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. 2009 Sep;55(9):902–903.e5.

Teaching-skills training programs for family medicine residents

Systematic review of formats, content, and effects of existing programs

Miriam Lacasse 1,✉, Savithiri Ratnapalan 2
PMCID: PMC2743590  PMID: 19752261

ABSTRACT

OBJECTIVE

To review the literature on teaching-skills training programs for family medicine residents and to identify formats and content of these programs and their effects.

DATA SOURCES

Ovid MEDLINE (1950 to mid-July 2008) and the Education Resources Information Center database (pre-1966 to mid-July 2008) were searched using and combining the MeSH terms teaching, internship and residency, and family practice; and teaching, graduate medical education, and family practice.

STUDY SELECTION

The initial MEDLINE and Education Resources Information Center database searches identified 362 and 33 references, respectively. Titles and abstracts were reviewed and studies were included if they described the format or content of a teaching-skills program or if they were primary studies of the effects of a teaching-skills program for family medicine residents or family medicine and other specialty trainees. The bibliographies of those articles were reviewed for unidentified studies. A total of 8 articles were identified for systematic review. Selection was limited to articles published in English.

SYNTHESIS

Teaching-skills training programs for family medicine residents vary from half-day curricula to a few months of training. Their content includes leadership skills, effective clinical teaching skills, technical teaching skills, as well as feedback and evaluation skills. Evaluations mainly assessed the programs’ effects on teaching behaviour, which was generally found to improve following participation in the programs. Evaluations of learner reactions and learning outcomes also suggested that the programs have positive effects.

CONCLUSION

Family medicine residency training programs differ from all other residency training programs in their shorter duration, usually 2 years, and the broader scope of learning within those 2 years. Few studies on teaching-skills training, however, were designed specifically for family medicine residents. Further studies assessing the effects of teaching-skills training in family medicine residents are needed to stimulate development of adapted programs for the discipline. Future research should also assess how residents’ teaching-skills training can affect their learners’ clinical training and eventually patient care.

Medical residents are often involved in teaching undergraduate medical students or junior residents, in addition to teaching and caring for patients, during their postgraduate training period. Many medical schools and residency training programs offer teaching-skills training sessions to prepare residents to be better teachers. The format, content, and duration of these teaching programs, however, vary widely. Wamsley et al published a literature review of “resident-as-teacher” curricula, which included residents from different specialties. This review identified various formats of such courses and found that participants improved self-assessed teaching behaviour and teaching confidence, in addition to receiving improved evaluations from their students.1

Residents need to find balance between their own learning, patient care, and teaching. They also have to balance their needs for learning clinical knowledge with their needs for teaching-skills training.2–4 These barriers are especially obvious in family medicine residency.

Family medicine residency training programs differ from all other training programs in their shorter duration (usually 2 or 3 years in North America) and their broader scope of learning within this period. Teaching-skills training, however, is considered mandatory,5–8 as family medicine residents, and residents in other disciplines, are often expected to provide a considerable amount of formal and informal teaching to junior trainees. Most of them will also receive trainees when they begin practice. Family physicians are primary providers and are often the only providers of patient education and public education, which further stresses the importance of teaching-skills training for family medicine residents.

The College of Family Physicians of Canada’s Standards for Accreditation of Residency Training Programs states the following: “Residents must be given opportunities to develop effective teaching skills through organized activities focused on teaching techniques.”5 The CanMEDS Physician Competency Framework also states that physicians should be scholars, “able to facilitate the learning of patients, families, students, residents, other health professionals, the public, and others, as appropriate, and to contribute to the creation, dissemination, application, and translation of new medical knowledge and practices.”8 According to the Accreditation Council for Graduate Medical Education’s Common Program Requirements for practice-based learning and improvement, “residents/fellows are expected to develop skills and habits to be able to participate in the education of patients, families, students, residents and other health professionals, as documented by evaluations of a resident’s teaching abilities by faculty and/or learners.”6 Moreover, the Liaison Committee on Medical Education’s Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree states that “[r]esidents who supervise or teach medical students, as well as graduate students and postdoctoral fellows in the biomedical sciences who serve as teachers or teaching assistants, must be familiar with the educational objectives of the course or clerkship and be prepared for their roles in teaching and evaluation.”7 As prescribed by these organizations, teaching is not only a possibility, but also a responsibility for physicians in training.

Residents consider teaching medical students to be one of their primary responsibilities and they learn themselves in the process of teaching.4 Most learners feel that resident teachers, who are close to their own training level, facilitate their learning and have a good understanding of how they should be taught.9 Teaching also seems to enhance the teacher’s own knowledge acquisition.10 A literature review concluded that teaching also improved teachers’ perceived professional competency: physicians seen as competent were those who taught effectively and possessed a basic understanding of teaching and learning.11

This systematic review aims to evaluate the formats used and the content usually taught in existing teaching-skills training programs for family medicine residents, and will appraise the reported effects of such programs.

DATA SOURCES

We searched Ovid MEDLINE (1950 to mid-July 2008) and the Education Resources Information Center (ERIC) database, which indexes education journals, (pre-1966 to mid-July 2008) using and combining the MeSH terms teaching, internship and residency, and family practice (MEDLINE) and teaching, graduate medical education, and family practice (medicine) (ERIC), and reviewed the bibliographies of identified articles. This search was specific to family medicine training. To make sure that we did not miss any relevant articles published since Wamsley and colleagues’ review,1 we also conducted a search using only the terms they used (internship and residency and teaching) for articles published after their review time frame (ie, June 2003 until mid-July 2008).

Study selection

The initial MEDLINE and ERIC searches identified 362 and 33 references, respectively. Titles and abstracts were reviewed to identify the articles relevant to our analysis. References were included if they described the format or the content of a teaching-skills program or if they presented the results of primary studies of the effects of a teaching-skills program for family medicine residents or which included residents in family medicine among other specialty trainees. Only articles published in English were selected. Three references were identified as relevant to this review. The bibliographies of these articles were reviewed, and 4 additional relevant articles were identified. The broader search extending Wamsley and colleagues’ review1 found 907 references, from which 1 additional article was identified. Therefore, we included a total of 8 articles in our systematic review.

SYNTHESIS

Format and content of teaching-skills training

Teaching-skills training programs in which family medicine residents are involved have various formats: 1-hour weekly sessions over a few months,12–15 half-day courses,13,14,16 1-day intensive workshops,17 and on-line modules.18

Various teaching strategies are used, such as lectures,15 interactive discussions,13–15 role playing or simulated teaching activities,13–15,17 discussion of sample cases,15,17 videotaped vignettes,15 on-line teaching resources,15,18 one-on-one mentoring,15 and guidance by faculty supervisors.15

The content taught in teaching-skills curricula included the following skills.

Leadership skills

Program content covered leadership and role modeling,13,14 motivation,16 and directing attention.16

Effective clinical teaching skills

Specific areas of focus included general principles of clinical teaching and adult learning15,18; orienting learners13,14,17; objectives and planning12,16,17; the “teachable moment” concept13,14; delivery methods12; group teaching and inpatient work rounds13,14; discussion and questioning12,18; tips for effective teaching,15 such as the “five-step microskills” model of clinical teaching13,14,17; bedside teaching13,14; and audiovisual and presentation skills.12–14,18,19

Technical teaching skills

These included demonstration techniques,12 teaching with high-fidelity patient simulation,18 teaching procedures,13,14,16,18 and teaching charting.13,14

Feedback and evaluation skills

Residents learned to give feedback13–18 and to evaluate16–17 learners.

The description of format and content for each program is summarized in Table 1.12–20

Table 1.

Summary of format, content, and effects of teaching-skills training programs involving family medicine residents

TEACHING-SKILLS CURRICULUM
 EVALUATION (ACCORDING TO KIRKPATRICK’S LEVELS OF EVALUATION 20)*
STUDY PARTICIPANTS FORMAT CONTENT MEASUREMENT TOOL REACTIONS (APPRECIATION) LEARNING BEHAVIOUR (TEACHING BEHAVIOUR) FM FINDINGS
Lawson and Harvill,12 1980 FM and internal medicine residents 13 1-hour weekly sessions Objectives and planning; delivery methods; discussion and questioning; demonstration techniques (audiovisual and lecturing) Videotaped teaching performances and written questionnaire NA NA Significant (P < .001) gains in teaching performance (eg, delivery, organization, explanation, use of audiovisuals) and in attitude toward participating in a teaching-skills program Not mentioned
Edwards et al,16 1988 First-year residents in medicine, FM, obstetrics, and gynecology 1 half-day course Communicating objectives; motivating; directing attention; teaching procedures; feedback; evaluation Randomized controlled trial; trained raters’ evaluation of videotapes, residents’ self- rating, and students’ ratings NA NA Higher scores on evaluation of teaching skills in the experimental group compared with the control group Before instruction, FM and medicine residents were rated significantly higher on formulating differential diagnoses; no other differences between specialties were statistically significant
Swanson et al,19 1992 FM residents Not specified Presentation skills Randomized controlled time series design; presentations were evaluated using a standardized format NA NA Educational intervention can improve FM residents’ presentation skills; education coupled with repeated opportunities for presentation produces greater improvement than repeated presentations alone Not mentioned
Morrison et al,13 2003 Generalist residents (FM, internal medicine, pediatrics) Longitudinal curriculum: 3-hour mini-retreat and 10 1-hour noon conference sessions in which interdisciplinary groups of 10 residents reviewed homework, brainstormed about teaching skills, and for 30 minutes actively practised the module’s skills in pairs or groups (with “standardized learners”) and mutually provided feedback “Teachable moment” concept; “five-step microskills” model of clinical teaching
Teaching skills: leadership and role modeling; orienting learners; giving feedback; bedside teaching; teaching procedures; group teaching, inpatient work rounds; teaching charting; giving mini- lectures		 Randomized controlled trial; 3.5-hour, 8-station OSTE designed specifically to test clinical teaching skills of primary care residents; CTPI, a 28-item Q-sort instrument that measures comfort with clinical teaching NA NA Intervention group improved their mean overall OSTE scores by 22.3% (more than 2 SD) from pretest to posttest Not mentioned
Morrison et al,14 2004 Generalist residents (FM, internal medicine, pediatrics) Longitudinal curriculum: 3-hour mini-retreat and 10 1-hour noon conference sessions in which interdisciplinary groups of 10 residents reviewed homework, brainstormed about teaching skills, and for 30 minutes actively practised the module’s skills in pairs or groups (with “standardized learners”) and mutually provided feedback “Teachable moment” concept; “five-step microskills” model of clinical teaching Teaching skills: leadership and role modeling; orienting learners; giving feedback; bedside teaching; teaching procedures; group teaching, inpatient work rounds; teaching charting; giving mini- lectures Randomized, controlled trial; 3.5-hour, 8-station OSTE for generalist resident teachers; semistructured interviews 1 year after the curriculum for some participants If the curriculum were shortened, participants recommended that the modules on teaching charting and bedside teaching be eliminated 1 year after the program, residents in the intervention group had a richer, more elaborate understanding of teaching principles and skills Mean overall posttest score for residents in the intervention group improved by 28.5%; control residents did not improve significantly on the overall posttest (2.7%) or on any station; 1 year after the program, intervention residents had greater enthusiasm for teaching during and after residency, had greater learner-centred approaches, and most planned to teach after residency (most control residents did not) Not mentioned
Farrell et al,18 2006 Program aimed at emergency medicine residents 6 on-line modules General principles of clinical teaching; effective feedback; teaching procedures; teaching with high-fidelity patient simulation; effective discussion-leading and lecturing NA NA NA NA NA
Jain,15 2007 Third-year FM residents 10–12 1-hour weekly sessions: lectures, interactive discussions, video vignettes, role- playing sessions; residents referred to multiple resources (eg, websites); guidance from faculty supervisors Qualities of adult learners; assessment of knowledge, attitude, and skills; tips for effective teaching; provision of effective and useful feedback NA NA NA NA NA
Aiyer et al,17 2008 First-year residents in various specialties (emergency medicine, FM, internal medicine, pediatrics, neurology, neurosurgery, obstetrics, gynecology, radiology, surgery) 1-day mandatory intensive workshop, repeated 3 times a year so that all first-year residents could attend; concludes with an OSTE followed by a discussion Orienting the learner, which included discussion of the individual clerkship goals and objectives; using clinical teaching microskills; giving feedback to learners; and evaluating student learners Pre-post self- assessment surveys Residents felt more prepared, enthusiastic, and confident about their ability to teach; increased understanding of what was expected of them as teachers; lower anxiety level regarding teaching; unchanged perception of teaching by positive example Increased understanding of the difference between feedback and evaluation; no difference in understanding of the differences between giving someone feedback and a compliment or criticism Residents more inclined to explain their role to team members, solicit learning goals from team members, and plan to meet each learner’s personal learning objectives; increased willingness to use the clinical teaching microskills and to make learners aware of the extent to which they give feedback, provide daily feedback, and provide feedback that is descriptive in nature; no increased willingness to admit “I don’t know,” to teach by positive example, or to wait at least 3 seconds for a response after asking a question No specific analysis for FM residents; primary care residents noted a greater increase in their confidence in teaching ability and in assuming team control compared with non primary care residents; primary care residents’ self- ratings of their willingness to encourage bedside teaching and provide daily feedback to their learners showed a much greater increase compared with non primary care residents
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CTPI Clinical Teaching Perception Inventory, FM family medicine, NA not applicable or not assessed, OSTE objective structured teaching evaluation.

*

None of the studies assessed results (patient or learner outcomes), Kirkpatrick’s fourth level of evaluation.

Effects of teaching-skills programs

According to Kirkpatrick,20 4 levels of evaluation can be assessed: reactions, learning, behaviour, and results. His model for evaluating educational outcomes was modified by Freeth et al21 and was adopted by the Best Evidence in Medical Education Collaboration. This model was further adapted by Steinert et al22 to include students, residents, and colleagues (instead of patients). The results of studies on the effects of teaching-skills programs retrieved by this review are presented in Table 112–20 in terms of those 4 levels.

The evaluation of most programs was very positive in terms of curriculum appreciation (reactions),14,17 learning outcomes14,17 and teaching behaviour.12–14,16,17,19 None of the retrieved studies assessed the outcome on learners (results).

DISCUSSION

This review demonstrates that teaching-skills programs for family medicine residents exist in many formats and shows what content is usually discussed. Specific data on the effects of teaching-skills curricula for family medicine residents are, however, lacking. Most studies involved “primary care residents,” which usually included family medicine, internal medicine, and pediatrics residents.

When compared with studies aimed at various specialty programs, few data are available for family medicine residents on curriculum appreciation23–31 or learning outcomes of teaching-skills curricula.23,27,29,32 As for most studies involving residents from other programs,23–25,28,29,32–38 most studies for family medicine residents have assessed the effects of this training on residents’ teaching behaviour. Considerable gains were noted on several teaching skills in the various studies.

Not surprisingly, there are no data analyzing the highest evaluation level, which is outcome on learners (results). Such data are limited even when residents from all specialties are considered.24

The findings on primary care residents from Aiyer et al are of interest for family medicine training programs.17 When compared with non–primary care residents, primary care residents showed a greater increase in confidence in their teaching ability and in some teaching skills (improved perceptions of encouraging bedside teaching and providing daily feedback to their learners). This suggests a great potential for teaching in these residents.

After reviewing literature in 1990 on training residents as teachers, Chamberland and Boulé proposed 4 recommendations that still seem to be accurate and particularly relevant to family medicine residents: 1) because of residents’ time constraints, short (2 to 3 hours), periodic sessions are preferred to curricula presented over a few days in a row; 2) course content should be practical and relevant to the residents’ practices and should integrate basic education principles rather than teaching in a theoretical way; 3) educational strategies should encourage an active role for residents (workshops, role playing, videotapes, etc); and 4) teaching-skills training should be included in residency programs to establish and valorize residents’ teaching role and ensure evaluation of their teaching skills.39

Limitations

This review has some limitations. Publication bias is an important limitation, and some unpublished studies might have given a different view. Also, most articles that were retrieved targeted primary care residents, not specifically family medicine residents. This might have an effect because duration of training in internal medicine and pediatrics is longer than for family medicine.

Furthermore, applicability of these findings still needs to be carefully assessed, as the 8 studies that were included in this review were not conducted in Canadian settings. Most of the family medicine programs examined in the retrieved articles are 3 years in length, leaving more time for teaching-skills training. Canadian family medicine residency programs are very different from those of the other specialties owing to their 2-year duration. There is a paucity of papers on teaching skills for family medicine residents. This review is based on published literature and thus most of the papers on which the review is based have 3-year programs. Some of the findings, however, can be extrapolated to family medicine residents and should be considered during the development of teaching-skills curricula in the context of our shorter programs.

Conclusion

Teaching-skills training programs for family medicine residents use many teaching strategies in curricula presented over a half-day to a few months. Their content includes leadership skills, effective clinical teaching skills, technical teaching skills, as well as feedback and evaluation skills. Program evaluation mainly targeted the effects of the programs on teaching behaviour, which was generally found to improve after completion of these programs.

Because family medicine training covers a broad scope of clinical content in the context of a short duration of training, further studies assessing the effects of teaching-skills training for family medicine residents are needed. Educators should, however, develop programs based on the available knowledge that would benefit family medicine residents in Canada and evaluate the effects of these programs. Future research should also concentrate on the learners’ outcomes to assess how residents’ teaching-skills training can affect their learners’ clinical training and eventually patient care.

Acknowlegment

We thank Mrs Elizabeth M. Uleryk, Director of the Hospital for Sick Children’s library, Mrs Rita Shaughnessy, librarian for the Department of Family and Community Medicine at the University of Toronto, and Mrs Denise Paquet and Mrs Patricia Chamberland, library technicians at the Centre hospitalier de l’Université Laval, for helpful guidance with the literature search.

EDITOR’S KEY POINTS

  • This review focused on teaching-skills training programs designed for or including family medicine residents. It reviews the format and content and appraises the effects of such programs.

  • Teaching-skills programs for family medicine residents exist in many formats.

  • Few data are available on the effects of teaching-skills curricula for family medicine residents specifically.

POINTS DE REPÈRE DU RÉDACTEUR

  • Cette synthèse porte sur les programmes de formation en enseignement concus pour les résidents, incluant ceux en médecine familiale. Elle examine la forme et le contenu de ces programmes ainsi que leurs effets.

  • Il existe plusieurs formes de programmes de formation en enseignement pour les résidents en médecine familiale.

  • Il y a peu de données portant sur les effets des programmes de formation en enseignement spécifiquement sur les résidents en médecine familiale.

Footnotes

Contributors

Dr Lacasse developed the concept and design of the study, conducted the literature review, selected and analyzed the studies, interpreted the analysis, and prepared the manuscript for submission. Dr Ratnapalan provided support for the development of the concept and design of the study and participated in the interpretation of the analysis and preparation of the manuscript for submission.

Competing interests

None declared

*Full text is available in English at www.cfp.ca.

This article has been peer reviewed.

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