Understanding Resident Learning Preferences Within an Internal Medicine Noon Conference Lecture Series: A Qualitative Study Open Access

The Accreditation Council for Graduate Medical Education (ACGME) mandates that residency programs provide regularly scheduled didactic sessions.1 While there is flexibility in this process, a review of family medicine residency programs found that most programs offered 60-minute lectures during the noon hour an average of 3 times per week.2 The lecture remains popular because it is an efficient and inexpensive way to disseminate medical knowledge to a large group of residents. Yet, studies show that lectures demonstrate short-term knowledge gains but no long-term retention.3–8 Several studies report a variable correlation between residents' conference attendance and scores on specialty-specific national in-training examinations.9–14 Because of variability in the evidence supporting the use of the lecture format, it is not clear whether the lecture format should be improved or replaced with another learning modality.15 

With changes in residency education from duty hour reforms and the ACGME's Next Accreditation System, educators need to provide optimal learning opportunities for residents to achieve the complex medical knowledge Milestones.16 It is important to understand the unique challenges of teaching residents, including resident-specific learning preferences and their learning environment. To explore the richness and depth of internal medicine residents' perspectives on noon conference, we used a qualitative design to identify (1) motivations for attending conferences, (2) appropriate content, (3) effective teaching methods, and (4) attitudes about enhancing active learning.

The University of Pittsburgh Internal Medicine Residency Program includes a longitudinal core curriculum conference series that occurs twice weekly from noon to 1:00 pm, with food provided to attendees. Subspecialty education coordinators are given a list of topics to present at the conference. There is little guidance given to faculty regarding teaching methods, and lecture is the predominant educational method. Some lecturers choose to use an electronic audience response system as part of the conference.

We conducted focus groups to elicit residents' perceptions about the use of a lecture-based conference series.17 We invited all 144 internal medicine, internal medicine–pediatrics (medicine-pediatrics), preliminary, and transitional year residents at our institution to participate via an announcement at the noon conference and e-mail. We sent follow-up e-mails and made personal contact to encourage participation.

The study was approved by the Institutional Review Board of the University of Pittsburgh.

The study investigators, comprising core residency faculty, developed a focus group guide according to described focus group methodology.18 The guide included questions about demographics and perspectives on noon conference. A draft of the guide was pilot-tested, first as an interview and second as a focus group with general internal medicine fellows. Using feedback from the pilots, we refined and finalized the focus group guide (provided as online supplemental material).

We conducted 7 one-hour focus groups, 3 with postgraduate year (PGY)–1 and 4 with upper-level (PGY-2–PGY-4) residents. The number of participants per focus group ranged from 5 to 7. A team member (D.L.) trained as a focus group moderator, and independent from the residency training program, served as moderator for all sessions. The principal investigator (A.P.S.) took notes at each session. All focus groups were completed in the spring of 2012 and were audio recorded for further analysis. Lunch and refreshments were served in appreciation for participation.

The moderator transcribed each focus group verbatim and deidentified the transcripts for analysis. The transcripts were uploaded to ATLAS.ti version 6 (Scientific Software Development, Berlin, Germany), a computer software program to support the analysis of qualitative data. We used the “editing approach” to qualitative analysis developed by Crabtree and Miller.19 The principal investigator and the qualitative expert (S.L.Z.) reviewed each transcript and developed a codebook. Two coders trained in qualitative methods (A.P.S. and K.B.) applied the codebook to the pilot transcripts and refined the codebook, which was further reviewed by the qualitative expert. The 2 coders independently applied codes to the focus group transcripts and adjudicated differences through discussion. The study investigators entered the final codes into the coding database, analyzed the codes with subsequent quotations, outlined the main themes, and picked exemplary quotations.

Before the adjudication process, we used the individual coding files to calculate intercoder reliability by using the Cohen κ statistic. The total mean κ value for the assignment of codes was 0.80, demonstrating what Landis and Koch20 describe as a “substantial” agreement.

Forty-one internal medicine, medicine-pediatrics, preliminary, and transitional year residents participated in 1 of 7 focus groups; 17 (41%) were PGY-1 and 24 (59%) were PGY-2 through PGY-4 residents. Twenty-two (54%) were men.

We identified central themes on resident learning preferences and categorized them into 4 domains: (1) motivations for attendance; (2) appropriate content; (3) effective teaching methods; and (4) perspectives on active participation during noon conference.

The main external factor motivating conference attendance was the opportunity for a break in the day and time to eat lunch; these motivations were discussed as often as intrinsic attributes of the conference. First-year residents also discussed their appreciation of an attendance requirement. The main external factor that affected nonattendance was workload, including being on a busy rotation (ie, inpatient floor or intensive care unit) or rotating at an off-site location. Residents also discussed needing to leave conference if they received multiple pages about clinical care.

All residents discussed attending lectures for the opportunity to learn and were motivated by the topic or the speaker. First-year residents discussed learning to enhance their confidence, while upper-level residents were more likely to discuss the pressure to prepare for their national board examination as a motivation for attendance. Residents were more likely to attend when topics were interesting or clinically relevant, and the speaker's reputation was good. Upper-level residents were more likely not to attend on the basis of previous negative experiences with the lecturer or topic (table 1).

Residents desired topics that were clinically relevant, practical, and readily applicable to patient care. They noted that content should be geared to an appropriate resident level. Upper-level residents were more likely to want information that is included on national certification examinations. Residents uniformly expressed that subspecialty lecturers should not include topics that are too specialized, as they are perceived as irrelevant to their current practice and geared to a more advanced level of learner.

Residents reported that conferences should present balanced evidence to support clinical practice. Presenting too much evidence was overwhelming, and residents suggested focusing on landmark trials that would change their current clinical practice. Presenting research that is not clinically relevant (ie, basic science research) should be avoided (table 2).

Residents believed that the most effective lectures had 3 to 5 clearly stated learning points, presented succinctly and with frequent summarization.

Residents stated that making sessions shorter (30 to 45 minutes) would allow for a more focused discussion of salient learning points, hold their attention, and create less conflict with the other demands on their time.

Residents considered lectures to be the most useful if they were centered on clinical cases and questions, highlighting clinical reasoning to make the learning points clear, applicable, and engaging (table 3).

Residents believed that active participation engaged them in learning, but could be stressful. They discussed the need to create a safe environment for active participation, specifically one safe from judgment or embarrassment. Residents noted that setting the expectations ahead of time would encourage participation and alleviate some of the unnecessary stress, and that asking questions in a nonthreatening way encourages engagement. Residents shared that they did not want to be put on the spot or forced to answer questions. Another identified stressor was the number of people in the audience. Programs need to address resident culture and expectations; residents may not be prepared to regularly participate unless it is established as part of the residency program culture.

Residents noted that an audience response system could be a good way to invite participation without the stress of speaking in a larger group, but others indicated it may be ineffective at maintaining resident engagement in the lecture (table 4).

The results of these focus groups demonstrate important concepts to drive innovation in residency education. Awareness of residents' motivation for attending or not attending noon conference, their perception of topics as clinically relevant and readily applicable, and their desire for shorter sessions and a safe learning environment may contribute to creating an effective learning experience.

In an era of duty hour limits, educators need to focus attention on efficient and effective education strategies to meet goals for competency in medical knowledge.21 Internal medicine residents reported less exposure to formal conferences after the 2003 restrictions on duty hours.22 Because of its efficiency at delivering content in the cognitive domain, the standard lecture is the most common way to provide didactics despite limited evidence of its durable effectiveness. The literature on the effect of the lecture format on long-term knowledge retention and test performance is very small, with only 1 study finding “educationally significant” gains in in-training examination scores after a year of conference attendance.14 This raises the question of whether the conference needs to be improved or whether there needs to be a fundamental change in the way we teach residents. Our study is a step in helping to resolve that question and our data can serve as a guide for future innovation within the lecture format. Our findings on resident learning preferences concur with adult-learning principles outlined by Knowles and colleagues23 and further research in adult learning.24 Knowles et al23 describe adult learners as individuals who are self-directed, are able to take responsibility for their learning, are reliant on their previous experience, and are motivated to learn to perform tasks or deal with problems. Adult-learning principles suggest that adults do not learn well in passive, static settings where they cannot immediately see the relevance of the material to their everyday practice.

Our study also helps explain findings from other areas of research on improving resident education. Attempts at increasing active learning through audience response systems have demonstrated variable impact on knowledge acquisition and retention when compared to traditional lecture format without audience response.25–27 Residents reported that this mode of engagement, while being safe, may not be able to maintain interest after the novelty subsides. Allowing residents to tailor their own learning by using online or podcast lecture series has shown no detriment to learning compared to the traditional conference format,28–33 although this may not cater to the residents' need for break time, food, and socialization. Other formats may be better in addressing residents' need for a safe environment, and there may be a need to create a culture that sets expectations for participation. Using a small group format was better than using a lecture for teaching evidence-based medicine to residents,34 as residents feel more comfortable in smaller groups. Engagement in problem-based learning can increase residents' self-directed learning behaviors.35 And, team-based learning improved residents' satisfaction with learning.36 

Several factors may limit the generalizability of our findings. First, the primary author played a large role in data collection and analysis. Second, our study used data from a single specialty and was conducted at a single, large, university-based institution, and the findings may not be applicable to other disciplines and settings. Third, our internal medicine residency participated in ACGME's Education Innovation Project, which may affect the views of our residents toward innovation.

In the changing environment of residency education, medical educators need to evaluate how residency programs structure their educational curriculum. This study furthers our knowledge of the learning preferences of residents within this changing environment and can be used, in conjunction with principles of adult learning, to reform how we deliver core medical knowledge in residency education and improve educational outcomes.