These days, teaching residents seems to be all about doing more with less.
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November 2014Nasir I. Bhatti, MD, FACS, FRCS, MHS, recalls his exhausting days as a resident at Johns Hopkins University in Baltimore, where he and his fellow residents often worked more than 100 hours a week. But this all changed in 2011 when the Accreditation Council for Graduate Medical Education (ACGME) passed new standards that limited the resident workweek to 80 hours.
The result? “[Residents] have at least one-third less time to learn because the overall length of training is the same, but they have more things to learn: new technology, new operations like endoscopic sinus surgery, robotic surgery,” said Dr. Bhatti, associate professor of otolaryngology-head and neck surgery and the director of Johns Hopkins Adult Tracheostomy Services in the department of anesthesiology critical care medicine at Johns Hopkins University School of Medicine in Baltimore. “The bottom line in surgical training is, ‘How do we make the learning curve for individual residents more efficient?’” he said.
To be a more effective educator, you have to understand that not all residents learn the same, Dr. Bhatti said. That’s why, over the last few years, he and other academic physicians have been at work assessing residents’ learning styles and adapting the curriculum to the way their students say they learn best.
Learning Styles
In 1970, educational theorist David A. Kolb, PhD, published descriptions of four main learning styles (Acad Manag Learn Edu. 2005;4:193-212):
1 Accommodating (active): Prefers to work with others and learn through “hands on” experience.
2 Converging (practical): Prefers practical uses for ideas, including simulations and laboratory assignments.
3 Diverging (imaginative): Prefers to work in groups and receive personalized feedback.
4 Assimilating (inductive): Prefers readings, lectures, exploring analytical models.
Dr. Bhatti suggests that for each new class of residents, residency directors should distribute Kolb’s Learning Style Index, a 12-item questionnaire. (The questionnaire, which takes approximately 15 to 20 minutes to complete, can be purchased at learningfromexperience.com/tools.)
In a paper published in 2011 in The Laryngoscope, Dr. Bhatti and colleagues used the survey to assess the learning styles of a group of pediatric otolaryngology and otology/neurotology fellows from Johns Hopkins (121:2548-2552). Ten pediatric otolaryngology and 20 otology/neurology fellows completed the survey, with a majority of them reporting that they preferred a learning style that incorporated all four learning styles. The rest preferred converging, accommodating, or a combination of the two.
A previous study he worked on analyzed the results of a survey completed by 43 otolaryngology residents from Johns Hopkins University and Kansas University otolaryngology–head and neck surgery programs (Laryngoscope. 2009;119:2360-2365). The predominant learning style was converging (56%), followed by accommodating (19%).
The bottom line in surgical training is, “How do we make the learning curve for individual residents more efficient?”—Nasir I. Bhatti, MD, MHS
“If the findings from our study hold for all residency programs in the U.S., that means the converging and accommodating learning styles will be predominant,” Dr. Bhatti said. “These types of learners don’t like lectures [and] they don’t like seeing videos of something being done or being shown how to do an operation; they want hands-on experience.” Outside of the operating room, these experiences could include animal labs and temporal bone labs, he said.
The Kolb Learning Style Index can be administered early in the year, on a year-to-year basis, to determine whether students’ learning styles are changing, said John A. van Aalst, MD, MA, associate professor of surgery and director of pediatric and craniofacial plastic surgery at the University of North Carolina School of Medicine in Chapel Hill. “I believe that early in residency there may be changes; later in residency, as learning and teaching styles have matured, they may not change significantly,” he said. “This in itself could be a study performed by a residency program.”
In 2010, Dr. van Aalst and colleagues published a paper in the Journal of Surgical Education that analyzed the preferred learning styles of surgical residents and faculty from the University of North Carolina at Chapel Hill (67:290-296). The researchers found that surgical residents preferred active learning with interactive teaching methods, while faculty preferred reflective learning, as in traditional, lecture-based formats.
“To me, that is interesting, because those two teaching styles are going to clash. You either have a student at the center of teaching or a professor at the center,” Dr. van Aalst said.
The take-away, he said, is that students don’t want a curriculum entirely based on lectures. Programs should incorporate small discussion groups in which residents discuss readings and present cases.
Curriculum Changes
Over the last few years, the faculty at Johns Hopkins has changed its residency curriculum to a learner-centered approach, said Douglas D. Reh, MD, assistant professor and residency program director within the department of otolaryngology-head and neck surgery at Johns Hopkins.
“This was something the residents wanted,” he said. “They felt that we could further improve their learning if we added resident-directed reading sessions to our current lectures and clinical vignettes.”
Dr. Reh was part of a team at Johns Hopkins that in 2008 created a new program to help residents prepare for the Otolaryngology Training Examination (OTE). This involved setting up weekly, 60- to 90- minute interactive case reviews led by faculty members. In 2011, they revamped the program again by making the residents responsible for the curriculum. Each week, one or two residents are asked to create an outline of a textbook chapter and lead a discussion about it. They also develop, organize, and adjust the didactic curriculum.
During the three years following the first intervention, Dr. Reh and colleagues reported an increase of 0.69 in mean national and 0.78 in mean group stanine scoring (P=.01). After the second intervention, scores increased by 1.36 in mean national and 1.58 in mean group (P=.001).
Dr. Reh said he often sits in on the review sessions and gives feedback, but he mostly lets the residents lead the discussions.
“Other programs should look at developing more of a learner-centered approach for residents. If you review the current education literature, and not just in medicine, making learners responsible for their own education seems to be a more effective teaching method,” he said.