Editorial

Creative Solutions to Psychiatry’s IncreasingReliance on Residents as Teachers

H. Jonathan Polan, M.D.Michelle Riba, M.D., M.S.

This special issue answers an urgent need in academicpsychiatry to find creative new solutions to our field’s

increasing reliance on residents as teachers.Two forces are driving this. One is an old problem that

is now getting the recognition that it deserves. Medicalschools and their affiliated hospitals have long neglectedthe preparation of residents to teach despite the fact thatresidents work more directly with medical students inclinical settings than do attendings, making residents thestudents’ main, real-time, “in the trenches” teachers, theirmost immediate interpreters of clinical material, and theirmost direct supervisors. It is undeniable that residentsmust be better prepared for this teaching role than theyhave been. The second is a new problem. Increasing pres-sures on faculty to spend more time in direct clinical careor externally funded research are making protected timefor faculty teaching scarcer, which, by default, makesteaching by the residents that much more critical. Thissecond pressure makes it imperative that education pro-gram directors and departmental administrators guardagainst simply inserting residents as inexpensive substituteteachers into curricula that were designed to be taught byfaculty. We must be sure that, in fairness to our students,their residents are well prepared to teach, and that, infulfilling our educational obligations to the residents,learning to teach and teaching itself advance their profes-sional development.

This issue therefore collects in one place 12 articlesreporting 14 new projects and one review from the UnitedStates and Canada that demonstrate the great range andvariation of current efforts to raise the quality of teaching

by psychiatric residents. The collection sheds much newlight on what types of techniques residents can use, whatcontent areas they are good at teaching, and even whatteaching interventions residents themselves have devel-oped on the basis of their interests and perceptions ofresident and medical student educational needs. The issuecontains an excellent review on assessment tools to eval-uate such curricula (1).

Among the issue’s reports of specific projects is anexciting variability in all aspects of structure and con-tent—from the level of resident involvement in the cre-ation of the project to the teaching methods employed andthe topics, methods, and duration of the courses. For ex-ample, the durations of the teaching programs describedranged from a 1.5-hour single session (2), to multiyearclinician-educator tracks (3). Another dimension of inter-est, the degree of resident input into the formation of thesenew courses, ranged from a program that used the resultsof a resident survey to guide how much time to devote toteaching to teach in the residency curriculum (4) to severalprojects that were initiated and/or developed and imple-mented by the residents themselves (5–7). There are alsovaried structures, from a half-day teaching workshop (4) toseveral forms of Education Chief Residents (8–10). Thus,this issue of Academic Psychiatry is sure to give its readersnew models to fit their program’s unique needs and tomatch any level of availability of resident, faculty, andcurricular time.

The specific teaching techniques or combinations ofskills that the resident teachers were taught to use in theirteaching is truly dazzling. Some examples include:

• How to teach interviewing, mental status examination,and case formulation (11)• How to be an oral examiner (10)• How to give feedback (10, 11)• How to obtain and use student feedback in the contextof designing a course (6)

Received and accepted March 30, 2010. Dr. Polan is affiliated with theDepartment of Psychiatry at Weill-Cornell Medical College in NewYork. Dr. Riba is affiliated with the Department of Psychiatry at theUniversity of Michigan School of Medicine, Ann Arbor. Address corre-spondence to H. Jonathan Polan, M.D., Weill-Cornell Medical College,525 E 68th St., New York, NY 10021; jpolan@med.cornell.edu (e-mail).

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• The 1-minute preceptor and challenging teaching sce-narios (4)• Administrative and teaching skill development andtopics for supervision of junior residents: the disruptivestudent, professional attire, and professional boundaries(10)• How to plan, teach, and evaluate a course (12)• Research design, career development and how to de-velop a scholarly project (3)• Alternative teaching methods, supervision skills, re-search methods, and writing for publication (3)• Preparing or delivering a lecture (3, 9)• Small group leader (10)• Teach a seminar course (8)• Journal club (9)• Principles of good medical teaching (2)• Use of video, role play, case examples and electronicslides (6)• Being a professionalism coach, tutoring at-risk stu-dents (10)• Team-based learning modules that contained detailedlesson plans with instructions for facilitating team-basedlearning (13)• Active-learning game-show style team sessions (5)

Interestingly, in this collection of articles residentsshowed a special appreciation for active-learning, game-show formats as a teaching method and for psychotherapyas a topic area. One of the programs that prominentlyfeatured a game format was developed by residents—aPRITE review course taught to fellow residents (5). Thesecond format, team-based learning, was motivated by theauthors’ idea that team-based learning would overcomebarriers to teaching by residents in the clerkship (13),suggesting that faculty appreciate the residents’ affinity forsuch teaching modalities. Two other programs that weredeveloped by residents resulted from the residents’ per-ception that they could fill a need in the teaching of psy-chotherapy to fellow residents (8) and to medical students(6). One other resident-driven project was unique becauseit was developed by PGY-2s, who are usually the busiestpsychiatric residents with the most demanding clinicalworkloads. That they took the initiative and time to createa teaching manual for teaching medical students coreclerkship topics (7) indicates that the need and potentialfor residents to develop as teachers is strongly felt by theresidents themselves at all levels of training.

As important as what the residents taught to their stu-

dents is how the residents were taught to teach and whatthey were taught.

The techniques that were used to teach the residents toteach were also quite varied. For example:

• Regular supervision by the director of medical studenteducation (10) or residency director (9)• Mentoring (3, 6, 12)• Direct observation and feedback by a faculty supervi-sor of the resident’s lecture (6)• Training by faculty to be oral examiners (10)• Detailed lesson plans with instructions for facilitatingteam-based groups (13)• Faculty facilitated recollection of experiences of beingtaught as medical students (2)• Participation in faculty development programs (3)

Most of the projects had medical students as the teach-ing audience and so most of the benefits of these projectsaccrue to the medical students. However, a number of thereports call attention to the important benefits for the res-idents of learning how to be teachers: preparation for theboards and for assuming the attending role (9); encour-agement to embark on an academic career; and careerdevelopment (3).

Three of the articles describe PGY-4 education or teach-ing chief residents. Variants of this position are chiefresident for psychotherapy (8), a 2-month teaching resi-dent rotation that supervises junior residents and medicalstudents (9), and a chief resident for medical student ed-ucation (10). Although it is not precisely an educationchief or teaching chief resident position, one article (12)describes a novel elective for PGY-4s evocatively called“Growing Teachers” that mentors the senior residentthrough the design and teaching of a new course to aresident or medical student audience of his or her choice.

The most ambitious programs are three that place resi-dents in clinician-educator tracks from the PGY-2 throughPGY-4 years of their residencies (3). These three programsat the University of Michigan, Baylor, and the Universityof California at Davis emphasize the career developmentof their residents into educators by mentoring themthrough the production of curricula or scholarly projectsand teaching supervisory, research, and writing skills.

The Assessment Toolbox (1) searched PubMed andPsycINFO for the terms residents, residents as teachers,teaching skills, assessments, and rating scales and exam-ined the instruments yielded by this search for their psy-chometric properties. The authors found 11 fully accessi-ble tools that used self-report, learner evaluation, or one

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observed standardized teaching evaluation (OSTE). Mostof the instruments satisfied tests of validity and reliability.The article’s table is very helpful in indicating whetherspecific domains of knowledge, attitudes, or skills aremeasured by each tool. This review should facilitate rig-orous research on residents as teachers in the next crop ofresidents as teachers programs that we hope this issue willstimulate.

At the time of submission, Dr. Polan reported no competinginterests. Disclosures of Academic Psychiatry editors are pub-lished in each January issue.

References

1. Coverdale J, Ismail N, Mian A, et al: Toolbox for evaluatingresidents as teachers. Acad Psychiatry 2010; 34:298–301

2. Polan HJ: Experiential anamnesis and group consensus: aninnovative method to teach residents to teach. Acad Psychi-atry 2010; 34:287–290

3. Jibson MD, Hilty DM, Arlinghaus K, et al: Clinician-educa-tor tracks for residents: three pilot programs. Acad Psychiatry2010; 34:269–276

4. Dang K, Waddell AE, Lofchy J: Teaching to teach in To-ronto. Acad Psychiatry 2010; 34:277–281

5. Vautrot V, Festin FE, Bauer MS: The feasibility and effec-tiveness of a pilot resident-organized and -led knowledge-based review. Acad Psychiatry 2010; 34:258–262

6. Aboul-Fotouh F, Asghar-Ali AA: Therapy 101: a psycho-therapy curriculum for medical students. Acad Psychiatry2010; 34:248–252

7. Swainson J, Marsh M, Tibbo PG: Psychiatric residents asteachers: development and evaluation of a teaching manual.Acad Psychiatry 2010; 34:305–309

8. Ferri MJ, Stovall J, Bartek A, et al: The chief resident forpsychotherapy: a novel teaching role for senior residents.Acad Psychiatry 2010; 34:302–304

9. Daniels-Brady C, Rieder R: An assigned teaching residentrotation. Acad Psychiatry 2010; 34:263–268

10. Roman B, Khavari A, Hart D: The education chief resident inmedical student education: indicators of success. Acad Psy-chiatry 2010; 34:253–257

11. Lehmann SW: A longitudinal “teaching-to-teach” curriculumfor psychiatric residents. Acad Psychiatry 2010; 34:282–286

12. Martins AR, Arbuckle MR, Rojas AA, et al: Growing teach-ers: using electives to teach senior residents how to teach.Acad Psychiatry 2010; 34:291–293

13. Ravindranath D, Gay TL, Riba MB: Trainees as teachers inteam-based learning. Acad Psychiatry 2010; 34:294–297

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