci1itator for a demonstrationproblem-solving group composed of res­ident volunteers . This group workedthrough a case from the Harvard MedicalSchool New Pathway curriculum of a pa­tient in an emergency room having a panicattack. After working on the case, the volun­teers discussed their leaming experience inthis problem-solving group with observers.

Two separate activities, one focusing onbedside clinical teaching and supervision forPGY-2 residents and the other on didacticlecturing for PGY-3 and PGY-4 residents fol­lowed. The activity for PGY-2 residents

utilized a small discussion group format inwhich participants viewed a videotape of amedical student interviewing a psychiatriepatient while a psychiatry resident sUper­vised. In the videotape, the resident first ex­plained to the student the specific goals ofthe interview. The student then interviewedthe patient for 20 minutes. The PGY-2 resi­dents were given the task of arriving at agroup consensus of what the resident in thevideotape should say to the medical studentin supervision of the interview.

The PGY-3 and PGY-4 residents partici­pated in a small-group activity aimed at im­proving their lecture skills. The task was topresent a Iü-minute lecture on a preassignedtopic to their small group, receive feedback,and develop criteria for an effective lecture.Each participant was first asked to developa list of five criteria for a good lecture andthen to rate each mini-lecture on a four-pointscale for each criterion. After giving his/herlecture, each resident gave a self-evaluationand then received feedback on their perfor­mance from each small-group member,using that member's evaluation criteria list.After the mini-lectures, the facilitator 100 adiscussion of what makes a good lecture,discussing the individuallists of criteria andgenerating a common list of criteria for aneffective lecture. For example, one group'ssummary list included the following criteria:enthusiasm; knowledge; clear, succinct pre­sentation; appropriate quantity of content;and lecture organized with overview andsummary.

The day's final activity was a discussionof methods used to teach and evaluate theclinical work of medical students in psy­chiatry. Essential clinical skills to be gainedduring a core psychiatry rotation and gen­eral principles important for a standardizedevaluation of students were presented in agroup discussion format. Problematic en­counters among students, residents, and pa­tients were modeled in a role-play format,using as examples one student's dilemmaswith a difficult borderline patient and an-

other student who had poor patient careskills and an "intolerance" for psychiatriedisorders. The role plays stimulated livelydiscussions about appropriate ways to giveuseful feedback to medical students in suchsituations. The role plays are available fromthe authors on request. Finally, the residentswere given a list of reading materials to helpthose interested in leaming more aboutteaching (13,15-18).

EVALUATION OF TEACHING DAY

The purpose of evaluating this workshopwas to leam if the participants feit it was avaluable leaming experience and to provideguidance in designing future workshops.The question we hope to eventually answeris whether a workshop like Teaching Daycan change psychiatric resident teaching be­havior in a way that positively impacts onthe medical students they teach. Althoughthe evaluation instruments used in this pilotstudy cannot directly answer this question,they do help identify the variables that needto be objectively studied in future work­shops. We gave residents participating inTeaching Day four separate evaluation in­struments (available from the authors on re­quest). A teaching attitude survey and acognitive assessment of knowledge of teach­ing methods were given immediately beforeand after the workshop. A course evaluationwas given at the end of the workshop, andan individual follow-up interview was con­ducted 8 months after the workshop.

The attitude survey showed increasedpost-workshop agreement that residentsshould have a major role in medical studenteducation and increased feelings of compe­tence in giving short lectures, in evaluatingmedical student interviews, and in evalu­ating student clinical performance. The res­idents' attitudes about the stressfulness ofobjectively evaluating medical students, therole teaching would play in their profes­sionallives, and how they would hypothet­ically divide an additional five free hours

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between clinical care, research, and teachingdid not change between the pre- and post­workshop administrations of the attitudesurvey.

The cognitive test of teaching methodscontained questions about each TeachingDay activity (lecture, small-group discus­sion, tutorial, supervision) posed in multiplechoice and short answer formats. The aver­age score on the pretest given immediatelyprior to starting Teaching Day was 65%.Thesame test administered at the end of the dayhad an average score of 88%.

All ten residents who completed thepost-eourse evaluation said they would rec­ommend the workshop to other residentsand were unanimous in their belief that itwould affect their teaching in a positivemanner. All the Teaching Day activities av­eraged at least a four ("very useful") ratingon a five-point scale, while the panel discus­sion, seminar on problem-based leaming,mini-Iecture, and supervision of medicalstudent interviewing activities all received afive rating ("great activity") . Several partici­pants noted the unexpected benefit of hav­ing all three resident classes workingtogether with faculty in a retreat-like settingas an important factor in establishing a stim­ulating leaming environment.

The impact ofTeaching Day on residentteaching skills was evaluated by interview­ing 12 of the 16 participating residents 8months after they completed the workshop.They were asked "How much ofan effecthasthe Teaching Day Workshop had on yourteaching?" Of the 12 respondents, 6 feit ithad significantly improved their teaching, 4felt it had minimally improved it, 1 said ithad not changed his/her teaching, and 1wasunsure of its effect. When asked what wouldhave made the workshop better, all 12 re­spondents favored having follow-up ses­sions, 10 of the 12 favored having expertteaching supervisors to help them use theideas leamed at Teaching Day, and 3 of the12 feit additional written material wouldhave been helpful.

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DISCUSSION

The Teaching Day Workshop was designedto create a stimulating, low-stress leamingenvironment in which psychiatry residentscould be introduced to basic educational the­ory, leam a few specific skills to improvetheir teaching of medical students, and en­courage their interest in learning more aboutteaching. Based on the formal post-courseevaluations and 8-month follow -up inter­views with the participants, there was astrong consensus that the workshop stimu­lated new interest in teaching and generatedresident and faculty support for expandingthe Teaching Day Workshop into an ongo­ing series of seminars about teaching in theresidency's core curriculum. Based on thisexperience with Teaching Day, the psychia­try residency program at MGH has initiatedseparate seminars on teaching skills in thecore curriculum of each of the three years ofresidency to help residents' teachingabilitiesgrow along with their clinical skills.

Because this pilot program was limitedto a single psychiatric residency programand the number of participants was small,statistical assessment of changes in teachingattitudes, knowledge, and behavior was im­practical. A larger controlled study of ateaching program did show statistical1y sig­nificant differences in teaching behavior inthose who had and had not participated (5).It demonstrated that resident teaching skillscan be improved by instruction and thatwithout such input residents' teaching skillsdo not automatically improve as their clini­cal competence increases.

There has been little research on whatvariables determine the success of residentteaching programs and even less informa­tion on how to design the optimal programfor psychiatry residents. Our experiencewith Teaching Day helped us delineate fivecategories of variables that need to be ad­dressed in developing such a program: 1) theroles of residents in medical student edu­cation, 2) workshop goals, 3) workshop de-

velopment and format, 4) administrativesupport arrangements, and 5) evaluationscheme. Defining the resident's role in med­ical studenteducation is the first step. Is suchteaching mandatory, voluntary, or elective?Do residents give lectures, provide bedsideteaching, supervise students in inpatient oroutpatient settings, or lead discussiongroups? It is also important to assess theresidents' backgrounds in education and thefaculty's areas of expertise. The goals of theworkshop can then be developed based onthe needs of the residents and the specificeducational assets available to the program.Workshop development and format followfrom the goals. The format of the workshopis shaped by trade-offs involving an in-hos­pital vs . retreat-like location, a single day vs.multiple day format, voluntary vs. manda­tory participation, and the intermingling ofresidency classes vs. separate programs foreach class . Administrative considerations indeveloping the workshop include schedul­ing and financial constraints, faculty cov­erage of resident clinical responsibilitiesduring the program, availability of an edu­cational consultant, resident participation inprogram development, and the level of ad­ministrative and facuIty support for theworkshop. Evaluation tools can focus onchanges in attitudes about teaching, cog­nitive growth in teaching concepts, andchanges in teaching behaviors.

There has been wide variability reportedin resident participation in and enthusiasmabout prior programs to improve residentteaching skills. We believe Teaching Dayhad a relatively high level of participation(50%) for a voluntary weekend workshopdue to the high level of resident involvementin the planning and implementation of thecourse, the limited time commitment re­quired of participants, and the strong sup­port and direct participation of the residencydirector. Our follow-up interviews suggestthat Teaching Day may have had lastingeffects on residents' teaching.

Cooper (11) recently wrote, "Teachers

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are central in the definition of a professionand a specialty . What the teachers do, howthey perceive their field, how they live theirprofessionallives, as weIl as how they teach,have traditionally been major shaping fac­tors in the development of any specialty ."We agree and hope that our experience withTeaching Day will stimulate other psychi­atry programs to use this model as a starting

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point in developing their own programs toteach residents the art and skills of goodteaching .

The authors thank Gerald Adler, MD .,Susan Skea, M.D., Paul Summergrad, MD.,and Luanne Wilkerson , Ed.D., tor their help indeveloping andimplementing theTeaching DayWorkshop.

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18. Ende J: Feedback in clinical medieal education.JAMA 1983;250:777-781

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