Development of a residents-as-teachers curriculum for neurosurgical training programs

Sarah Nguyen MD1, Kyril L. Cole MPH2, Kathleen H. Timme MD, MEd3, and Randy L. Jensen MD, PhD, MHPE1
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  • 1 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City;
  • | 2 School of Medicine, University of Utah, Salt Lake City; and
  • | 3 Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Neurosurgery residents spend a significant amount of their time teaching patients, families, students, residents, and other health professionals. To help ensure competence in their residents’ teaching abilities, many specialties have established formal residents-as-teachers (RAT) curricula; however, such formalized curricula are often lacking in neurosurgery programs. The authors’ goal was to develop and implement a formal RAT curriculum, designed with neurosurgery residents’ other responsibilities in mind, to improve residents’ formal and informal teaching abilities. Here, the authors report on the design of a formalized teaching curriculum tailored for the needs of neurosurgical residents, with a focus on deliberate practice and minimal time needed for preparation. The curriculum, designed using Kern’s 6 steps of curriculum design as a framework, comprises 5 lecture series spread over 3 years, repeated twice through a resident’s training, with each lecture series outlined with its respective topics and objectives. Opportunities for observed teaching as well as informal and formal evaluation will be provided to residents. The program will be evaluated on a yearly basis using direct and anonymized resident feedback on the RAT curriculum. Measures of program success will also include pre- and postprogram medical student and peer evaluation of residents. These data will be used for continual improvement of the curriculum as it is implemented. Successes and shortcomings of this program will be disseminated by publication, presentations, and placement on the authors’ department website and social media. This paper may serve as a foundation for other neurosurgical programs to develop RAT curricula for greater enhancement of resident teaching abilities.

ABBREVIATIONS

ACGME = Accreditation Council for Graduate Medical Education; RAT = residents-as-teachers.

Neurosurgery residents spend a significant amount of their time teaching patients, families, students, residents, and other health professionals. To help ensure competence in their residents’ teaching abilities, many specialties have established formal residents-as-teachers (RAT) curricula; however, such formalized curricula are often lacking in neurosurgery programs. The authors’ goal was to develop and implement a formal RAT curriculum, designed with neurosurgery residents’ other responsibilities in mind, to improve residents’ formal and informal teaching abilities. Here, the authors report on the design of a formalized teaching curriculum tailored for the needs of neurosurgical residents, with a focus on deliberate practice and minimal time needed for preparation. The curriculum, designed using Kern’s 6 steps of curriculum design as a framework, comprises 5 lecture series spread over 3 years, repeated twice through a resident’s training, with each lecture series outlined with its respective topics and objectives. Opportunities for observed teaching as well as informal and formal evaluation will be provided to residents. The program will be evaluated on a yearly basis using direct and anonymized resident feedback on the RAT curriculum. Measures of program success will also include pre- and postprogram medical student and peer evaluation of residents. These data will be used for continual improvement of the curriculum as it is implemented. Successes and shortcomings of this program will be disseminated by publication, presentations, and placement on the authors’ department website and social media. This paper may serve as a foundation for other neurosurgical programs to develop RAT curricula for greater enhancement of resident teaching abilities.

Residents are important educators on clinical teams, with some estimating that residents spend up to 20% of their time teaching.1,2 In alignment with the Accreditation Council for Graduate Medical Education (ACGME) core competency that residents must demonstrate competence in “educating patients, families, students, residents, and other health professionals,”3 many specialties have established formal residents-as-teachers (RAT) curricula. Although RAT programs are becoming more common in residency programs generally, they are somewhat lacking in surgical specialty programs, including neurosurgery.4 In this paper, we outline our newly developed RAT curriculum for the University of Utah neurosurgery residency program, which was designed to help meet that educational need for our residents while providing a foundation for other programs to do the same.

Curriculum

Program Development

We formulated our curriculum using Kern’s 6 steps of curriculum design as a framework (Table 1).5 We began by identifying our educational need, notably the lack of a formal teaching curriculum for the neurosurgery residents. As with other residency programs, neurosurgery residents spend a large portion of their time teaching patients, peers, and students; however, a formal curriculum and evaluation program had not yet been developed. The primary goal of this endeavor was to improve residents’ formal and informal teaching skills. We designed our curriculum with a focus on deliberate practice,6 allowing for didactic sessions followed by time for practice, coaching, and immediate feedback. Additional goals of this design included maximizing learning during session time and minimizing preparation time to increase buy-in from residents and decrease the additional work for already-busy residents.

TABLE 1.

Kern’s 6 steps of curriculum design

StepNeurosurgery-Specific Description
Problem identificationResidents as teachers
Needs assessmentResidents teach frequently but receive little or no formal training
Goals & objectivesImprove residents’ teaching skills
Educational strategiesDidactic & practice-based sessions w/ immediate feedback
ImplementationQuarterly hour-long sessions w/ time for didactic lecture, active practice, & feedback/debriefing
EvaluationResident feedback on teaching curricula & evaluation of residents’ teaching ability over time

Based on Thomas et al., 2016.5

This specific development of this curriculum was based on a pilot study done in 3 interactive sessions with our resident group by the senior author (R.L.J.). One session included an informal poll-focused group discussion of what our residents knew about adult learning principles and how they assessed their desire to be better teachers. The second was a formal lecture on adult learning followed by a debriefing session by the resident learners on what was useful and what was not helpful. The third session was an interactive practice session on giving and receiving feedback with an after-session discussion of what worked and what did not. The results of this initial work were then used to develop the curriculum described here.

Educational Objectives

This curriculum aims to provide formalized didactics as well as deliberate practice sessions to improve residents’ teaching skills. Neurosurgery residents have many opportunities and circumstances in which they teach. These begin with the patient, including educating the patient at the bedside, in the emergency department, and in clinic about their diagnosis, treatment options, prognosis, and surgery. These opportunities continue with medical students and junior residents on rounds, at the bedside, and in the operating room. Because residents have so many opportunities to teach, it is imperative that they have the necessary skills to maximize these teaching and learning opportunities. The topic of “teaching when there is no time to teach” is a common discussion among medical educators. This curriculum includes discussions of how to recognize situations that lend to teaching. How to break down a complicated topic into smaller sections that can be discussed in a limited time frame is also a learning objective. These encounters can be extemporaneously precipitated by a patient, a learner, or the teacher themselves. More informal experiences are found as a senior resident discusses the upcoming case with the junior resident as they scrub prior to a case or as a junior resident and medical student discuss a consultation when walking to the emergency department. These are learner-centered, active learning moments based on experiential and problem-based situations and may prove to be one of the most effective methods of teaching clinical medicine. When done correctly, a positive learning environment is created, especially when both learner and teacher give feedback to each other. More formalized opportunities include teaching during grand rounds or teaching lectures to medical students.

As we designed this curriculum, we were also mindful of the many other roles and responsibilities residents filled and sought to create a beneficial curriculum that would not add significantly to the residents’ workload but still provide useful instruction.

Timeline and Plan for Implementation

This curriculum comprises 5 lecture series spread over a 3-year time span, in which each resident would complete the curriculum once as a junior resident and again as a senior resident (Table 2). Residents in postgraduate year 7 and formal fellows would not take part in the curriculum. Fellowship is a time to practice the skills gained in this curriculum and transition into “experiential learning” rather than structured sessions. If fellows in our program have been exposed to the curriculum over several years, we believe that fellowship is a more appropriate opportunity for focused learning in their chosen subspecialty. For fellows who come from another program and have not been exposed to our RAT curriculum, we could include them in these sessions if they choose.

TABLE 2.

Curriculum time frame

PGYLecture Series
PGY-1Series 1 & 2
PGY-2Series 3
PGY-3Series 4 & 5
PGY-4Series 1 & 2
PGY-5Series 3
PGY-6Series 4 & 5
PGY-7*

PGY = postgraduate year.

Residents in PGY-7 would not take part in the curriculum.

Each lecture series contains 2 to 3 sessions that will occur quarterly. Each session will begin with a 20-minute didactic lecture, followed by a 30-minute active practice session, allowing for 10 minutes of feedback and debriefing the session. Session topics and objectives are outlined in Table 3. Each session will have an associated optional reading to allow residents to further explore each topic on their own time as they see fit. Interested faculty (program director, associate program director, and other department educational leadership faculty) will deliver the short lecture and facilitate the practice sessions. We foresee that multiple faculty members might be necessary for each session to give each resident the most in-depth learning experience. These sessions will be conducted during previously scheduled resident education hours so as not to increase resident education hours or impinge on resident work hours. The didactic lectures will be in the form of Microsoft PowerPoint slides and available on our website for review by our residents and dissemination to other programs as the program matures, along with a detailed outline of learning objectives for each lecture with their respective supplemental material.

TABLE 3.

RAT curriculum topic outline

SeriesLecture TopicsObjectives
Series 1: Introduction to Adult Education PrinciplesIntroduction to RAT curriculumReview curriculum content & objectives; understand purpose of RAT curriculum
Introduction to adult education principlesUnderstand needs of the adult learner; review best practices for education of adults
Series 2: Formal Teaching SkillsTeaching surgical anatomy Understand principles of teaching surgical anatomy; practice teaching surgically relevant anatomy to students at various stages of training (i.e., medical student, junior resident, senior resident)
Optimizing presentation toolsIdentify best practices in optimizing presentations using standard platforms (e.g., PowerPoint, chalk talk); improve presentation to increase interest for audience
Series 3: Informal Teaching SkillsPrinciples of just-in-time teachingUnderstand principle of just-in-time teaching; practice short teaching moments
Teaching at the scrub sinkReview techniques to improve preop review & teaching prior to surgeries; identify daily brief teaching opportunities; practice teaching brief clinically & surgically relevant topics to peers & near-peers
Teaching under the microscopeUnderstand best practices for intraop teaching & coaching; practice teaching technical skills including suturing, microsurgical technique, etc.
Series 4: Patient EducationEducating at bedsideDiscuss opportunities & barriers to patient education; practice educating a patient in the settings of clinic, inpatient, emergency department, & perioperatively
How to implement patient education resourcesReview available patient education resources; identify patient education resources to use in patient interactions
Series 5: Feedback & AssessmentHow to give feedback when there is a problemDiscuss principles of providing feedback & conflict resolution; practice providing feedback to a peer or near-peer
Good to great: how to give feedback when there is not a problem Discuss techniques for providing feedback to encourage additional growth; practice providing feedback to a peer or near-peer who seeks to improve

Assessment

Residents will have the opportunity to provide feedback on the session during each session’s final debrief/feedback portion. Residents will also provide anonymized feedback on the RAT curriculum on the annual program survey. This will allow for continual improvement of the curriculum as it is implemented. Residents’ teaching will also be evaluated as a portion of this program. Informal feedback will be provided during the active practice portion of each session as well as during each resident’s annual review. Residents will undergo formal evaluation of their teaching skills using the Cleveland Clinic’s Clinical Teaching Effectiveness instrument.7 This instrument will be completed by medical students who rotate on the neurosurgery service and the residents’ peers to assess baseline teaching abilities of all residents prior to initiation of this curriculum and annually to evaluate the effectiveness of this curriculum in improving residents’ teaching abilities.

One of the tangential goals of improving the teaching skills of residents is the improvement of the resident as a surgeon. To this end, ACGME competency milestones will also be tracked for individual residents both before and after implementation of this curriculum to evaluate whether residents improve across other milestones because of improving their teaching skills. Although many of the “Medical Knowledge” milestones may not be related to an RAT curriculum, the “Practice-Based Learning and Improvement 3: Mentoring and Teaching” milestone is directly related to the curriculum, and “Professionalism,” “Interpersonal and Communication Skills,” and “Practice-Based Learning and Improvement” milestones may be indirectly improved.

Resident feedback and data from the clinical teaching instrument will be used in the evaluation of the program annually. Adjustments in the curriculum will occur with each round of the curriculum based on these evaluations. Any success or difficulties encountered in this curriculum will be disseminated in the form of a program director’s toolkit placed on our website and that of the Society of Neurological Surgeons, or by expanding processes to other programs or publishing the curriculum.

Discussion

A key conceptual framework used in creating this program was Ericsson’s concept of deliberate practice.6 Surgical specialties, such as neurosurgery, often use deliberate practice and coaching as trainees practice procedures and receive immediate feedback as they learn to operate. We used this concept to mirror the learning environment that residents are already accustomed to, namely, active, deliberate practice, into the teaching environment of this RAT curriculum. During the active practice sessions associated with each learning session, residents will practice the teaching skill they just learned in the didactic portion of the session. The faculty facilitators described above will help guide these sessions and provide immediate feedback during this time.

The curriculum we have proposed is focused on training specific teaching skills, such as just-in-time teaching, presentations, and procedural teaching. Neurosurgical concepts and skills are covered in other areas of the residency training program, including weekly lectures, grand rounds, and teaching provided by senior residents, fellows, and attendings. Conceptual knowledge is evaluated throughout the program, specifically on resident evaluations and based on milestone competencies. One aspect lacking in our RAT curriculum is a formal method to evaluate conceptual knowledge prior to allowing residents to teach the concept to a learner. Our initial thinking is that as residents learn to teach more effectively, their conceptual knowledge will also improve as they teach these concepts. As this curriculum matures, we may find that a formal evaluation of competence or minimal proficiency to teach a given concept or skill is necessary before allowing a resident to teach others these concepts or skills.

One key concern in adding more sessions to neurosurgery resident didactics is the increased time and work. Residents are incredibly busy, balancing clinical work, research, and study time, and it can be difficult to gain buy-in from residents when instituting a new curriculum. To this end, we designed sessions to fit within previously scheduled educational time, requiring no additional time away from clinical duties for residents. This means that the sessions occur less commonly than those in some other programs, but we established that the frequency is not significantly below average for surgical program RAT curricula.4 The length and frequency of sessions will be a key point of evaluation in the resident surveys.

Here, we have outlined our planned RAT program. This curriculum will provide didactic and active practice sessions for neurosurgery residents quarterly, during previously scheduled educational time. Residents will have the opportunity to evaluate the program informally during the sessions and formally on annual program surveys. Residents’ teaching skills will be evaluated formally with a validated teaching instrument and informally by student and faculty evaluations and comments. These data will be used to further edit and optimize the teaching curriculum to create an environment of excellent educators within the neurosurgery residency program.

Conclusions

The development of a formal RAT curriculum, as done in many other specialties, could have great benefit in helping neurosurgery residents comfortably develop their teaching abilities inside and outside the operating room. Here, we present the planned RAT curriculum for our neurosurgery residency program, including a structured timeline with assessment plans. This may serve as a foundation for other neurosurgery residency programs to develop and implement their own RAT curricula with greater ease.

Acknowledgments

We would like to acknowledge Kristin Kraus, MSc, for her expert editing and review of this paper.

Disclosures

Dr. Jensen: consultant for Medtronic.

Author Contributions

Conception and design: Jensen, Timme. Acquisition of data: Cole. Drafting the article: all authors. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Jensen. Implementation: Nguyen.

References

  • 1

    Zabar S, Hanley K, Stevens DL, et al. Measuring the competence of residents as teachers. J Gen Intern Med. 2004;19(5 Pt 2):530533.

  • 2

    Messman A, Kryzaniak SM, Alden S, Pasirstein MJ, Chan TM. Recommendations for the development and implementation of a residents as teachers curriculum. Cureus. 2018;10(7):e3053.

    • Search Google Scholar
    • Export Citation
  • 3

    ACGME Common Program Requirements (Residency). ACGME; 2020. https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRResidency2020.pdf

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  • 4

    Geary A, Hess DT, Pernar LIM. Resident-as-teacher programs in general surgery residency—a review of published curricula. Am J Surg. 2019;217(2):209213.

    • Crossref
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  • 5

    Thomas P, Kern D, Hughes M, Chen B. Curriculum Development for Medical Education. 3rd ed. Johns Hopkins University Press; 2016.

  • 6

    Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 suppl):S70S81.

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  • 7

    Copeland HL, Hewson MG. Developing and testing an instrument to measure the effectiveness of clinical teaching in an academic medical center. Acad Med. 2000;75(2):161166.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 1

    Zabar S, Hanley K, Stevens DL, et al. Measuring the competence of residents as teachers. J Gen Intern Med. 2004;19(5 Pt 2):530533.

  • 2

    Messman A, Kryzaniak SM, Alden S, Pasirstein MJ, Chan TM. Recommendations for the development and implementation of a residents as teachers curriculum. Cureus. 2018;10(7):e3053.

    • Search Google Scholar
    • Export Citation
  • 3

    ACGME Common Program Requirements (Residency). ACGME; 2020. https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRResidency2020.pdf

    • Search Google Scholar
    • Export Citation
  • 4

    Geary A, Hess DT, Pernar LIM. Resident-as-teacher programs in general surgery residency—a review of published curricula. Am J Surg. 2019;217(2):209213.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Thomas P, Kern D, Hughes M, Chen B. Curriculum Development for Medical Education. 3rd ed. Johns Hopkins University Press; 2016.

  • 6

    Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 suppl):S70S81.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Copeland HL, Hewson MG. Developing and testing an instrument to measure the effectiveness of clinical teaching in an academic medical center. Acad Med. 2000;75(2):161166.

    • Crossref
    • Search Google Scholar
    • Export Citation

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