Three-Year Longitudinal Skill-based Teaching Curriculum for All Residents

BACKGROUND. Despite signicant teaching responsibilities and national accreditation standards, most residents do not receive adequate instruction in teaching methods. Published reports of residents-as-teachers programs vary from brief one-time exposures to curricula delivered over several months. A majority of interventions described are one or two-day workshops with no clear follow-up or reinforcement of skills. A three-year longitudinal teaching skills curriculum was implemented with these goals: 1) deliver an experiential skill-based teaching curriculum allowing all residents to acquire, practice and implement specic skills; 2) provide spaced skills instruction promoting deliberate practice/reection; and 3) help residents gain condence in their teaching skills. METHODS. One hundred percent of internal medicine residents (82/82) participated in the curriculum. Every 10 weeks residents attended a topic-specic experiential skills-based workshop. Each workshop followed the same pedagogy starting with debrieng/reection on residents’ deliberate practice of the previously taught skill and introduction of a new skill followed by skill practice with feedback. Every year, participants completed: 1) assessment of overall condence in each skill and 2) retrospective pre-post self-assessment. A post-curriculum survey was completed at the end of three years. RESULTS. Residents reported improved condence and self-assessed competence in their teaching skills after the rst year of the curriculum which was sustained through the three-year curriculum. The curriculum was well received and valued by residents. CONCLUSIONS. A formal longitudinal, experiential skills-based teaching skills curriculum is feasible and can be delivered to all residents. For meaningful skill acquisition to occur, recurrent continuous skill-based practice with feedback and reection is important. Wilcoxon signed-rank test was used to test change in response at each post-assessment compared to baseline and compared to prior year post-assessment. Jonckheere-Terpstra test for ordered differences was used to assess the differences in condence scores among program years. Statistical analyses were performed using SAS version 9.4.

experiential skills-based workshop which utilized various educational strategies including video-taped scenarios, small-group discussions, roleplay, and re ection. IM/OCRME faculty and chief residents facilitated the workshops. Each workshop followed the same pedagogy ( Figure 2) starting with debrie ng/ re ection on residents' deliberate practice of the previously taught skill and introduction of a new skill followed by practice with feedback from clinician educators and peers. To promote deliberate practice, before leaving the workshop every resident committed to personal action plan aimed at furthering skill development related to that session topic. Pocket cards summarizing key takehome points were distributed at the end of each session (Supplemental table 2A-H). Residents were expected to attempt to implement their personal action plan and these experiences were debriefed allowing for individual/group re ection to deepen learning and e cacy in using these skills. Pocket cards with workshop learning objectives were distributed electronically to all departmental faculty allowing them to reinforce and provide workplace-based feedback on the teaching skill residents were practicing. (Supplemental table 3).

Data Collection
Several measures were used to assess characteristics of participants and perceived impact of the curriculum on learners' con dence and skills.
Information on baseline experience and teaching interest (Supplemental table 4) was collected from all residents at the beginning of Year One. At the end of each year (for three years), participants completed: 1) assessment of overall con dence in using each teaching skill (Supplemental table 5); and 2) retrospective pre-post self-assessment comparing their perceived competence with each teaching skill at the end of each year. (Supplemental table 6).
Overall data was collected for three years; PGY1, PGY2 and PGY3 cohort data was collected for three, two and one year, respectively. Participants completed a curricular satisfaction at the end of three years (Supplemental table 7).
Response to the Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) survey asking medical students to evaluate IM resident teaching effectiveness during their clerkships was reviewed prior to and after implementation of the teaching skills curriculum to further assess impact of the curriculum.

Data Analysis
Con dence and self-assessed competence in performing each teaching skill was assessed using a 5-point Likert scale ("4" or "5" considered con dent and self-assessed competence). Wilcoxon signed-rank test was used to test change in response at each post-assessment compared to baseline and compared to prior year post-assessment. Jonckheere-Terpstra test for ordered differences was used to assess the differences in con dence scores among program years. Statistical analyses were performed using SAS version 9.4. This project was deemed non-human-subjects research by the Institutional Review Board of the University of Iowa.
The baseline survey was completed by 92% (75/82) of participants. Eighty-nine percent (67/75) of residents indicated interest in teaching, 77% (58/75) anticipated teaching will be part of their career and 25% (19/75) reported previous participation in a formal teaching course.
Con dence scores after one year of curriculum indicated majority of residents felt con dent in their teaching skills (Supplemental table 8A). Con dence scores (creating a positive learning environment, showing respect for learners and using wait time when questioning learners) showed signi cant improvement after two years of the curriculum (Supplemental table 8B). There were signi cant differences noted in the con dence skills between PGY1s and PGY 2/3s in four categories (dealing with challenging learners, facilitating a small group, providing feedback consistently and identifying important skills for teachers). The only signi cant con dence measure difference between PGY2/3s after two years in the curriculum was facilitating a small group session. No degradation was seen in third-year residents' self-reported con dence in teaching skills.
Data reported by PGY1s after participating in the curriculum for one year showed signi cant improvement in all self-assessed skills (Table 2A).
PGY2s reported signi cant improvement in all but three categories (engaging in discussion about medical issues, feeling comfortable stating "I am not sure" and showing respect for learners). PGY3s reported signi cant improvement in all categories except two (feeling comfortable stating "I am not sure" and showing respect for learners). Self-assessment of teaching skills after participating in the curriculum for two years continued to show signi cant improvement in all but one of the teaching skills in the PGY 2/3s (showing respect for learners) (Table 2B).
Curriculum evaluation was completed by 67% (55/82) participants. Residents rated the curriculum highly and 82% (45/55) thought it provided them with longitudinal comprehensive teaching skills and 75 % (41/55) reported it provided a comprehensive program for their development as a teacher. Only 49 % (27/55) reported getting feedback from faculty on teaching skills being taught during the curriculum (Table 3). Following the implementation of the curriculum IM residents' ratings by medical students on the question "Residents provide effective teaching during the clerkship" signi cantly exceeded all medical schools as compared to prior to implementation ratings (Supplemental table 9).

Discussion
Based on accreditation standards, residents must be introduced to teaching skills on an annual basis. [3,4] Irrespective of the external standards, residency programs have a vested interest in developing residents into effective teachers. In a national survey of residency program directors, 55% reported their programs offered residents formal teaching skills instruction. [5] While most of our residents expressed interest in teaching, the majority lacked previous experience in a formal teaching curriculum.
We successfully implemented a longitudinal three-year skill-based curriculum which incorporated skill practice, deliberate practice and re ection. Continuous skills-based practice and feedback is vital for acquisition and maintenance of any skill. [15] Having a dedicated block of time enabled this longitudinal teaching skills curriculum to be delivered to all IM residents on a scheduled, recurring basis. This allowed residents to engage in formal teaching skills practice and re ection over regular predictable intervals which likely enhanced their skill acquisition and con dence. Wamsley et al. and Edwards et al. have argued for the importance of reinforcing teaching principles to prevent degradation of teaching skills over time. [7,11] This longitudinal structure for curricular implementation is also supported by a study which demonstrated that 'spaced education' (educational encounters spread out and repeated over time) improved learner retention of skills/curricular material. [16] While it is not possible to know whether interest and satisfaction would remain high without the teaching skill curriculum, it is likely that the curriculum may contribute to sustaining enthusiasm for teaching by providing on-going mentored support, practice and discussion. Skill improvement in all cohorts suggests that this longitudinal curriculum helped minimize skill degradation.
Residents reported improved con dence and self-assessed competence in their teaching skills after the rst year of the curriculum and this was sustained through the three-years. The curriculum was well received and valued by our residents. Comparison of pre-post intervention responses to the AAMC GQ for effective clerkship teaching by IM residents also showed improvement in the residents' ratings as effective teachers.
There are several possible limitations to this study. It was conducted at one program in a single university setting which limits its generalizability. Teaching skill con dence and competence were assessed by self-report. However, the results were strengthened by the fact they compared the same individual's progression in the curriculum over three years. The con dence and self-assessment surveys are selfadministered instruments, making them subject to social desirability biases. The retrospective pre-post format was chosen for the selfassessment of skill competence to minimize response shift bias. This bias can underestimate program effectiveness in traditional pre-post surveys because participants may overestimate their knowledge prior to training. [17,18] This study involved different cohorts over a three-year period whom may have different characteristics (previous teaching skills training as well as teaching experiences), though the results presented followed the same individuals' progression through the curriculum. In addition, it was an educational intervention study where the cohort with more time on task would generally be expected to have better outcomes. Therefore, a more accurate picture of teaching skill ability would require an objective measurement of teaching skills as well as work-place based assessment. Using Objective Structured Teaching Exercise (OSTE) performance data for the skills taught in the curriculum would be an objective way to assess the utility of our intervention. Some valuable lessons were learned during the implementation of this curriculum. First-year residents are now provided a separate session to orient them to the curriculum. To ensure that all residents receive a similar experience, a cohort of motivated faculty are required to deliver the same content for ve consecutive weeks. For meaningful skill acquisition continuous skill-based practice and feedback is important. Only half of the residents who responded to the survey reported getting feedback from faculty regarding their teaching skills in the workplace. This suggests more deliberate faculty development is needed rather than simply relying on electronic messaging. To more objectively study resident teaching skill acquisition and retention, we are in the process of designing and implementing annual OSTEs and incorporating workplace-based direct observation with feedback. Other tools which have been studied to successfully incorporate faculty feedback based on workplace-based observation include mini-CEX, clinical encounter cards, multi-source feedback and direct observation of teaching skills. [19,20] Conclusions A formal longitudinal, experiential skills-based teaching skills curriculum is feasible and can be delivered to all residents. While IM residents expressed great interest in teaching, most had not participated in a formal teaching skills curriculum. Self-reported assessment data indicated improvement in resident con dence and teaching skills. Implementation of the curriculum is time-intensive and requires dedicated faculty. For meaningful skill acquisition to occur, recurrent continuous skill-based practice with feedback and re ection is important.     Figure 1 Sample "Y" week schedule Figure 2