Anesthesiology Residents-as-Teachers Program: A Pilot Study

The word doctor derives from the Latin docere, which means “to teach.” Teaching by residents has been shown to benefit their own learning, whether informally at the bedside1 or through formal lectures.2 To address the need for resident competency as educators, studies in various specialties, including internal medicine, obstetrics-gynecology, pediatrics, surgery, and family medicine, have documented that residents can improve their teaching skills through interventions that focus on knowledge and behavior change.3,4 One of the most rigorously studied interventions, the Bringing Education & Service Together (BEST) model, described by Morrison and colleagues5 in 2 randomized controlled trials, was proven effective for family medicine, internal medicine, and pediatrics residents compared to controls. The effectiveness of residents-as-teachers programs has been assessed via medical student evaluations of residents,5,6 objective structured teaching examination (OSTE) scores,7 faculty evaluations,6 and blinded evaluation by education specialists.8 Generally, it has been concluded that teaching skills improve as a result of an instructional program.3,5–8 

The aim of a residents-as-teachers program for anesthesiology residents is to prepare residents to meet the demands of providing supervision for other health practitioners such as medical students, more junior residents, nurse anesthetists, and anesthesia assistants, as well as provide bedside teaching that occurs in perioperative care, acute and chronic pain practices, and critical care medicine. To date, there are no reports of residents-as-teachers programs in the anesthesiology literature. Our study assesses the feasibility and effectiveness of such a program. We hypothesize that a concise series of evidence-based workshops that focus on 6 core teaching skills will improve the teaching skills of anesthesiology residents as measured by self-assessment.

During 2 academic years (2009–2010 and 2010–2011), all 14 anesthesiology postgraduate year–2 residents consented to participate in the intervention. The Anesthesiology Residents-as-Teachers Program (ART) was adapted from the Obstetrics and Gynecology Residents-as-Teachers Program at our institution,7 which was in turn based on the BEST program.5 The Institutional Review Board at George Washington University approved the study.

The authors chose 6 teaching skills deemed essential for the anesthesiologist for presentation during the ART workshops. These skills included (1) giving feedback, (2) teaching around a case, (3) orienting a learner, (4) teaching a skill, (5) teaching at the bedside, and (6) delivering a mini-lecture. The workshops were created over several years and modified from resident evaluation and reflective focus groups at our institution.7 Specific cases were modified to fit the needs of anesthesiology resident teachers.

To create a self-sustaining program within the department of anesthesiology, ART used a train-the-trainer model. From their prior experience with the workshops, senior faculty teachers mentored junior faculty teachers from the Department of Anesthesiology. The junior faculty teachers also received 1.5 hours of training in residents-as-teachers principles and reviewed the specific goals and objectives of individual workshops with the senior faculty teachers.

Medical students recruited from the medical school's senior students-as-teachers elective participated in the workshops as standardized learners, providing opportunities for residents to practice and reinforce workshop skills.9 

The 8-hour intervention consisted of an introduction (1 hour), ART program workshops (1 hour each, 6 hours total), and summary (1 hour). The workshops were presented during the July–August Introductory Lecture Series for first-year anesthesiology residents in four, 2-hour sessions (provided as online supplemental material).

As an introduction to the workshops, the residents were given a primer on adult learning principles. The primer included a learner-led discussion recalling effective and ineffective teaching, a review of several adult learning–themed readings, and a video demonstration. Additionally, the introduction presented our 3-function model for clinical teaching or 3Ps: Prepare for the exercise (clarify goals and make them meaningful to the learner by eliciting the learner's prior experience and building on it); Perform the exercise (teach the unique content of the exercise, eg, teaching at the bedside will be performed differently than teaching a skill); and Process the results (encourage learner reflection, summarize, give feedback, and coordinate follow-up and/or resources for further learning).7 

The model provided a common structure for each of the 6 workshops and was emphasized by pocket cards that displayed each workshop's teaching points within the 3Ps format (provided as online supplemental material).

The summary session reviewed the 3 Ps as they related to the 6 skills taught in the ART program workshops. Residents discussed the future application of the 3Ps' principles with respect to patient education, teaching, and interactions with nursing staff, including certified registered nurse anesthetists. Residents provided feedback for the ART program for future planning.

Immediately following each workshop, residents completed an evaluation of the workshop itself. The 9-item evaluation, developed and tested by our group, rated each component of a workshop on a 1- to 5-point Likert scale (1  =  low, 5  =  high; instrument provided as online supplemental material).

Residents completed a self-assessment of teaching skills before the introductory session and 6 months after the conclusion of the ART program workshops after reviewing 6 months of medical student evaluations of their skills with the principle investigator. The 14-question self-assessment was adapted from The Clinical Educator Self-Assessment, an unpublished tool developed by Dennis Baker, PhD, at Florida State University. This assessment has been used in a similar study conducted at our institution and has evidence of content validity.7 

Data were analyzed with SAS, version 9.1 (2011; SAS Institute, Cary, NC). Paired t test was used for analysis. A P value ≤ .05 was considered significant.

Teaching workshops were given an average rating of 4.2 of 5 (3.9–4.7) across 9 items. The average preintervention self-assessment score was 2.83 (95% confidence interval, 2.53–3.13). The average postintervention self-assessment score at 6 months was 3.87 (3.64–4.09). Significant improvement was noted in 13 of 14 individual self-assessment categories. The mean increase was 1.04. A paired t test comparing the preprogram self-assessment to the 6-month postprogram self-assessment shows an improvement post ART program (P < .001). A summary of self-assessment scoring can be found in the table. Residents reported the greatest improvement in writing/using teaching objectives (+1.29, P < .001), teaching at the bedside (+1.57, P  =  .002), and leading case discussions (+1.64, P  =  .001).

The ART program provided our anesthesiology residents with teaching skills through a concise series of workshops grounded in adult-learning theory. The workshops were rated highly by residents and incorporated extensive, interactive practice opportunities with standardized students. To our knowledge, our ART program is the first reported teaching program for anesthesiology residents. Residents perceived their teaching skills as improved in almost all domains after the program.

The BEST method5 plus the 3Ps facilitate skills acquisition by providing residents with structures common across workshops. Our results suggest that the ART program is effective at improving resident teaching skills, and along with the Gaba Obstetrics-Gynecology trial,7 extend the success of the BEST model from generalist to subspecialist residencies.

The costs of ART included faculty time (2 teachers for 14 residents) and staff time (1 person to coordinate the sessions), for 8 total sessions. The sessions occurred during usual resident teaching sessions. The time involved includes program design and execution; 8 hours of workshops plus training of junior teachers and student volunteers. We provided packets with relevant articles, the 3Ps model cards, and ART workshop schedules in folders for each session. The sustainability of the ART program is due to the train-the-trainers model. Senior faculty educators who had created the institution's first successful residents-as-teachers program mentored junior faculty teachers from the Department of Anesthesiology in the first year. In the second year, the anesthesiology faculty members were able to conduct the program independently.

There are several limitations to our study. We selected participants by residency year instead of random assignment. The lack of a control group self-assessment over the same time period may suggest that perceived improvement in teaching skills would occur during 6 months without the intervention simply by participating in standard residency training. In addition, self-assessment measurements are inherently less objective than other, more rigorous measurements. Finally, it is possible that the Hawthorne effect limited postintervention self-assessment of teaching skills.

This study presents several directions for future research. A controlled trial featuring residents who do not have access to the ART program would provide a baseline comparison for learning; additionally, a trial using objective assessment by facilitators during OSTEs or medical student assessment of resident teaching following ART would be an improvement over self-assessment as an outcome measure. In this preliminary study with anesthesiology residents, self-reported improvement in teaching was substantial across almost all domains.