Setting and Problem
Train-the-trainer programs in international settings focus on teaching medical content to local faculty.1 Local faculty are then tasked with becoming the teachers of medical content to other hospitals and regional health care providers as part of the development of a sustainable educational program. However, faculty are rarely taught effective teaching techniques during their medical training or as a part of a train-the-trainer course.2
Advanced Pediatric Life Support (APLS) courses3 are designed by the American Academy of Pediatrics (AAP) to be adaptable to different practice environments. The course materials include a student manual and an instructor “toolkit” with 21 modules of medical content in PowerPoint slides and small group session scripts, skill stations, and administrative materials, including recommended course schedules and pre- and posttests. All materials can be modified according to setting. After taking the course, students can become course instructors. Additionally, the AAP outlines parameters for instructors to become course directors, who can submit a course schedule to the AAP and obtain official certification for students. We have used the APLS program and a train-the-trainer approach to increase pediatric capacity in global health.
Intervention
We proposed to include modules on teaching pedagogy within our APLS train-the-trainer programs. In April 2018, we implemented an APLS course at the University Teaching Hospital of Kigali in Rwanda with 2 iterations of the course over 1 week. The first APLS course was designed as a train-the-trainer session for faculty and chief residents in anesthesiology, pediatrics, and emergency medicine, with special interest in teaching. In addition to medical content, the train-the-trainer course included 4 interactive presentations on learner-focused teaching methods with the objective that course participants must be able to use learner-centered techniques during didactic and bedside teaching sessions. Teaching pedagogy sessions included adult learning principles, procedure and bedside teaching, simulation and small group sessions, and how to give feedback.4 The sessions were designed to be interactive and encourage questions.
The second APLS course was held for 28 additional residents by the newly trained “trainers.” During these sessions, the trainers were encouraged to update their topics to focus on material and resources important for their practice in Rwanda. The trainers also received feedback about their use of teaching techniques during lectures, skills sessions, and small group cases.
Outcomes to Date
After completion of each course, students took the APLS subject content examination. The pass rate (> 80% on the posttest) was 67% for group 1 and 79% for group 2. As presented in the Table, the scores did not differ among students who took the course from the initial or the new instructors. Both groups showed improvement in their comfort level in caring for sick children after the APLS course. The trainers were very engaged and thoughtful throughout the discussions on pedagogical topics. For example, during the session on feedback, the trainers discussed how most feedback they received during medical school and residency focused on negative evaluations. Therefore, they were unsure how to provide effective feedback to their students, leading to questions on how to implement feedback in their clinical teaching. The written feedback regarding the pedagogy modules included [the topic on] “teaching skills was good” and “this course was very helpful.” The new trainers identified key takeaway learning points on pedagogy, including “learner-centered approach with closer monitoring and regular and constructive feedback,” “interactive group discussions,” “know how to give feedback and receive feedback,” and “engage the audience.” The trainers were observed to lead interactive presentations and small group discussions and provided real-time feedback during simulations to their students.
Table.
Comparison of Course Results Between Group Taught by Initial Faculty and Trainers
| Results | Group 1 (9 Future Trainers Taught by Faculty) | Group 2 (28 Students Taught by Trainers From Group 1) |
| Pretest scores, median (SD) | ||
| All specialties | 71% (7%) | 65% (15%) |
| Pediatrics | 75% (5%) | 77% (7%) |
| Emergency medicine | 71% (6%) | 63% (13%) |
| Anesthesiology | 63% (7%) | 47% (15%) |
| Posttest scores, median (SD) | ||
| All specialties | 85% (9%) | 85% (7%) |
| Pediatrics | 80% (10%) | 85% (4%) |
| Emergency medicine | 93% (0%) | 89% (6%) |
| Anesthesiology | 78% (4%) | 81% (7%) |
| Questionnaire responses, median score (1, strongly agree; 2, agree; 3, neutral; 4, disagree; 5, strongly disagree) | ||
| “Before this APLS course, I felt comfortable taking care of sick children.” | 2.4 (SD 0.9) | 2.4 (SD 0.7) |
| “After this APLS course, I feel comfortable taking care of sick children.” | 1.3 (SD 0.6) | 1.5 (0.5) |
Abbreviation: APLS, Advanced Pediatric Life Support.
We feel that train-the-trainer programs are important for developing local expertise and sustainable medical knowledge, especially in global settings. However, future trainers would benefit from training in teaching pedagogy during the train-the-trainer program itself. We believe that integrating medical knowledge and education pedagogy and practice will increase the success of train-the-trainer programs.
References
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