Teaching Experiences of Family Medicine Residents: Toward an Encompassing Teaching Framework

Abstract

Background

Canadian family medicine (FM) residency programs are required to provide teaching opportunities to trainees to enable the development of teaching skills in order for residents to become the next generation of FM teachers. The College of Family Physicians of Canada's Fundamental Teaching Activities (FTA) Framework outlines the roles, tasks, and activities expected of FM teachers across three domains: Clinical Preceptor, Teacher Outside the Clinical Setting, and Educational Leader. The purpose of this study was to describe resident teaching opportunities within a Canadian FM residency program and examine the degree to which they align with the domains of the FTA Framework.

Methods

This was a qualitative study employing one-on-one semistructured virtual interviews with 10 rural and urban FM residents and 12 academic teachers from May 2021 to May 2022. Interviews explored FM resident teaching opportunities, including the setting where the teaching occurred, who the learners were, and the teaching topics. Qualitative, iterative thematic data analysis techniques were used with a coding template.

Results

Mapping resident teaching opportunities onto the FTA Framework required some modifications. The Clinical Preceptor domain was refined to Clinical Teacher; the Teacher Outside the Clinical Setting domain remained unchanged; and a new domain of Educational Collaborator emerged. Resident teaching opportunities spanned diverse settings, including outpatient clinics, inpatient hospital wards, large/small groups, and one-on-one sessions. These activities included direct clinical teaching, curriculum development, and peer education.

Conclusions

The study findings suggest that a FM resident-specific teaching framework is warranted to help guide residents and academic teachers to optimize FM resident teaching opportunities.

Introduction

The education of future physicians depends on skilled academic teachers. In family medicine (FM) in particular, the demand for academic teachers is growing as medical school classes grow in size and residency program enrollments are expected to increase. To facilitate teaching development, the College of Family Physicians of Canada (CFPC) created the Fundamental Teaching Activities (FTA) Framework, ¹ describing the domains where teachers may be involved, along with the tasks that the teacher may take on and activities required for each task. In Canadian FM residency programs, the scholar competency role of the CanMEDS-FM Framework ² requires that residents also develop teaching skills to be able to teach medical learners in various settings, both in residency and future clinical practice. While there are known benefits to residents engaging in teaching, ³ residents may find it challenging to identify teaching opportunities available to them during training. Residency programs and academic teachers may also require such knowledge to most effectively guide residents in their teaching activities, cultivate a culture of teaching skill development,^4,5 and even consider explicit teaching competencies for residents. ⁶

The question arises as to what teaching opportunities exist in residency training. Canadian FM residency programs are mandated to provide teaching opportunities for their trainees to develop medical education skills, ⁷ therefore, many residency programs have introduced Resident-As-Teacher (RAT) curricula, which is one such teaching opportunity.^8–11 The benefits of such programs have been demonstrated, including positive changes in residents’ attitudes toward teaching, an increase in knowledge of educational principles, improved clinical teaching skills, increased teaching confidence, and encouragement of self-directed learning.^8,9,12–14 The recipients of resident teaching also benefit greatly. ¹⁵ Their successes, however, heavily rely on the availability and skills of educational leaders and dedicated academic teachers. ⁴ In addition to teaching opportunities provided by residency curricula, resident-identified teaching activities also exist during training. These activities, which likely contribute to residents’ experience and influence their future teaching interests and abilities, may not be known by residency programs nor by academic teachers. Identifying resident teaching activities is necessary for making both residents and programs aware of the full range of opportunities that exist for the development of teaching skills. Academic teachers can then, more effectively, guide residents to identify teaching opportunities within specific learning environments. Residents can also purposefully seek out opportunities that facilitate the development of teaching skills.

Throughout medical education and residency training, learners progress along an evolving continuum of developing competencies in teaching skills, which continues into clinical practice as part of lifelong professional development. The Dreyfus Model of Knowledge Development identifies five stages of knowledge and skill development: novice, advanced beginner, competent, proficient, and expert.^16,17 As residents progress along this trajectory to become academic teachers, they will need to develop teaching skills in the educational roles outlined in the FTA Framework. The FTA Framework includes three educational roles or domains where academic teachers may be engaged: Clinical Preceptor, Teacher Outside the Clinical Setting, and Educational Leader. The Clinical Preceptor domain involves teaching in the clinical setting during patient care. The Teacher Outside the Clinical Setting domain involves design and delivery of small- and large-group teaching sessions outside the direct patient care setting. The Educational Leader domain involves the design, development, and evaluation of curricula, as well as leadership roles in educational programs.

Although the FTA Framework was not developed for residents in training programs, identifying FM resident teaching opportunities using this established framework is appropriate, given that, upon graduation, many will become teachers for future generations of medical learners. It can also help identify where gaps exist in resident training in teaching activities, informing curricular innovation and guidance by physician-educators. Therefore, the purpose of this study was twofold: to identify and describe resident teaching opportunities from the perspectives of FM residents and academic teachers; and to examine the degree to which they map onto the domains of the FTA Framework.

Methods

Study design, setting, and participant recruitment

This was a qualitative study employing one-on-one semistructured interviews with residents and academic teacher participants in the Department of Family Medicine, University of Alberta, Canada. Interviews were conducted to obtain participant perspectives on teaching opportunities and encourage dialogue between participants and interviewers. Residents enrolled in the urban or rural stream of the two-year FM residency program were eligible to take part in the study. Residents in a third-year enhanced skills program were excluded. Academic teachers included family physician teachers with academic appointments in the department who taught FM residents. Family physician teachers who taught only undergraduate medical students were excluded.

Residents and academic teachers were emailed recruitment notices, which included the study description and an invitation to participate. Recruitment notices were also posted on the resident association Facebook page and distributed at organized resident and department events (eg, Resident Academic Day, Family Medicine Grand Rounds, and Department Business Group Meeting). Those interested in participating were directed to contact the study coordinator, who provided them with the study information and consent letter. Taking part in the study was voluntary. All study participants provided audio-recorded verbal informed consent prior to their interviews. The study was approved by the University of Alberta Research Ethics Board (Pro00099314).

Data collection

Separate interview guides were developed for residents (Supplemental Appendix 1) and academic teachers (Supplemental Appendix 2). Interview guides included questions and prompts to encourage discussion. The semistructured interview questions explored the breadth of teaching activities experienced by residents throughout their training program, the setting(s) in which the teaching occurred, the learners involved, and the topics that were addressed. The interview questions were reviewed by internal academic leadership staff to assess the degree to which they addressed the intended concepts (face validity). Pilot testing of each of the interview guides was conducted with two recently graduated FM residents who were not eligible to participate in the study. All interviews took place between May 2021 and May 2022 and were conducted virtually by the study coordinator using Zoom to comply with protocols and restrictions during the COVID-19 pandemic. Participants were informed of the study purpose, assured of confidentiality, and could withdraw from the study at any time during data collection. Resident participants received a $20 gift card as a token of appreciation. Audio-recorded interviews ranged between 45 and 60 min in duration and were transcribed verbatim by a professional transcription service, including confirmation of participant consent that was provided verbally at the beginning of the interview. Transcripts were cleaned by the study coordinator to remove identifiers and were assigned an alphanumeric code for anonymity (R = Resident and TL = Academic Teacher/Leader), and transcription of each participant's consent was stored electronically, separate from the data. This was approved by the University of Alberta Research Ethics Board.

Data analysis

Descriptive and thematic qualitative analysis methodologies were employed using an iterative coding approach. To mitigate researcher bias and ensure trustworthiness of data analysis, each member of the research team reviewed the transcripts independently, then met together repeatedly to develop a coding template in an iterative manner until no new themes emerged and data saturation was achieved. The list of codes was modified through successive readings of transcripts until a full description of the data was obtained. After coding was completed, transcripts were further reviewed by the team to reach consensus on emergent themes. Throughout data analysis, we addressed the influence that each individual researcher had in shaping the data findings through regular meetings with all study team members. These meetings promoted reflexivity and reflection among the research team on how personal views and predispositions could influence the study and findings. This also allowed for various perspectives to be considered and biases to be addressed.

After thematic analysis was complete, we applied the FTA Framework to structure and organize the data to facilitate the interpretation of the study findings. Mapping the findings onto the FTA Framework enabled us to see to what extent resident teaching opportunities align with FM academic teacher educational domains. Employing a framework in the analysis stage is supported by qualitative research. ¹⁸

We employed the Standard Reporting Qualitative Research reporting guidelines for this manuscript, and the completed checklist is available as a Supplemental File. ¹⁹

Results

Ten residents (70% female) and 12 FM academic teachers (50% female) took part in the study. In terms of age, 80% of the resident participants were <30 years old; 50% of academic teachers were ≥50 years of age. The majority of the participants were from the urban residency stream (80% of residents) and urban training centers (83% of academic teachers). Of the 10 residents, 60% were in their first year of the two-year FM residency program.

Mapping of the findings onto the FTA Framework domains required some adaptation, as the existing FTA Framework domains for FM academic teachers did not map seamlessly onto resident teaching. The FTA Framework domain of Clinical Preceptor was modified to Clinical Teacher to better reflect resident teaching roles within clinical settings. Residents are not actually preceptors (as learners, they are being precepted) but rather assume the role of clinical teacher in various instances. FM residents did not supervise or have roles such as assessment, like FM academic teachers or clinical preceptors do. The domain of Teacher Outside the Clinical Setting was comparable for resident teachers in that residents were involved in designing and delivering teaching sessions outside of direct patient care settings, including seminars, lectures, and conference presentations in large and small groups and one-on-one sessions. Therefore, this domain name remained unchanged for the purposes of our study. The domain of Educational Leader, which encompasses leadership roles that FM academic teachers assume in educational programs, curriculum planning, and administration, was not directly relevant to resident teaching. Instead, the new domain name of Educational Collaborator emerged, which better reflects the collaborative work of residents in adapting and creating curricula. Table 1 depicts the three adapted domains of the FTA Framework relevant to resident teaching and corresponding teaching opportunities identified by residents and academic teachers.

Table 1.

Resident Teaching Opportunities.

Domain	Resident Teaching Opportunities
	Areas	Residents	Academic Teachers
Clinical Teacher	Clinic Outpatient Setting	Day-to-day teaching of medical and interdisciplinary learners in the FM clinic Teaching procedural skills	Half-days back to the FM clinic Teaching procedural skills Teaching off-service residents Longitudinal Clinical Experience (medical students) Medical student shadowing Interdisciplinary teaching (eg, nurses and support staff)
	Hospital Inpatient Setting	Teaching during off-service rotations (medical students and other residents) Interdisciplinary teaching (eg, nurses and support staff)	Primary Care Hospital Team Teaching during off-service rotations (medical students, other residents) Medical student shadowing Interdisciplinary teaching (eg, nurses and support staff)
Teacher Outside the Clinical Setting	Large Group	Off-service rounds presentations FM site rounds presentations	Didactic sessions during off-service and FM rotations Research Day presentations Conference presentations
	Small Group	Resident-As-Teacher program Ad hoc small-group facilitation (medical students) Brief Evidence-Based Assessment of Research (BEARs) presentations Quality improvement presentations Site rounds presentations Academic Day presentations Simulation Club demonstrations	Family Medicine Interest Group BEARs presentations Quality improvement presentations Site rounds presentations Clinic didactic presentations
	One-on-One	Objective structured clinical exam evaluators Providing general clinical advice (eg, favorite topical agents)	Case review with other residents or medical students BEAR's presentations to the preceptor
Educational Collaborator	Adapting Curricula	Academic curriculum committee resident advisor Membership on advisory group (review of rotations within the program) Education Committees Academic Day planning group Providing general teaching feedback	Case revisions for medical student small-group learning Academic Day planning group Course planning (eg, wilderness medicine)
	Creating Curricula	Creating objectives for presentations to junior residents Creating teaching videos Organizing workshops on clinical topics for resident colleagues	Organizing new learning opportunities outside the scope of the residency program (eg, bedside ultrasound sessions)

Clinical Teacher

In the domain of Clinical Teacher, resident teaching opportunities were identified in two areas, specifically teaching in the clinic outpatient setting and in the hospital inpatient setting. Such teaching was often unplanned and occurred spontaneously.

Clinic outpatient setting

Within the FM clinic setting, both residents and academic teachers identified a wide range of opportunities for residents to teach medical students, other FM residents, allied health professionals, clinical staff, patients, as well as their academic teachers. This teaching was on topics related to patient care, clinical management, and procedural skills. While there were similarities between residents and academic teachers’ responses, academic teachers more specifically listed distinctive teaching opportunities with medical students enrolled in (a) Longitudinal Clinical Experience (an undergraduate program during which medical students participate in FM clinics periodically throughout their pre-clinical training years); (b) shadowing programs (undergraduate programs during which medical students follow FM physicians in clinics, but do not participate in patient care); (c) half-days back (which are clinics during which FM residents return to their home FM clinic periodically during off-service rotations); and (d) with off-service residents in the clinic.

On different rotations, particularly during rural family medicine rotation or rotations in the city, anytime we would have medical students or even junior residents on the same rotation as us, [allowed us to engage] in teaching through those interactions. (Participant R7)

I have teaching opportunities every day when I engage my patients and … when I do patient education, I teach my patients everyday about things to look out for that would warrant … the emergency department or call back to the clinic. (Participant R8)

The clinical teaching that I witness is with my residents on their Family Medicine block time, so clinical teaching of undergraduate learners, like LCE [longitudinal clinical experience] students, elective students. (Participant TL12)

Hospital inpatient setting

Generally, both residents and academic teachers identified similar resident teaching opportunities within the hospital setting involving medical students, residents, and allied health professionals. Quite often, this teaching was spontaneous, multidisciplinary in nature, and generally focused on topics related to acute or chronic patient care.

…while we are seeing our own patients admitted to the units that we’re working on or if there was a consultation to do in the emergency department or in the hospital, and a student was taking a lead on it, we would often be there to review with them. So, our attending physician … put that responsibility onto us to, you know, be sort of acting as if we were going to be supervising physician in the next year or two anyways by having the medical students review their work with us. (Participant R7)

Teacher Outside the Clinical Setting

Three areas emerged in the domain of Teacher Outside the Clinical Setting—resident teaching in large group, small group, and one-on-one situations.

Large group

Whereas residents identified limited large-group teaching opportunities, academic teachers noted many, including resident opportunities to present at Research Day, research conferences, and large didactic sessions on various rotations. These teaching opportunities tended to be more structured and required advance preparation.

I know that one of our residents had been working on a research project and so she’d presented that to her peers … teaching to other family medicine residents on individual research projects. (Participant TL4)

Small group

Both residents and academic teachers commented on resident opportunities to teach others as part of mandatory program requirements, such as the short critical appraisal projects (eg, BEAR – Brief Evidence-Based Assessment of Research, which uses evidence-based resources to find answers rapidly), and practice quality improvement projects. In addition, both groups of participants noted the RAT curriculum, which is a joint collaboration between undergraduate and postgraduate FM, in which residents learn foundational education skills and then apply them by teaching communication topics to medical students in small groups. ⁶

We do have the Residents as Teachers … with … first-year medical students … so we each had a group of like four medical students to one resident and we’re teaching them on their first communication session … my one tomorrow is also interview-taking skills in a prenatal history, so that’ll be another opportunity to work with medical students, four or so in a group to one resident. (Participant R9)

You break out into small groups and then they [residents] present … a BEAR basically, … this is their introduction to that brief evidence summary and then they present that to their group. (Participant TL4)

There's also a resident involved in a quality improvement project … So the resident of course is going to be presenting this project to her peers which will probably then educate hopefully her peer residents. (Participant TL12)

One-on-one

Academic teachers identified case reviews with other residents or medical students as the only opportunity for resident one-on-one teaching outside the clinical setting. Residents mentioned opportunities to provide general clinical advice to other learners or for them to be involved as evaluators in the Structured Clinical Exam.

[It is] nice to have some sessions to teach them [medical students], to maybe just help review cases, or give them some feedback about their case presentations, just help them learn the ropes about things. (Participant R1)

Academic teachers described being the learner for specific educational program requirements, where resident teaching often occurred one-on-one in nonclinical settings. In this example, BEARs were not presented in a small group, but one-on-one with the resident's preceptor.

They have to do a brief evidence review called a BEAR [Brief Evidence-Based Assessment of Research] and so they present that to their preceptor, so that would be kind of a form of teaching where they take a single topic and they review the evidence on it and they present it back to us. (Participant TL4)

Educational Collaborator

Two areas were identified in the domain of Educational Collaborator—adapting curricula and creating curricula. Residents provided more content in this domain than did academic teachers.

Adapting curricula

Residents and academic teachers described how residents engaged in adapting existing curricula within their training program by way of membership on curriculum planning groups or committees, enabling them to review existing materials and provide feedback for curricular changes in collaboration with their faculty educational leadership. Residents were able to specifically identify membership on committees more so than academic teachers (eg, Discipline Advisory Group, Academic Day Planning Group, Academic Curriculum Committee, and Integrated Clinical Clerkship Committee). Academic teachers noted resident involvement in case revisions for medical student small-group teaching.

[While on a Domain Advisory Group committee,] I had to summarize the evaluations that the residents had about a certain rotation. (Participant R2)

You’ll see that some of the residents even in first year have a hand in revising learning cases, they have a hand in doing some of that curricular stuff. (Participant TL3)

Creating curricula

Residents identified far more opportunities in creating new curricula than did academic teachers, including planning and organizing new learning opportunities for their resident colleagues, such as creating teaching videos, organizing workshops on clinical topics, and running simulation clubs. Most academic teachers were not aware of the full spectrum of resident-run teaching initiatives, which appeared to address an area of specific interest or a perceived gap in the training program.

I am involved in the simulation club and that's a resident-run initiative where we plan and schedule simulations for other residents in the program to attend. (Participant R8)

Sometimes the residents have themselves organized like a bedside ultrasound … and made an opportunity that perhaps didn’t exist happen. And so you’ll see a lot of residents actually creating material and delivering workshops around areas of interest that they have. (Participant TL3)

Discussion

In this study, we identified resident teaching opportunities and mapped them onto the domains of the FTA Framework, thereby expanding its scope to encompass residents’ teaching activities during residency and positioning it as a bridge to their future careers as educators. The study findings reveal that FM residents have various teaching opportunities available to them during their training. Some of the identified opportunities are structured and provided as part of the curriculum, whereas others are initiated by residents to address a particular interest area or a perceived gap in the residency program. These opportunities may also arise spontaneously, usually centering on a clinical situation, and in these instances are largely one-on-one. The results also show that resident teaching occurs in various settings, including clinic and hospital clinical settings, nonclinical environments, and within rural and urban communities, with residents teaching medical students, other residents, allied health professionals, patients, and other members of the community. The findings contribute to research conducted over a decade ago regarding the teaching interests and experiences of Canadian FM residents during their residency training. ²⁰ Learning to teach by experiencing teaching itself as the participants did is consistent with experiential learning theory, whereby residents are actively participating in teaching, learning how to teach, and making meaning of teaching for themselves. ²¹

The study findings offer new insights into the alignment of resident teaching opportunities with the domains of the FTA Framework. While there were a few differences in specific teaching opportunities identified by residents and academic teachers in the domains of Clinical Teacher and Teacher Outside the Clinical Setting, overall, the teaching opportunities mapped well onto the FTA Framework, and resident teaching roles are largely consistent with the teaching roles of academic teachers in these two domains. This finding is not unexpected, as residents frequently observe and interact with their academic teachers in both clinical and nonclinical settings, where teachers serve as role models for residents in these two domains. In contrast, residents reported significantly fewer opportunities to observe academic teachers in the FTA domain of Educational Leader, limiting the potential for role modelling in this domain. Therefore, compared to the other two domains, the teaching opportunities described by the residents in the Educational Leader domain were less conducive to mapping onto the FTA Framework.

The FTA domain of Educational Leader encompasses high-level leadership roles in educational programming and administration, which residents have neither acquired nor commonly observed their academic teachers engaging in during training. However, the results demonstrate that residents do experience and contribute to collaborative roles in adapting curricula within the training program (hence, Educational Collaborator), as well as initiate educational activities for their resident colleagues based on perceived need. While the residents shared several examples of specific teaching opportunities within this domain, the academic teachers offered comparatively fewer, suggesting that academic teachers may lack awareness of these activities, as these are not defined requirements of the residency program, or may not recognize them as resident teaching opportunities within this domain. It is not surprising that academic teachers are generally less aware of resident-run initiatives, as these largely occur without direct academic teacher involvement and are outside of any residency program influence. Nonetheless, it is important that residency programs recognize that such resident teaching opportunities exist and facilitate skill development for residents in this domain.

The study findings suggest that the FTA Framework has the potential to serve as the foundation for developing a resident-specific teaching framework or a tool for residents and residency programs to enhance resident teaching skill development. However, further work is needed to accurately capture resident contributions in the Educational Collaborator domain. Doing so would not only acknowledge the work of FM residents as Educational Collaborators but also provide residency programs and academic teachers with a clearer understanding of the contributions of residents in this domain. This may also have curricular implications, as residency programs innovate to intentionally direct residents toward teaching opportunities in this domain.

A strength of this study is its detailed summary of the teaching opportunities available to FM residents during residency training, identified by both residents and academic teachers. This is also the first study to map resident teaching opportunities onto the FTA Framework, thereby aligning these opportunities with academic teacher educational domains. It is also important to note the limitations of the study. While most resident participants were female and enrolled in the urban stream, these proportions are largely consistent with the sex and rural-urban distributions within our FM residency program. The interview questions were only assessed for face validity; more robust validation and pilot testing would have been beneficial. This study was conducted in one FM residency program and, while certain teaching opportunities may not be present in other FM residency programs, the areas identified in this study within each FTA domain are likely transferable to other programs. This study was conducted during the COVID-19 pandemic, which may have constrained the range of participants to take part in this study, and the teaching experiences they were able to engage in due to pandemic restrictions. Finally, the study was conducted within the context of FM; future research could examine the transferability of the study findings to other disciplines.

Conclusion

While many FM resident teaching experiences are amenable for mapping onto the FTA Framework, some teaching experiences are not encompassed by the FTA Framework, especially in the Educational Collaborator domain. It is important to recognize resident teaching activities and guide resident teaching skill development during residency training. Just as the CFPC coordinated the creation of the FTA Framework for family physicians, so could a parallel teaching activities framework specific to FM residents be created, guided with input from both residents and academic teachers. Residents and academic teachers could then make use of such a framework to more intentionally direct resident teaching opportunities during training, thus creating competent FM teachers who are equipped to teach across all the FTA domains upon graduation.