Anesthesiology, Perioperative and Pain Medicine

The New Face of Medical Education: Stanford Teaching Scholars

Teaching Scholars

An innovative faculty education program at Stanford promises to make physicians better educators and transform the experience of medical residents

On a recent Monday afternoon at Stanford Hospital, faculty member Dr. Aileen Adriano sat down with a first-year anesthesia resident to provide feedback on his efforts that day in the outpatient surgery center. The resident had performed an intubation–the insertion of a tube into the airway–that had given him some difficulty. During his debriefing with Dr. Adriano, however, the resident learned that there is no completely accurate way of predicting which patients will be difficult to intubate. Instead of narrowly focusing on the intubation, Dr. Adriano also examined all aspects of his clinical training, praising his professionalism and the positive doctor-patient relationship he had demonstrated. The resident’s learning was deepened, and he left the meeting feeling encouraged by his progress.

This interaction was emblematic of the modern teaching methods cultivated by a groundbreaking new program in Stanford’s Department of Anesthesia. In the popular culture, the image of medical education remains that of senior physicians grilling harried residents, but in fact, today’s medical educators instead embrace more effective teaching methods that encourage residents to ask questions, admit when they don’t know something, and participate more fully in their own education. The department’s program promises to advance that trend by training young faculty to become innovative teachers who create an environment that fosters learning.

The Teaching Scholars Program, now in its third year, gives participating faculty an opportunity to learn the latest teaching methodologies, as well as a chance to put what they’ve learned into practice by redesigning various aspects of the resident curriculum. One of the early accomplishments has been the development of a month-long mentoring program for new residents. Residents have responded enthusiastically to these changes, and other departments and medical schools are already showing an interest in adopting the Teaching Scholars Program.

Residency Director Dr. Alex Macario, one of the architects of the new program, says, “We hope this program will make our faculty as skilled in education theory and tools as they already are in clinical care.”

Teaching the Teachers

The Teaching Scholars Program began in 2007 as the brainchild of Dr. Alice Edler, Assistant Professor of Anesthesia, who wanted to find a way to promote the teaching abilities of young faculty. Dr. Ronald Pearl, Chair of the Anesthesia Department, provided the internal funding for the program, and Dr. Macario selected the six junior faculty members who would make up the first cohort: Drs. Aileen Adriano, Michael Chen, Jeremy Collins, Kyle Harrison, Daryl Oakes-Gavi, and. RJ Ramamurthi.

The program allows the faculty to trade some of their clinical days to attend the nationally-renowned Clinical Teaching Program offered by the Stanford Faculty Development Center. This 16-hour course developed by Dr. Kelley Skeff, Associate Chair for Educational Programs, and educational psychologist Dr. Georgette Stratos communicates the latest in teaching methodologies gleaned from decades of research in the field. In addition, the scholars have the opportunity to attend other special teaching seminars and a national education meeting, such as the annual meeting of the Society for Education in Anesthesia.

The Teaching Scholars Program is based on the premise that teaching is a skill that must be taught like any other. “No one is born a great teacher,” Dr. Harrison says. Dr. Oakes-Gavi agrees: “We’re often made to feel that teaching ability should be automatic, and there’s no reason why it should be.”

Yet medical school provides no formal training in the art of teaching. Without such training, many clinicians assume their role as teachers is to convey information, a one-way flow from the teacher to the student, whereas the student’s role is to passively absorb and parrot back the learning. The trouble with this old-style model is that it doesn’t produce effective learning.

Dr. Daryl Oakes-Gavi with Dr. Stephen Fink

“If you only ask the questions residents know how to answer, you haven’t really taught them anything,” Dr. Oakes-Gavi says. “You want to get to the place where they can’t answer questions.” By creating a scenario where residents don’t need to know all the answers already, “You get a much deeper learning opportunity for them.”

In order to do that, a clinician needs to provide a positive learning climate, says Dr. Skeff, one that is “open and safe enough for learners to be able to bring up and acknowledge their limitations and have them be addressed as part of the teaching program.”

The Science of Teaching

Dr. Skeff can speak with authority about the factors that promote learning, based on more than 30 years he has devoted to analyzing teaching behaviors and observing what works and what doesn’t. His Clinical Teaching Program breaks down teaching into seven core components, which include areas such as setting goals, promoting understanding and retention of the material, evaluating what’s been learned, and providing feedback to the student. For each component, the teachers-in-training learn not only the concepts, but also the specific behaviors they can use to improve their teaching in that area. This organized and systematic approach, Dr. Skeff says, gives teachers a mechanism for analyzing and improving their teaching that they will use for the rest of their careers.

The first cohort of Teaching Scholars says the effect of Dr. Skeff’s seminars has been “fantastic” and “inspirational.” “It changed how I thought about what my job was as a teacher,” Dr. Oakes-Gavi says. She learned not to be the person doing all the talking, but instead to listen more to the student, finding out what his previous knowledge was, what his questions were and how well he had learned what she taught. “The education process has to be a dialogue.”

The scholars now give residents more control over the process of learning. “I’m getting the residents to ask for what they need instead of me dictating to them what they should learn,” Dr. Ramamurthi says. Getting the residents more involved also allows him to learn from them, he says; for example, a resident may have read an article suggesting a better way to perform a technique.

The seminars not only inspired the teaching scholars  to think about teaching in a different way, but also to get more involved in resident education and to collaborate more with other faculty on new innovations. “You’re always looking for potential projects,” Dr. Adriano says. “You’re always thinking about what you could do to make things better.”

Reshaping the Resident Experience

As part of the Teaching Scholars Program, each participant took on a project to revise some aspect of the residents’ curriculum. A common theme running through all the projects was the desire to provide more structure to residents’ education and ensure that all students learn a basic set of knowledge and skills.

These curriculum changes have already enhanced the residents’ experience, most dramatically in the development of a month-long mentoring program for new anesthesia residents. The mentoring curriculum was established by Dr. Adriano, working closely with resident Dr. Ryan Greene, and later revised with the help of third-year resident Dr. Jerry Ingrande. The program consists of an afternoon lecture series, a tutorial textbook on core topics, and the establishment of a mentoring relationship between new residents and senior residents and attendings that allows incoming residents to shadow the senior staff.

The mentoring program gives new residents a strong foundation to build their year upon, Dr. Ingrande says. Because most medical schools don’t train students in the practice of anesthesia, the learning curve can be quite steep for freshmen residents. “At some institutions, residents would essentially be thrown into the fire. They would show up on their first day and be expected to work and function as new anesthesia residents,” Dr. Ingrande says.

But for the past two years, residents in Stanford’s Department of Anesthesia have had the benefit of the month-long mentoring, and the response from the residents has been “phenomenal,” Dr. Ingrande says. Residents reported they felt more comfortable in the operating room, had the opportunity to ask more questions, and developed a solid footing for further learning.

Evolving Curriculum

Other faculty projects are bearing fruit as well. Dr. Ramamurthi was interested in assessing how well operating room teaching was communicating the six ACGME core competencies to residents, including values such as professionalism, communication skills, and system-based practice. He considered assessing this with a questionnaire, but realized that would test only the residents’ knowledge. A session at the June 2008 meeting of the Society for Education in Anesthesiology inspired him to think of a new approach. He developed a Personal Learning Portfolio that empowers the resident to take responsibility for her own education. On every day the resident spends in the operating room, she will assess how well she learned all of the topics covered. If there are any deficiencies, the resident is encouraged to talk to the scheduler and make sure she has the opportunity to do all the techniques.

The portfolio, rolled out in the spring, had already gotten enthusiastic feedback from residents who participated in its creation. “Residents loved the idea of having some kind of structure to overall learning,” Dr. Ramamurthi says. “One common criticism from residents has been that teaching is not uniform across the board, and some get it, some don’t get it.”

To rectify some of these teaching inequalities, Dr. Oakes-Gavi provided a formalized curriculum for the cardiac anesthesia fellows, and she plans to develop a similar curriculum for the cardiac anesthesia residents. Because residents get only two months in cardiac anesthesia, Dr. Oakes-Gavi wants them to learn a defined set of skills. She envisions an introductory lecture in how to use the echocardiogram, numerous practice problems in making specific diagnostic calls based on what the echo reveals, an evaluation, and guidance for residents in how to understand their limits and know when to call in a consultant. Residents would walk away with a fixed package of skills.

Although some projects are farther along than others, none of the scholars considers projects finished. This is largely because the entire faculty wants their projects to continue to evolve as residents offer feedback on how well they’re working. The month-long mentoring program, for example, is constantly adding new lectures and lecturers and expanding the tutorial textbook. Resident feedback has been a crucial element in the success of these projects, and a key part of the Teaching Scholars Program, Dr. Macario says, because the residents act as sounding boards for faculty ideas.

Teachers of Tomorrow

Even as new cohorts of Teaching Scholars dive into the program, members of the first cohort continue to develop their teaching abilities, refine their projects, and look for new ways to improve resident education. The faculty members consider the skills they have learned to be a toolbox for lifetime learning, helping establish them in their roles as physician teachers.

They wholeheartedly recommend the program for young faculty. “I think anybody who wants to seriously take on resident education should take part in this program,” Dr. Ramamurthi says. Dr. Adriano points out that by improving the training of residents, patients benefit as well, and says “Ultimately what you achieve out of participating in the program is getting involved and contributing to the department.”

As young as the Teaching Scholars Program is, Dr. Macario says, its success has already generated interest from other departments at Stanford School of Medicine and other medical schools around the country, who want to learn how to establish their own versions. “The program is still in its infancy,” Dr. Ingrande says, “but based upon the feedback we’ve gotten so far, we think it certainly has the potential to transform the way residents are trained.”

 

 

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