Use of a Policy Debate to Teach Residents About Health Care Reform

Editor's Note: The online version of this article contains the debate structure and the debate score sheet.

The health care reform bill, signed into law on March 23, 2010, as the Patient Protection and Affordable Care Act (PPACA), is the largest health care initiative in the United States since the creation of Medicare and Medicaid.1,2 Changes in the quality of health care could profoundly alter resident physicians' future practice environment. Although supporters hail the PPACA as a major advance in health care reform, research suggests physicians rarely are given voice in the health care debate.3–5 

The Accreditation Council for Graduate Medical Education's mission has been to advance the nation's health care by advancing the quality of resident physician education.6 Educating residents about current policy issues (such as health care reform) is important to their understanding of the larger system in which they will practice. There are no pedagogic guidelines on how policy issues could be taught, and the matter is left to the creativity of the residency program director and faculty. Traditional pedagogic methods used to educate medical students and residents, such as didactics (eg, daily lectures, grand rounds, conferences) and Socratic methods (eg, patient rounds, workshops, and morbidity and mortality conferences), have been commonly used.

We developed our central question (“Is America's health care system among the very best in the world?”) through discussion among our faculty and residents. The idea of using a debate as a health care reform teaching tool originated with our program director.7–10 Debates are formal methods of interactive argumentation.7 They are relatively inexpensive compared with purchasing textbooks or inviting topic-expert speakers, and have the potential to encourage collaboration and reflective thinking. Arguably, these are key skills to becoming an effective physician. Debate as a teaching tool has obvious merits,8–10 but to date there have been no reports of its use in resident education. The primary aim of our study was to pilot the use of debate as a resident teaching tool.

The debate consisted of 3 distinct periods: (1) getting “buy-in” from the resident physicians; (2) preparing the debate; and (3) follow-up. Each component is described in the following section.

The program director approached 2 residents who he felt were effective self-learners, to teach the broad and complex topic of health care reform and to enhance their understanding of the environment in which they will practice. The 2 residents agreed to be debate team captains. The program director then presented the idea of a health care policy debate as a teaching tool to the other residents. As expected, most residents expressed apprehension about speaking in public, being able to find adequate resources, lacking experience in debating, being able to comprehend the health care reform bill at all, or having time and energy to prepare, given their already busy lives. Being publicly judged for their private beliefs was another concern. After some reassurance, all residents agreed to participate in the debate.

After some brainstorming, we adopted a policy debate format. A policy debate is “a formal style of debating where 2 teams advocate or oppose a plan derived from a resolution that usually calls for a change in policy by a government.”7 We considered discussing the pros and cons of debating the health care proposals being advocated at the national level, as well as whether the nation needed health care reform. In the end, we decided to focus on the question “Is America's health care system among the very best in the world?” We chose this topic because we felt it would encompass the breadth of the problem that was being contested at the national scene. We used the cross-examination method as an accepted, standardized format for the debate.11 The program director allowed the debate team captains to choose their preferred positions in the debate before randomly assigning 5 of the 11 residents in the program to the “affirmative” team and 6 residents to the “opposition” team. The cross-examination format involved 12 speech sections (provided as online supplemental content), and the team captains assigned team members to their respective parts in debate. Each resident was required to have at least one speaking role.

To prepare for the debate, the team captains met separately with their teams on several occasions, and assigned aspects to be researched prior to the debate based on residents' personal interest. Each resident was responsible for researching and preparing the arguments for his or her subtopic, and to forward results to the rest of the team. The 2 teams used e-mail to educate team members, discuss counterpoints, and identify areas of weakness that needed further investigation. Each team met a final time to determine the order and logic of its argument, and the order of the presentations.

The debate was held on December 17, 2009, in a large conference room, with both teams facing each other. The audience comprised the physical medicine and rehabilitation faculty, administrative leaders, the vice president of education, the director of curriculum and evaluation, the department chair, and the program director. The program director invited the designated institution official to serve as the moderator and judge for the debate. The chief legal executive and the vice president of government relations also served as judges. The 3 judges were provided with the format for the debate, the position of each team member (eg, affirmative or opposition) and a modified scoring sheet.11 The scoring sheet (provided as online supplemental content) was shared with the 2 captains prior to the debate.

One month following the debate, we surveyed residents' attitudes toward health care reform using questions 3a(box) developed by the authors, adapted from a recent Harvard School of Public Health and Harris Interactive study on Americans' views on the US health care system.12 

Although debate has not been widely used in medical education, it appears to enjoy growing popularity as a teaching tool in health-related training programs.13–20 The primary aim of our study was to explore its use in a residency training program, in the hope it may prove useful for other programs. Based on our experience, we believe a debate approach to learning is useful because it allowed us to effectively teach the complex issue of health care delivery and encourages residents to critically evaluate the larger health care system. We struggled with teaching the subject matter while balancing the personal political beliefs at play in each teacher and learner, as well as at the national level. We were not able to locate a comprehensive, in-depth article or reference that could be used to teach the subject. The policy debate format allowed each resident to study a specific area in depth and then share that understanding with the group. This allowed the large, complex topic to be divided into manageable portions. The group meetings to prepare for the debate also allowed the residents to discuss the breadth of the topic.21 Another important attribute of our debate approach is the active engagement of residents in the learning process. Most lectures rely on technology, such as PowerPoint (Microsoft, Redmond, WA), to convey information. PowerPoint lectures can create a situation where information is presented in a passive, fragmented, and linear manner, and with little active input from learners. Research suggests that a learning environment with a high reliance on technology such as PowerPoint may affect the learner's ability to visualize subtle nuances between similar schemes.22 In contrast, doing critical research on the topic followed by active debate, which increases comprehension and retention,8–10 requires a high level of activity and participation.

Our approach has several limitations. Our use of the debate was a single intervention to teach resident physicians about health care policy at a single institution, and we did not seek to measure changes in health care knowledge or physician attitudes towards health care reform. Our sole aim was to explore the use of debate in graduate medical education and to describe the steps to allow others to replicate or adapt our approach.

Debate is an innovative, useful, if underused, teaching method in resident education. Our use of policy debate as a teaching tool in residency education contributed to the development of critical thinking skills among resident physicians. Future studies may explore the use of debate to more broadly explore resident physicians' perceptions of the effect of health policy reform and/or the role of the federal government in the delivery and financing of health care.