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(Chest. 2005;128:401-406.)
© 2005 American College of Chest Physicians

Fellows as Teachers

The Teacher-Assistant Experience During Pulmonary Subspecialty Training*

Robert R. Kempainen, MD; Teal S. Hallstrand, MD, MPH; Bruce H. Culver, MD and Mark R. Tonelli, MD, MA

* From the Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, Washington.

Correspondence to: Robert Kempainen, MD, University of Minnesota School of Medicine, MMC 276, 420 Delaware St. SE, Minneapolis, MN 55455; e-mail: kempa001{at}umn.edu


   Abstract
TOP
 Abstract
Introduction
 Description of Teaching...
 Survey of Graduates
 Results
 Discussion
 References
 
Study objectives: Physicians undergoing medical subspecialty training, referred to as "fellows" in the United States, often serve as small group tutors. There are few reports, however, on whether fellows benefit from their experience teaching in the classroom. The purpose of this article is to describe the teacher-assistant requirement for fellows in a pulmonary and critical care training program and gain the perspectives of program graduates on their experiences as teacher assistants.

Design, setting, and participants: The structure of the teacher-assistant requirement is described in detail. We also surveyed 55 consecutive graduates of our Pulmonary and Critical Care Fellowship program located in the United States on the educational value of teaching pathophysiology to preclinical medical students.

Results: Fellows and one or two faculty members coteach groups of 15 to 25 second-year medical students during 22 h of case-based conferences over a 6-week period. Weekly meetings for teacher assistants foster improved teaching skills and provide insight into the basic tenets of structuring and implementing the course. Fellows receive formal and informal feedback on their performance. Fifty of 55 graduates (91%) returned the survey. Respondents rated the acquisition of teaching skills and knowledge of pulmonary pathophysiology as the most useful aspects of their experience. Eighty-seven percent rated their overall experience favorably, and 90% agreed that teaching the course should remain a curriculum requirement. The responses of physicians in academic and community practice were comparable.

Conclusions: Graduates of our Pulmonary and Critical Care Fellowship valued their teacher-assistant experience. This article may serve as a model for other subspecialty programs that are interested in formally incorporating teaching into their training program and may provide an impetus for the additional exploration of teacher-assistant experiences at other institutions.

Key Words: curricula • fellowship • physician-patient relations • teaching skills


   Introduction
TOP
 Abstract
 Introduction
Description of Teaching...
 Survey of Graduates
 Results
 Discussion
 References
 
Recent curricular reforms in medical schools have created a growing demand for clinical teachers. Many institutions are curtailing the use of lectures during the preclinical years in favor of problem-based, small-group formats that emphasize the clinical relevance of basic scientific knowledge.12 The greater use of community sites for ambulatory and inpatient clinical training will likely also increase the number of faculty involved in teaching.12 Academic medical centers, seeking to maintain high-quality instruction and to retain skilled teachers, are placing increasing emphasis on proficiency in teaching in determining the promotion of clinical faculty.3

The importance of developing good teaching skills during medical training is well-recognized.456 Physicians undergoing subspecialty training in the United States (commonly referred to as "fellows") typically obtain sustained classroom teaching experience while serving as teacher assistants. However, it is unclear whether teacher assistants receive the supervision and feedback necessary to maximally develop their ability to teach. Furthermore, we are unaware of studies examining the experience of fellows and nonmedical graduate students as teachers of residents and medical students.

For the past 25 years, physicians receiving subspecialty training in pulmonary and critical care medicine at the University of Washington have participated in an intense, sustained, supervised experience teaching respiratory pathophysiology to second-year medical students. The stated curricular objective of the teaching requirement is to improve fellows’ understanding of pulmonary pathophysiology, but there are a number of other potential benefits. The experience provides sustained contact with potential faculty mentors, is an opportunity to improve teaching skills, and potentially fosters interest in teaching and a career in academic medicine. To what extent fellows benefit from their teacher-assistant experience, however, was unclear. Given the lack of studies examining the value of the teacher-assistant experience for graduate students and fellows, the coauthors thought a description and evaluation of our programs’ teaching requirement would be of interest to other institutions. This article provides an overview of the teaching experience and summarizes the results of a cross-sectional survey of recent graduates of our program. We focused on graduates in order to better ascertain the enduring value of the teaching experience.


   Description of Teaching Experience
TOP
 Abstract
 Introduction
 Description of Teaching...
Survey of Graduates
 Results
 Discussion
 References
 
The second-year medical student course on the respiratory system consists of a series of lectures alternating with problem-based conferences. Pulmonary and critical care fellows are paired with one or two division faculty members in leading groups of 15 to 25 students through a total of 22 h of conference time over a 6-week period. Conferences serve as a review of topics covered in large group lectures but also expand on the clinical relevance of the material. Three to five clinical case presentations, each with a set of assigned questions, are used to guide the content of discussion. The format is designed to promote the active discussion and exchange of information among students and between instructors and students. Most fellows have minimal experience in classroom instruction, and these sessions offer a practical introduction to a variety of approaches to achieving an interactive learning environment. A commonly used format is for groups of students to study specific case presentations in advance of the conference and then lead a discussion of the problem at the subsequent conference.

Instructors meet weekly in order to review the cases for the coming week. This provides an opportunity to clarify learning objectives and for seasoned faculty to share insights on teaching the more challenging aspects of respiratory pathophysiology. The meetings foster improved teaching skills but also provide insight into the basic tenets of structuring and implementing the course. Fellows also review the performance of their students on the midterm examination. This serves to identify learners that may need individualized instruction but also allows faculty and fellows to assess their overall effectiveness and modify the format of subsequent conferences accordingly. In addition, instructors write test questions for the final examination, which then undergo group review at the final weekly meeting. Fellows thereby receive direct feedback on the ability of their questions to test key concepts. The exposure to course administration offered by these meetings may be particularly helpful to graduates entering careers in academic medicine or taking on active roles in continuing medical education.

Unlike giving an isolated student lecture, the teaching experience is sustained and coupled with ongoing informal feedback from faculty throughout the course. This gives fellows ample opportunity to apply new knowledge and to refine their teaching skills. At the conclusion of the term, faculty members offer a summary assessment of the fellows’ performance, and students complete an evaluation in which they rate their teacher assistant’s overall teaching effectiveness. Fellows receive their overall score with written comments from students. The report also contains the average scores for all of the fellows and faculty, thereby allowing teacher assistants to gauge their performance relative to their peers.


   Survey of Graduates
TOP
 Abstract
 Introduction
 Description of Teaching...
 Survey of Graduates
Results
 Discussion
 References
 
Materials and Methods
Subjects:
All of the consecutive graduates of the University of Washington Pulmonary and Critical Care Fellowship that entered the program in 1987 through 1997 were targeted for inclusion in the study. The names and mailing addresses of former fellows were obtained from division records and medical society directories.

Survey Content and Administration:
Our survey consisted of 16 questions that addressed demographic information and the educational value of being a teacher assistant. Respondents rated the value of the teaching experience for improving teaching skills, understanding pulmonary pathophysiology, preparing for specialty board examinations, and improving clinical skills using a five-point scale (1 = little or no value, 3 = moderate value, and 5 = great value). Respondents were also asked the extent to which they agreed with a series of questions using a five-point scale (1 = strongly disagree, 3 = unsure/neutral, 5 = strongly agree). These questions addressed graduates’ perceptions of working with faculty, receiving feedback from students, and whether the experience increased their interest in a career in academic medicine. Graduates received a maximum of two requests to participate. The survey was anonymous; the code linking subjects to their responses was destroyed prior to viewing completed surveys. The University of Washington Human Subjects Division approved the study.

Medical student ratings of faculty and fellow teacher assistants for the 5-year period from 1996 to 2000 were also compiled and are reported as mean (±SD) values for each group. Students responded to a single question about each of their teacher assistants: "Rate the overall teaching effectiveness of Leader XXX" using a six-point scale (1 = very poor to 6 = excellent).

Analysis:
Responses to survey questions were described by their mean and SD. The mean values according to the practice type and gender were compared using the unpaired Student t test. We grouped graduates in university-affiliated and community-affiliated teaching hospitals into a single category (academic medicine). Statistical significance was defined as a two-tailed p value of < 0.05.


   Results
TOP
 Abstract
 Introduction
 Description of Teaching...
 Survey of Graduates
 Results
Discussion
 References
 
Fifty of 55 graduates (91%) responded to the survey. Four of the five nonresponders currently practice at an academic medical center; the practice setting of the fifth nonresponder is unknown. Five respondents did not teach the course during fellowship. Our analysis includes data from the remaining 45 respondents, which represents a minimum of 90% of graduates that taught the course (45 of 50). The majority of respondents were male, and the group is divided equally between community-based and university-based practice (see Table 1 ). Of note, most graduates served as teacher assistants for ≥ 2 years, although they are required to teach only a single semester.


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  		Table 1. Characteristics of Graduates Responding to Survey*

 
Graduates rated the acquisition of teaching skills and knowledge of pulmonary pathophysiology as the most valuable aspects of being teacher assistants (see Fig 1 ). Nearly all of the graduates (95%) indicated that being an instructor was of at least "moderate value," and one third thought it was of "great value" for improving teaching skills. Similarly, nearly two thirds said their experience was of great value for learning pulmonary pathophysiology, and all of the respondents indicated it was of at least "moderate value" for this purpose. The graduates overall viewed working with faculty coleaders and the feedback they received from students positively, although individual impressions varied substantially. On average, graduates said that teaching pulmonary pathophysiology was moderately helpful in preparing for pulmonary and critical care medicine specialty board examinations, but opinions were widely divergent on this issue. There also was little agreement on whether teaching the course improved clinical skills. Over one third of graduates thought it was of lesser value, but nearly one third indicated that the acquired knowledge was helpful in their clinical practice.



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  		Figure 1. Ratings of the value of teaching preclinical medical students pulmonary pathophysiology during subspecialty training. The results are described by the mean (thick line) and SD (whiskers).

 
The vast majority of graduates viewed being a teacher assistant positively, with 87% of the graduates rating their overall experience ≥ 4 on a five-point scale. More than 90% of respondents agreed that teaching the course should remain a required part of the fellowship curriculum, and > 75% indicated that the time they invested in the course was acceptable given the benefits. One respondent commented, "My experience (teaching the course) has had a profound influence on my career as both a clinician and teacher." More than one half of graduates said that the teacher-assistant experience had a negative or neutral impact on their interest in a career in academic medicine, and only 14% thought strongly that it enhanced their interest. Of note, the responses of graduates in community practice did not differ significantly from those in academic medicine for any of the survey questions. The results did not vary by gender or by the number of times the respondent taught the course.

During the 5-year period of 1996 through 2000, medical students used a six-point scale to rate the overall teaching effectiveness of 59 faculty and 46 fellow teacher assistants (1 = very poor, 6 = excellent). The mean faculty rating was 5.06 compared with a mean fellow rating of 4.95.


   Discussion
TOP
 Abstract
 Introduction
 Description of Teaching...
 Survey of Graduates
 Results
 Discussion
References
 
The survey results indicate that graduates of the program valued their experience as teacher assistants. Our findings suggest that support for a teaching requirement stems from the fellows’ positive interactions with faculty, the improvement in their teaching skills, and the gains in their understanding of respiratory pathophysiology. Interestingly, the teacher-assistant experience increased the interest in an academic career in only a minority of graduates. This may indicate that success and interest in research, rather than in teaching, is the predominant determinant of the decision to pursue an academic career. Regardless, the vast majority of respondents had a positive overall impression of being a teacher assistant and said that the teaching requirement should remain a required component of the curriculum.

Graduates in community practice and academic medicine valued the teaching experience equally, which suggests a need for sound teaching skills among all physicians. Effective consultation entails the timely and accurate exchange of knowledge between physicians. Furthermore, clinicians are routinely required to teach complex concepts to patients with differing educational and sociocultural backgrounds. Patients and their families often desire a thorough explanation of the treatment, prognosis, and pathophysiology of disease. Studies, however, indicate that although patient education is a major determinant of patient satisfaction, physicians underestimate the importance that patients place on receiving health-related information from their providers.78910

As a whole, respondents viewed the experience as only moderately helpful in improving their clinical skills or as a means to prepare for specialty board exams. However, respondents held widely divergent opinions on these issues. Perhaps this lack of consensus reflects differences in the cognitive processes by which physicians solve problems. That is, some graduates may rely heavily on physiologic rationale in their approach to clinical problem solving, whereas for others there is a disconnect between "book learning" and clinical practice. A limited overlap between material covered in the student course and material on board tests or simply a paucity of board questions focused on respiratory pathophysiology may also have limited the utility of the teaching experience in preparing for board exams.

The literature contains numerous descriptions61112131415161718 of workshops that are shown to improve the teaching ability of house officers. These programs largely consist of intensive 1-day to 2-day sessions designed to improve teaching on the hospital wards, but they do not necessarily include supervision of the trainee during an actual teaching encounter and are not entirely applicable to teaching in the classroom setting.613 We are unaware of reported interventions to improve the teaching skills of physicians undergoing internal medicine subspecialty training, although a survey19 of fellows in general internal medicine identified a desire for greater curricular emphasis on improving teaching skills.

The teaching experience provided to our fellows offers some potential advantages over many teaching skills programs for residents. The teaching activity occurs over a sustained period of time, is closely supervised, and entails actual teaching encounters. In addition, the emphasis on classroom teaching may be more applicable to graduates making the transition into faculty positions. Optimizing the classroom teaching skills of teacher assistants may become increasingly important given the rising use of small group learning formats in the preclinical years and the consequent need for larger numbers of skilled clinical teachers.12 The current dissemination of clinical teaching into ambulatory, community-based sites is also heightening the need for clinical teachers, although not necessarily faculty who are skilled in classroom instruction.12

Our study has a number of limitations. We did not attempt to quantify improvements in teaching ability as measured by the students or faculty following the course. Furthermore, the strengths and weaknesses particular to our faculty, fellows, and students could make this approach less applicable at other institutions. For instance, some institutions may rely on fellows’ independent teaching contributions in order to meet divisional teaching obligations. Our teacher-assistant experience, however, requires faculty to be present as coteachers, and, hence, the involvement of fellows does not impact the amount of teaching time required of division faculty.

In addition, the elapsed time between teaching the course and completing the survey may have compromised graduates ability to recall the details of their experience. Our survey of program graduates offers the potential advantage of eliciting more candid responses than a survey of fellows, whose position within the program is less well established. However, graduates’ favorable impressions of the teaching requirement may be falsely buoyed by an overall positive recollection of their time spent in the fellowship. One of the limitations of many studies evaluating teaching skills workshops is the unclear duration of benefit following the intervention. Only practicing physicians were included in our survey, which suggests that the perceived benefits of the teaching-assistant requirement extend beyond the training years. Another concern is that the benefits derived by fellows would be offset if their inclusion as instructors resulted in a compromised learning experience for the medical students. This is unlikely to be the case given that faculty and fellows received comparable ratings for teaching effectiveness from students.

We have presented a summary of our teacher-assistant requirement for pulmonary and critical care fellows. Our survey found that the fellows perceived lasting benefits from participating in a sustained, supervised teaching experience. Regardless of whether a training program is striving to train academic physicians or to elevate the quality of community practice, it is imperative that the teacher-assistant role serves an educational purpose for all fellows. In our view, time for such activities must be carved out of clinical and research responsibilities, even in the current environment of increasing pressure to provide more clinical service. Schools of medicine should recognize the value of fellows to the educational mission and find incentives to reward participating divisions accordingly. This report may serve as a useful model for other subspecialty training programs that are interested in formally incorporating teaching into their curriculum and may provide an impetus for additional discussion and assessment of the historically important and essential teaching role of fellows.

Received for publication August 10, 2004. Accepted for publication December 22, 2004.


   References
TOP
 Abstract
 Introduction
 Description of Teaching...
 Survey of Graduates
 Results
 Discussion
 References
 

  1. Whitcomb, ME, Anderson, MB (1999) Transformation of medical students’ education: work in progress and continuing challenges. Acad Med 74,1076-1079[ISI][Medline]
  2. Jones, R, Higgs, R, de Angelis, C, et al Changing face of medical curricula. Lancet 2001;357,699-703[CrossRef][ISI][Medline]
  3. Beasley, BW, Wright, SM, Cofrancesco, J, Jr, et al Promotion criteria for clinician-educators in the United States and Canada: a survey of promotion committee chairpersons. JAMA 1997;278,723-728[Abstract]
  4. Bordley, DR, Litzelman, DK Preparing residents to become more effective teachers: a priority for internal medicine. Am J Med 2000;109,693-696[CrossRef][ISI][Medline]
  5. Busari, JO, Scherpbier, AJ, van der Vleuten, CP, et al The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students. Med Educ 2003;37,241-247[CrossRef][ISI][Medline]
  6. Morrison, EH, Friedland, JA, Boker, J, et al Residents-as-teachers training in U.S. residency programs and offices of graduate medical education. Acad Med 2001;76,S1-S4[CrossRef][ISI][Medline]
  7. Keating, NL, Green, DC, Kao, AC, et al How are patients’specific ambulatory care experiences related to trust, satisfaction, and considering changing physicians? J Gen Intern Med 2002;17,29-39[CrossRef][ISI][Medline]
  8. Laine, C, Davidoff, F, Lewis, CE, et al Important elements of outpatient care: a comparison of patient‘s and physician’s opinions. Ann Intern Med 1996;125,640-645[Abstract/Free Full Text]
  9. Hickson, GB, Clayton, EC, Githens, PB, et al Factors that prompted families to file malpractice claims following perinatal injury. JAMA 1992;287,1359-1363
  10. Moore, PJ Medical malpractice: the effect of doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med 2000;173,244-250[CrossRef][ISI][Medline]
  11. Wipf, JE, Orlander, JD, Anderson, JJ The effect of a teaching skills course on interns’ and students’ evaluations of their resident-teachers. Acad Med 1999;74,938-942[ISI][Medline]
  12. Morrison, EH, Rucker, L, Boker, JR, et al A pilot randomized, controlled trial of a longitudinal residents-as-teachers curriculum. Acad Med 2003;78,722-729[ISI][Medline]
  13. Bing-You, RG, Tooker, J Teaching skills improvement programmes in US internal medicine residencies. Med Educ 1993;27,259-265[ISI][Medline]
  14. Troupin, RH The mini-fellowship in teaching: a senior resident elective. Invest Radiol 1990;25,751-753[ISI][Medline]
  15. Mitchell, S, Cook, J, Densen, P A teaching rotation for residents. Acad Med 1994;69,434[CrossRef][ISI][Medline]
  16. Litzelman, DK, Stratos, GA, Skeff, KM The effect of a clinical teaching retreat on resident‘s teaching skills. Acad Med 1994;69,433[Medline]
  17. Dunnington, GL, DaRosa, D A prospective randomized trial of a residents-as-teachers training program. Acad Med 1998;73,696-700[ISI][Medline]
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  19. Orlander, JD, Callahan, CM Fellowship training in academic general internal medicine: a curriculum survey. J Gen Intern Med 1991;6,460-465[ISI][Medline]




This Article
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