Teaching residents how to teach improves quality of clerkship

American Journal of Obstetrics and Gynecology (2004) 191, 1741e5

www.ajog.org

Teaching residents how to teach improves qualityof clerkship

Maya M. Hammoud, MD,a,* Hope K. Haefner, MD,a Amy Schigelone, PhD,b

Larry D. Gruppen, PhDb

Department of Obstetrics and Gynecology, University of Michigan Hospital, Ann Arbor, Mich,a and Department ofMedical Education, University of Michigan Medical School, Ann Arbor, Michb

Received for publication May 7, 2004; revised June 15, 2004; accepted July 6, 2004

KEY WORDSTeaching skillsResident

Quality of clerkshipMedical student

Objective: To evaluate the impact of a resident’s teaching skills workshop on the ratings of the

obstetrics and gynecology clerkship by third-year medical students.Study design: The 6-week obstetrics and gynecology clerkship at the University of Michigan isprovided at 4 different sites including the University of Michigan Hospital. At the end of each

rotation, medical students complete an evaluation form assessing various aspects of their learningexperience, including the overall quality of clerkship. A workshop, ‘‘Teaching Residents How toTeach,’’ was conducted at the University of Michigan Hospital, whereas the other 3 sites served as

the control. Clerkship evaluations were compared before and after the workshop using Studentt test.Results: Students at the University of Michigan Hospital rated all items on the evaluation formhigher after the teaching workshop. The overall quality of the clerkship at the University of

Michigan Hospital improved (P = .05), whereas the other sites remained stable.Conclusions: A ‘‘Teaching the Residents How to Teach’’ workshop improves the overall qualityof the clerkship.

� 2004 Elsevier Inc. All rights reserved.

Residents have important roles as teachers. Theyspend substantial amounts of time engaging in clinical

Supported by APGO/Ortho-McNeil Undergraduate Medical Edu-

cation Research Award. The study was conducted at the University of

Michigan Hospital, Department of Obstetrics and Gynecology, Ann

Arbor, Mich.

Presented at the 2004 CREOG and APGO Annual Meeting, Lake

Buena Vista, Fla, March 3-6, 2004.

* Reprint requests: Maya M. Hammoud, MD, University of

Michigan Hospital, Department of Obstetrics and Gynecology, 1500

East Medical Center Drive, L 4000 Women’s Hospital, Ann Arbor, MI

48109-0276.

E-mail: [email protected]

0002-9378/$ - see front matter � 2004 Elsevier Inc. All rights reserved.

doi:10.1016/j.ajog.2004.07.067

teaching of medical students and more junior residents.1

Brown2 reported that residents give between 20% and25% of their work time to teaching. Many residencyprograms offer their residents some training in teachingskills.3 Several studies have addressed the value of half-day or daylong courses on teaching skills for residents.One study of pediatric residents4 randomized half thegroup to take 2 half-day workshops on teaching skills.Those residents who participated in the workshopsreceived higher teaching evaluations and felt moreconfident in their teaching abilities. Another studyfound that half of the 44 participating residents whowere assigned to a 3-hour teaching course had improved

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1742 Hammoud et al

in giving feedback and establishing a good learningclimate.5 Wipf et al6 found that a 6-hour teaching skillscourse significantly improved residents’ teaching ratings.Two randomized, controlled studies7,8 showed thatresidents assigned to receive residents-as-teachers cur-riculum showed improved scores on objective structuredteaching examinations. No studies have specificallyreported the impact of such courses on obstetrics andgynecology residents.

Considering that more than 60% of medical studentsreported getting over 50% of their teaching fromresidents and fellows during their third year obstetricsand gynecology clerkships and that the obstetrics andgynecology clerkship is one of the lowest-rated clerk-ships by medical students,9 we wanted to study theimpact of a 1-day teaching skills workshop on theclerkship evaluations. More specifically, we wanted toanalyze items on the clerkship evaluations that wewould expect to improve based on the teaching curric-ulum including the quality of resident teaching and theoverall quality of the clerkship.

Our study goals were to evaluate the effectiveness ofa teaching workshop as a method to improve the qualityof the clerkship as measured by students’ evaluations andto evaluate the resident satisfaction with such a workshop.

Methods

The 6-week obstetrics and gynecology clerkship at theUniversity of Michigan Medical School is provided at 4different sites including the University Hospital. All siteshave residents who are involved in medical studenteducation. Students indicate their site preferences at thebeginning of the year, and we try to accommodate theirrequests as much as possible. At the end of each rotation,all medical students fill out a confidential, online, 24-itemquestionnaire rating the quality of their experiences ona 5-point Likert scale from 1 to 5 (1, poor; 2, fair; 3, good;4, very good; 5, excellent). The questionnaire coversseveral areas of their experiences including clarity of goalsand objectives, clarity of expectations, quality of feed-

Table I Residents’ agreement of usefulness of topics ad-dressed at teaching workshop (n = 16)

Mean (SD)*

Goals of the retreat 4.25 (0.77)What makes a good teacher 4.3 (0.62)Brief structured observation 4.3 (0.86)Feedback 4.3 (0.60)Students’ objectives and expectations 4.25 (0.45)Working in small groups 4.38 (0.50)Overall quality of the retreat 4.19 (0.66)

* Mean on a Likert scale of 1 to 5 (1, strongly disagree to 5,

strongly agree).

back, quality of faculty teaching, quality of house officerteaching, and overall quality of clerkship.

Teaching workshop

We developed the residents’ teaching skills workshopusing feedback and comments from the students’ clerk-ship evaluations. We particularly focused our efforts ondeveloping interactive sessions to engage the residentsand give them ownership of the teaching process. The 1-day workshop was held on a Wednesday in October2001 at an off-site location. Eighteen of 20 obstetrics andgynecology residents attended the session (2 were absentbecause of vacation). Their pagers were signed over tofaculty, so there were no interruptions during theworkshop. The workshop topics included the followingtopics: what makes a good teacher, exposure to thestudents’ objectives and exams, and how to givefeedback. The feedback specifically focused on the BriefStructured Observation model as described by Pituchet al.10 The residents had the opportunity to practice themodel with third-year medical students. In addition, theresidents worked in small groups to identify some of thechallenges to teaching in the clerkship and developteaching scripts for students. At the end of the day,the residents completed a retreat evaluation formassessing the value of the topics using a 5-point Likertscale (1, strongly disagree to 5, strongly agree).

Data analysis

An institutional review board exemption to conduct thestudy was obtained. To evaluate the effects of theresident retreat on improving the quality of the clerk-ship, we analyzed students’ clerkship evaluations beforeand after the retreat. We specifically examined theclerkship evaluations for the intervention group at theUniversity Hospital at 3 months for a total of 2rotations and at 9 months for a total of 6 rotationsfollowing the retreat (2001-2002 academic year). Thesewere compared with the equivalent rotations from theprior year (2000-2001 academic year). We also per-formed similar analyses for the clerkship evaluationsfrom the other 3 sites as a control group in which theresidents did not receive any teaching training. Statisti-cal methods included Student t test. A probability valueof .05 was considered statistically significant. Effect sizeswere also computed, with an effect size (d) of .2-.5 con-sidered small, .5-.8 moderate, and .8 and over large.11

Results

Program evaluation

The evaluation of the workshop ranged from a mean of 4to 4.38 of 5 on the value of the covered topics (Table I). In

Hammoud et al 1743

the comments section of the satisfaction survey, theresidents especially noted liking the small-group activitiesand the interactive sessions. More than half stated thiswas the first time they received formal instruction inteaching skills, and they asked for more similar opportu-nities. In addition, many commented that there is a needfor a similarworkshop for the faculty to achieve a strongerteaching commitment from them. But perhaps mostimportantly, 14 of the 16 residents who filled out theevaluation form agreed or strongly agreed that theircommitment to teaching medical students has increasedon the basis of the teaching workshop.

Clerkship evaluations

The clerkship evaluations at the University Hospital (theintervention group) showed improvement on all items atthe 3-month and 9-month intervals (Tables II and III).Several items improved significantly except the quality

Table II Means* and (SD) of students’ evaluations for 3months after retreat, compared with equivalent time period ofprior year for intervention group

2000-2001(n = 10)

2001-2002(n = 20) P value d

Clarity of goalsand objectives

3.40 (0.54) 4.20 (0.77) .02 1.2

Expectation of studentperformance

2.80 (1.23) 3.75 (0.85) .02 .9

Quality of feedback 2.30 (0.82) 3.25 (0.91) .01 1.1Quality of HO teaching 3.50 (1.51) 4.05 (0.76) NS .5Quality of attending

teaching4.00 (1.05) 4.15 (0.75) NS .2

Clerkship overall 3.40 (1.58) 4.25 (0.72) .05 .7

n, Number of students; d, effect size;HO, house officer;NS, not significant.

* Means on a 5-point Likert scale from 1 to 5 (1, poor; 2, fair; 3,

good; 4, very good; 5, excellent).

Table III Means* and (SD) of students’ evaluations for 9months after retreat, compared with equivalent time period ofprior year for intervention group

2000-2001(n = 40)

2001-2002(n = 55) P value d


3.44 (0.91) 3.69 (1.02) NS .3


2.80 (1.12) 3.27 (1.08) .04 .4

Quality of feedback 2.55 (1.09) 3.04 (1.21) .05 .4Quality of HO teaching 3.59 (1.27) 3.71 (1.13) NS .1Quality of attending

teaching3.79 (1.03) 3.96 (0.84) NS .2

Clerkship overall 3.33 (1.16) 3.65 (1.10) NS .3




of faculty teaching, as would be expected. Although theimprovement in the quality of house officer teaching didnot reach statistical significance, it did increase withmoderate effect size of .5. The significance of the changedecreased from 3 months to 9 months. The clarity ofgoals and objectives, expectations of student perfor-mance, and quality of feedback all showed improvementwith a large effect size.

Tables IV and V show the equivalent items from theclerkship evaluations at the other sites. There were nosignificant improvements noted at the 3- or 9-monthintervals during the same time periods in any of thecategories.

Comment

Residents play an important role in the evaluation ofmedical students, even though most residents are not

Table IV Means* and (SD) of students’ evaluations for 3months after retreat, compared with equivalent time period ofprior year for the control group

2000-2001(n = 29)

2001-2002(n = 23) P value d


2.93 (1.16) 3.26 (0.96) NS .3


2.72 (1.03) 3.17 (0.83) NS .5

Quality of feedback 2.86 (1.33) 3.00 (1.12) NS .1Quality of HO teaching 3.48 (1.40) 3.87 (0.92) NS .3Quality of attending

teaching3.79 (1.21) 4.00 (0.95) NS .2

Clerkship overall 3.52 (1.37) 3.54 (0.86) NS 0




Table V Means* and (SD) of students’ evaluations for 9months after retreat, compared with equivalent time period ofprior year for intervention group

2000-2001(n = 83)

2001-2002(n = 68) P value d


3.10 (1.03) 3.31 (0.95) NS .2


2.81 (0.92) 3.03 (0.98) NS .2

Quality of feedback 3.10 (1.24) 3.19 (1.27) NS .1Quality of HO teaching 3.46 (1.27) 3.54 (1.15) NS .1Quality of attending

teaching3.90 (1.12) 3.99 (0.87) NS .1

Clerkship overall 3.52 (1.10) 3.52 (0.89) NS .1




1744 Hammoud et al

trained to be teachers. Many programs to improve theteaching skills of residents have been reported,4-8 butmost of those assessed the changes in residents’ attitudestoward teaching or their performance on an objective-structured teaching examination. None of them havelooked at their effect on the overall quality of theclerkship. Since obstetrics and gynecology is one of thelowest-rated clerkships by medical students nationallyand because residents play a major role in medicalstudent teaching9, our intervention was directed towardimproving the residents’ teaching skills.

Our study showed that improving the residents’teaching skills does improve the overall quality of theclerkship at the 5% significance level (P = .05) for thefirst 3 months after the intervention. Those effects seemto wane over time to the point that at a 9-monthperiod, although the clerkship is rated better, theimprovement is much smaller. The results of our studysuggest that residents can learn effective clinical teach-ing skills in a limited time. They apply what they learnand can improve the students’ perceptions of theoverall quality of the clerkship. However, it seems thatthere is a time factor after which the residents’enthusiasm in teaching decreases and residents seemto go back to baseline teaching efforts. We did not findany long-term longitudinal studies that tracked resi-dents’ teaching skills over time. Therefore, it appearsthat an intervention to improve the residents’ teachingskills constantly needs to be reinforced to continue tohave the desired effect of improving the quality of theclerkship.

The decline of medical student interest in obstetricsand gynecology as a career continues at an alarmingrate.12 Few publications have specifically addressed whatattracts students to obstetrics and gynecology.13,14 Andalthough there is no good evidence that the quality of thethird-year obstetrics and gynecology clerkship influencesstudents’ decisions to go into the field, Schnuth et al14 didfind that many of the students who had a perceivedinterest in obstetrics and gynecology at the beginning ofmedical school changed theirminds, and a different groupof students became interested as a result of experiencesduring the curriculum. Therefore, interventions targetedtoward improving the obstetrics and gynecology clerk-ship might ultimately increase the number of studentswho are interested in the specialty. In addition, althoughvarious factors have been shown to influence the careerspecialty decisions that medical students make,15,16,17

with lifestyle considerations as one of the key elementsthat drive medical student specialty selections,18,19,20 rolemodels, both positive and negative, strongly influencemedical student selection of specialty.21,22,23,24 Cochranet al25 did find that medical students’ perceptions ofsurgeons and surgical careers generally improve duringthe surgical clerkship. Therefore, it seems that improvingthe quality of the third-year clerkship would have

a positive influence on students’ perceptions, and inter-ventions targeted toward achieving that goal should beinvestigated and implemented.

Improving the residents’ teaching skills has a pos-itive impact on the students’ perceptions of the overallquality of the obstetrics and gynecology clerkship.Sessions targeted toward improving those skillsshould be part of required curricula for all residencyprograms.

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Teaching residents how to teach improves quality of clerkship