3

1. ORIGINAL REPORTS
The Efficacy of Residents as Teachers in an
Ophthalmology Module
Peter A. Ryg, MD,* Janet P. Hafler, EdD,†
and Susan H. Forster, MD*
*
Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven,
Connecticut; and †
Teaching and Learning Center, Yale University School of Medicine, New Haven,
Connecticut
OBJECTIVE: Resident physicians have reported spending
upward of 25% of their time teaching fellow residents and
medical students. Until relatively recently, there have not
been formal requirements in residency programs to learn
teaching skills. The first goal of this study was to develop a
novel residents-as-teachers training program to educate
Ophthalmology residents on facilitating group learning
and emphasizing critical-thinking skills. The second goal
was to educate residents on how to teach clinical reasoning
skills.
DESIGN: We designed a longitudinal residents-as-teachers
program that consisted of a 2-hour workshop, voluntary
observation of their teaching in the small group, and
student feedback on their teaching. The focus of the
workshop was to educate the residents on how to facilitate
critical thinking and clinical reasoning in a small group
format.
Voluntary video recording of residents’ teaching was
offered, and feedback on their teaching was provided.
SETTING: Yale University School of Medicine, Department
of Ophthalmology and Visual Science.
PARTICIPANTS: In total, ten second-year medical student
groups consisting of approximately 7 to 11 students in each
group were organized in this course and each group had one
teacher: 4 senior Ophthalmology residents and 6 commun-
ity faculty.
RESULTS: This study found that the resident teachers who
completed the residents-as-teachers program were equally as
effective as community faculty teachers in building medical
students’ comprehension of ophthalmic principles during
small group seminars according to the students’ evaluation
of teaching performance. We also found that all of the
medical students’ responses were overwhelmingly positive
toward having residents as teachers. The medical students
particularly noted residents’ preparedness and effectiveness
in facilitating a discussion during the small group seminars.
CONCLUSIONS: Our novel program was effective at
teaching residents how to teach critical-thinking skills and
the resident teachers were well received by medical students
in the classroom. Given the requirement that residents learn
teaching skills during residency and our preliminary success,
we plan to continue inviting residents to teach small group
seminars in Ophthalmology, and we will continue to
provide them with the residents-as-teachers program.
( J Surg Ed 73:323-328. JC 2015 Association of Program
Directors in Surgery. Published by Elsevier Inc. All rights
reserved.)
KEY WORDS: resident-as-teacher, medical education,
resident education, ophthalmology
COMPETENCIES: Practice-Based Learning and Improve-
ment, Interpersonal and Communication Skills, Profession-
alism, Medical Knowledge
BACKGROUND
Residents-as-teachers programs have their roots in the
1960s1
and have subsequently spread to many sub-
specialties.2-8
Residents have reported spending upward of
25% or more of their time teaching,9-11
but until relatively
recently there have not been formal requirements to learn
teaching skills.12-14
Residents-as-teachers programs have
been shown to improve residents teaching skills,15
their
attitudes toward clinical teaching, and improve their clinical
knowledge and clinical skills.16
Data suggest that medical
students report more effective teaching by residents who
have completed a residents-as-teachers program.17
One
study has shown that medical students’ own clinical
evaluations correlated with students’ evaluations of their
Correspondence: Inquiries to Peter A. Ryg, MD, Ophthalmology and Visual Science,
Yale University School of Medicine, 40 Temple Street Suite 3D, New Haven, CT
06511; e-mail: Peter.Ryg@yale.edu
Journal of Surgical Education 2015 Association of Program Directors in Surgery. Published by
Elsevier Inc. All rights reserved.
1931-7204/$30.00
http://dx.doi.org/10.1016/j.jsurg.2015.10.014
323
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2. residents’ teaching skills.18
Both the American College of
Graduate Medical Education and the Liaison Committee
on Medical Education now require residency programs to
teach residents how to be teachers.12,13,19
There is a paucity of published research evaluating
residents-as-teachers programs in Ophthalmology train-
ing.20
At Yale School of Medicine, the teaching of Oph-
thalmology principles to second-year medical students has
traditionally included formal lectures by full-time faculty
and small group seminars led by community faculty.
Ophthalmology residents have not participated in this
curriculum.
We developed a novel residents-as-teachers program to
prepare residents to teach medical students in small group
seminars. This study was designed to evaluate the effective-
ness of residents as teachers following their participation in
the program.
Based on medical student feedback from prior years, we
revised the curriculum to focus more on teaching critical-
thinking skills and clinical reasoning and less on exposing
medical students to content addressed in a wide variety
of cases.
We hypothesized that residents who have completed the
residents-as-teachers program would be effective in facilitat-
ing seminars using the revised curriculum, as measured by
medical students’ perception of the teaching and medical
student comprehension of ophthalmic principles.
The Yale University Human Investigation Committee
approved this research study.
GOALS
(1) Develop a residents-as-teachers training program to
educate on facilitating group learning and emphasiz-
ing critical-thinking skills.
(2) Teach residents how to teach clinical reasoning
skills.
METHODS
A mixed-method design was implemented using both a
focus group strategy and a Likert-style survey to collect data.
Sample
We invited all 5 senior Ophthalmology residents at Yale
School of Medicine to participate in the residents-as-
teachers program and to teach small group seminars for
second-year medical students. In total, 4 residents and 6
community faculty members participated as teachers for the
small group seminars with 92 medical students divided into
groups of 7 to 11 students. One resident was not able to
participate owing to scheduling issues.
Procedure
In preparation of having residents teach small group semi-
nars, we began by revising the medical student curriculum
to include an in-depth, case-based format. Overall, 3 cases
representative of common and important ophthalmic clin-
ical presentations were developed for use in each of 3 90-
minute seminars.
We designed and implemented a longitudinal residents-
as-teachers program that consisted of a 2-hour workshop
before teaching, voluntary video recording of their teaching,
and feedback on their teaching. The workshop aimed to
educate residents on facilitating group learning emphasizing
critical-thinking and clinical reasoning skills. The course
director (S.H.F.), an ophthalmologist, and the director of
the Teaching and Learning Center at Yale School of
Medicine (J.P.H.), an educator with a background in
education and faculty development techniques, led the
workshop. We provided the residents with a theoretical
background to pedagogy and opportunities to practice how
to facilitate critical-thinking and clinical reasoning skills. We
explored how to facilitate an interactive discussion that
included student participation and tips to help students
speak up in class, using role-play and discussion strategies.
This allowed for both practice and space to encourage
questions on the application of concepts. We concluded
with a case discussion that followed a modified-Bayesian
method of teaching clinical reasoning.21
Before the first seminar, we sent preparatory material to
all community faculty and resident teachers that included
tips for teaching as well as encouragement to allow medical
students time to think critically about each case. The
community faculty members were all experienced teachers
who had previously taught the course and received feedback
on their teaching; each of whom had also been offered
teacher training in the past. We also offered video recording
equipment and a one-on-one feedback session22
with a
volunteer trained in providing feedback (J.P.H.) for any
teacher who volunteered.
Each resident teacher and community faculty teacher was
assigned a group of medical students and taught the same
group of medical students during 3 separate seminars over 2
days.
Data Collection
At the conclusion of the last seminar, medical students were
asked to complete an 8-question survey (Fig. 1). Of the
8 questions, 4 were knowledge-based content questions that
we used to extrapolate a correlation with objective compre-
hension, and 4 were Likert style using a 4-point response
scale: 2 addressed the student’s evaluation of the seminars’
content, one question asked the students about their level of
comfort in speaking up in class, and one question related to
their comfort describing ocular pathology. Resident teachers
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3. and community faculty teachers were asked to fill out a
separate 8-question free-response survey (Fig. 1) about their
experiences teaching the seminars and improvements for the
future. The research staff solicited comments from 10
medical students during a postcourse one-hour advisory
group meeting. The 10 students had been formally trained
in the Teaching and Learning Center at Yale School of
Medicine to give constructive feedback before participating
in the small group seminars. Each seminar group had at
least one trained student assigned to it. Additionally, each of
the trained students solicited information from 10 of their
classmates so that the feedback could reflect the consensus
of the entire class.
Data Analysis
Data from the Likert scales were analyzed with unpaired t
tests using Microsoft Excel. The data were grouped accord-
ing to the knowledge-based content questions (1 through 4)
from the medical student survey, how the students
perceived the seminars about learning about eye pathology,
and how the students perceived their comfort level about
speaking up in class. The qualitative data were analyzed
according to Miles and Huberman.23
Regarding the
knowledge-based content questions, we calculated the mean
for the 4 questions and compared the responses for the
students in the resident teachers’ seminars and faculty
teachers’ seminars.
RESULTS
Quantitative
Medical students’ knowledge-based comprehension was
found to be high in both resident-led (averaging 88%
correct) and faculty-led seminars (averaging 87% correct)
(p ¼ 0.86) (Fig. 2).
In answer to the question about finding the seminars
helpful in understanding eye pathology, all 32 medical
students in the resident-led and 55 of 60 in the faculty-led
FIGURE 1. A flowchart demonstrates the timeline of resident teachers’ and faculty teachers’ participation in teaching medical students. Teachers and
medical students were surveyed directly after the last seminar using the respective questions.
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4. seminars responded as being “extremely” or “pretty” helpful
on a 4-point scale (p ¼ 0.10). Interestingly, 5 students in
the community faculty teachers’ seminars rated the seminars
as “minimally helpful” in their understanding of eye
pathology, whereas no one in the resident teachers’ seminars
responded with the category “minimally helpful.”
When medical students responded to the question about
their comfort speaking up in class, 29 of 32 in the resident-
led seminars and 56 of 60 in the faculty-led seminars
responded as being either “extremely” or “pretty” comfort-
able (p ¼ 0.65).
Qualitative
All the medical students’ feedback from both the written
surveys and the medical student advisory group previously
described noted that the residents were “very well pre-
pared... to facilitate [the seminars].” Medical students also
noted that they enjoyed having residents as teachers of their
small groups, and they would like to continue having
residents teach medical students in this setting in the future.
Resident teachers’ and community faculty teachers’ feed-
back elicited by questionnaire and informal discussion with
S.H.F. noted an appreciation for having fewer cases than in
previous years that could be discussed in more depth. They
did ask for higher definition photographs and videos to
supplement the seminars. Residents had a variety of views
on the value of the residents-as-teachers program. They all
thought the program was valuable; however, one thought
the pedagogical theory was too esoteric, whereas another
resident voiced appreciation for the practical strategies
practiced during the workshop. The resident teachers
themselves appreciated the program and found it helpful
when conducting their seminars. They noted that the role-
playing portion of the workshop was particularly helpful in
applying and solidifying teaching concepts. The resident
teachers commented that given the length of the workshop,
they would have liked even more practical information on
application of concepts and less theoretical information. No
residents volunteered to have their teaching recorded.
DISCUSSION
Residents’ teaching has been identified as an important
component of residents’ and medical students’ educa-
tion.12,13
Residents-as-teachers programs have been found
to be effective in improving residents’ attitudes toward
teaching as well as improving their clinical knowledge and
skills. But in surgical residencies in particular, where a
significant portion of time is spent operating, there is less
time for formal teaching.20
This study found that residents who completed the
residents-as-teachers program were equally as effective as
community faculty teachers in building medical students’
comprehension of ophthalmic principles. This is the first
study we are aware of that has measured outcomes of
Ophthalmology residents as teachers, though at least one
other program has implemented a residents-as-teachers
program.20
These results validate our hypothesis that with
FIGURE 2. Medical students’ knowledge-based comprehension in resident-led and faculty-led seminars, as measured by the average scores from a
postseminar quiz (p ¼ 0.86). (R) Resident teacher and (F) Faculty teacher.
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5. training, residents can be effective in teaching basic oph-
thalmic principles.
We found that medical students felt equally comfortable
speaking up in seminars taught by residents and faculty.
One might expect medical students to be more comfortable
speaking up with resident teachers as they may be viewed
more as peers, but it is possible that medical students felt
equally comfortable with faculty teachers because the
majority of preclinical training hours are spent with faculty
in the classroom.
Although our sample size was small, the lack of statistical
significance between resident teachers and community
faculty teachers is not likely due to inadequate power, given
the marked similarity in results.
Overall, we found the medical students’ responses to be
overwhelmingly positive toward having residents as teachers
particularly noting their preparedness and training to
facilitate during seminars. Given this response, we plan to
continue inviting residents to teach small group seminars in
Ophthalmology and providing them with the residents-as-
teachers program. We intend to explore why the resident
teachers did not volunteer to be video recorded. In the
future, we plan to have the video recording as a mandatory
component of the residents-as-teachers program.
Most community faculty, all of whom had taught semi-
nars in past years with the past curriculum, responded
positively about the restructured curriculum.
Notably, the biggest criticism the teachers had was a
curricular issue; medical students reported to their instruc-
tors that the images provided had too low resolution and
there was not enough supplemental material to share, an
issue that will be easily amendable in coming years.
The limitations in our study include the brevity of our
post-intervention questionnaire, which limited the amount
of data we had to analyze. Also, we did not collect pre-
intervention data, which further limited our ability to
interpret the data.
ACKNOWLEDGMENTS
This work is supported by an unrestricted departmental
grant from Research to Prevent Blindness (RPB). The
authors also wish to acknowledge the contribution of John
Encandela, PhD, for assistance with statistics and figures.
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