RE-VITALIZING THE ACADEMIC HALF DAY: IMPROVING ACADEMIC TEACHING AND LEARNING IN RESIDENCY EDUCATION

Karen L. McClean MD FRCPC* Sharon E. Card MSc, MD FRCPC* Marcel D’Eon PhD

College of Medicine University of Saskatchewan Saskatoon, Canada

Abstract Academic Half Day (AHD) is a common educational strategy in residency training. However, the defining characteristics of AHD are highly variable from one program to another. Observation of AHDs in the authors’ Internal Medicine residency training program revealed that presentations were of poor educational value. The authors describe evaluation and renewal of their academic half day with development of a systematic strategy for quality improvement. Interventions included development of a structured approach to planning and conduct of AHD, development and implementation of ‘Theme Days’ and ‘Theme Weeks’, development of a teaching and learning skills instructional series, and systematic evaluation for presenters and incorporation of the CanMEDS roles other than medical expert into the content of AHD.

The authors observed a rapid and sustained improvement in the quality of teaching. Though many of the changes were quickly incorporated, several potentially valuable interventions have been difficult to implement and sustain in an effective way.

Background Academic Half Day (AHD) is a common educational strategy in residency training programs. A Google™ search using the exact term ‘academic half day’ yields over 890 listings covering all English language Postgraduate Faculties of Medicine in Canada as well as programs in the USA and UK and a broad range of disciplines. Despite this widespread uptake of AHD, there is no uniform definition of what constitutes an AHD. Frequency, duration, format, degree of faculty involvement and types of learning activities are highly variable from program to program. Nor is there much scientific literature documenting the origins and development of AHD, describing different strategies or formats, or addressing the efficacy of this approach.

One of the only references in the literature to what appears to be an AHD is found in Zweifler and colleagues1 who describe implementation of extended educational sessions in three separate family medicine programs. They list several reasons for replacing what was then a traditional one hour teaching session with longer sessions: accommodating

Page 1 of 9 interactive formats, role-playing exercises, and hands-on activities; barriers to attendance (conflict with clinical duties, need to commute to a central location); and disruption from pagers. These early descriptions of “bundled didactic time” were highly structured with defined curricula, largely presented by faculty and community based practitioners. They noted several benefits of extended educational sessions including improved attendance, more efficient use of faculty time, and improved coordination of educational sessions.

Identifying the Problems Prior to 1998, our academic half day (AHD) was comprised of one 3-hour session per week. At the beginning of each academic year, the academic chief resident assigned each resident to present two or three specific sessions over the course of the year. Two residents presented at each AHD, with each presentation scheduled for approximately 1½ hours. Resident presenters independently chose and researched a topic.

We observed AHD sessions in our program between January and June 1999 and identified similar problems noted by Zweifler at al1. We found that presentations contained too much factual detail, had no stated objectives, and only rarely emphasized key points. There was a heavy reliance on major medical texts for content information, and little inclusion of current evidence. Presentations frequently lacked practical relevance and often included outdated or inaccurate information. Residents rarely consulted with faculty members to assist them in refining content or selecting a presentation format. Presentations almost always focused exclusively on medical expertise. Active participation by the audience was rare. Resident attendees seldom completed or submitted the peer feedback form and there was no faculty feedback to assist residents in improving their presentation skills. Faculty attendance was near zero and resident attendance was only about 50% of the total resident group of about 24. Many residents left sessions to answer ‘pages’ or at the break and then did not return.

There was a general attitude among residents that AHD should be a comprehensive, exhaustive curriculum accompanied by a total lack of faculty participation in the planning and direction of AHDs. Resident presenters felt pressured to provide excessively detailed presentations through rapid-fire, lecture style presentations with little or no attempt to focus on selected key issues of practical relevance.

Revitalizing AHDs Having identified these problems, we embarked on a process to rejuvenate AHDs. We created an educational committee (comprised of faculty and residents) to address a series of important questions.

1. What should be the focus of AHD? The committee acknowledged that it was unreasonable to expect that one three-hour teaching session per week could replace systematic independent-study and extensive on- the-job learning from preceptors and attending faculty. We also decided that residents should be encouraged to integrate discussion of other CanMEDs roles2 into their presentations such as ethics, communication skills, practice management and legal issues (see Table 1).

Page 2 of 9 2. Who should present AHD? Residents were strongly in favor of continuing to present at AHDs. While also supporting a strong resident involvement in organizing and presenting at AHDs, the committee felt that increased faculty input was essential to success in improving the quality of presentations. They decided that the faculty role would be to assist residents in selecting appropriate content and identifying evidence-based resources and to help residents develop and use effective educational strategies.

3. Who should organize AHD? The education committee felt that increased collaboration between faculty and residents in the organization of AHD was necessary. The academic chief resident would continue a lead role in ensuring full resident participation and developing a presenter schedule, one way that our ADH differed from that described in Zweifler et al1. The educational committee took responsibility for developing a new format for AHD, and overseeing its implementation. To avoid over or under emphasis on a specific area, the committee created a schedule to ensure a balance of subspecialty and general topics (ie: General Internal Medicine, Respirology etc,) with the specific content for each session left to the presenters (and faculty advisors).

4. How can we improve attendance? It appeared that the poor quality of teaching failed to stimulate and sustain audience interest and that contributed to high attrition and poor attendance. Accordingly, the committee emphasized developing a systematic approach to improving teaching skills (see question 5 below).

Another contributing factor was that several clinical rotations outside of internal medicine interfered with resident attendance either by scheduling conflicting activities or by making it difficult for residents to sign-over clinical responsibilities. To emphasize the importance of AHD and empower residents to attend, we established a policy of mandatory attendance for all residents on rotations in the city. We asked clinical rotations to identify a sign-out strategy that would enable resident attendance. We implemented attendance sheets and developed questions from presentations for inclusion in the annual written examination. The attendance sheets allowed us to identify rotations that habitually made it difficult for residents to attend and to address this issue specifically with those rotation coordinators. The incorporation of questions from AHD into program examinations helped to emphasize to both residents and rotations the importance of attendance.

5. How can we improve the quality of teaching? We recognized the need to provide explicit instruction and demonstration of teaching skills if we hoped to make a sustainable impact on teaching quality. To this end, we encouraged residents to participate in TIPS for Residents (teaching improvement course) developed by the Educational Support and Development of the College of Medicine3. Since many residents did not complete this course until late in their training, we developed a series of learning skills and teaching skills sessions to incorporate into AHD

Page 3 of 9 sessions at the beginning of each academic year, prior to the beginning of the resident presented AHDs. Since we hoped to introduce wide-ranging changes in the style of resident presentations, we conducted several demonstration AHDs to model these changes.

The team approach is a key element in the revised AHD format. Each team is comprised of the following: - One senior (PGY3) resident (the “quarterback” or team leader) - 2-3 junior (PGY1-2) residents - 1 Faculty member with expertise in the content area (Content coach) - 1 Faculty member with interest / expertise in education (Teaching coach) As indicated by content and objectives, other presenters may be included. Guest presenters may include patients, graduate students in basic science fields, nurses, physical therapists, lawyers, business managers, and others.

We expect the content coach to attend the session to serve as an expert resource ensuring the accuracy of information and providing help with difficult questions. In some cases the content coach may also present a component of the session. The teaching coach is to encourage use of sound educational strategies and to provide feedback on teaching skills to presenters.

Teams are assigned a broad content area (ie: Gastroenterology) on a sign-up basis. The resident teams meet and collectively chose a specific theme within the content area (ie: Celiac disease). Residents identity a faculty member with expertise in the content area and then, in consultation with the faculty member, select specific key topics for presentation and learning. Each individual resident prepares and presents one or more of these topics, ideally from an evidence-based perspective, including several CanMEDs roles. The suggested duration for each segment is 15-30 minutes, rather than 1 ½ hours. We publish the overall objectives for each session on the weekly announcement of rounds for the department. Presenters are supposed to disclose objectives for each individual presentation at the time of the session. They are encouraged to use case presentations and other active learning strategies and problem solving activities to establish relevance, illustrate key points, or test learning.

Feedback to presenters is a key element of all AHDs. The teaching coach (or other designated faculty) completes an evaluation form covering use of objectives, presentation content (key points, organization etc.) and style (clarity, pace etc.), quality and effectiveness of audio-visual material, incorporation of active learning strategies, and other items. We revised the peer evaluation form to highlight the changes in presentation format and residents were encouraged to participate in the evaluation process.

We also created ‘Theme Days’, AHDs comprised of a related series of brief, focused presentations chosen around a central theme (see Table 2 for an example). About 60% of all AHDs were Theme Days. ‘Theme Weeks’ are an extension of Theme Days in that they include a variety of presentations or activities linked around a central theme. In

Page 4 of 9 addition to a single AHD we annex the one-hour daily noon rounds sessions and the Grand Rounds time slot to create a ‘Theme Week.’ Topics have included Addictions, Transplantation Medicine, Practice Management and Medical-Legal (see Table 3).

While the Theme Days are designed to be organized and presented mainly by resident presenters, Theme Weeks are organized by the educational committee and primarily presented by expert (and often external) speakers. The juxtaposition of Grand Rounds and AHD on consecutive days has allowed us to schedule up to three sessions (5 hours) over two days for invited out-of-town speakers. Results Implementation of our AHDs including Theme Days (and Weeks) has largely been successful. The quality of resident presentations increased dramatically. Most presentations receive a faculty rating of good to excellent for quality of visual aids (usually Power Point). The improvement in resident presentation skills appears to have spilled over into other venues such as our resident research day where we have noted a steady and consistent improvement in presentations over the past 5 years. Our AHD program has allowed us to assess several of the CanMEDs roles outside of the patient care context: collaboration (effective team working in preparing and presenting the AHD, leadership skills of the senior resident), scholar (use of evidence-based medicine, organization of presentation), and communicator (presenting in a large group setting). Furthermore, residents are more likely to use current, evidence-based resources and to reference material in their presentation. It seems clear to us that residents successfully made a transition from long, detailed lectures to shorter, more focused team presentations.

Some initial resistance to mandatory attendance was rapidly resolved and we have achieved a sustained improvement in attendance including attrition following breaks. Attendance records allowed us to continue to identify a number of problem rotations.

Perhaps the most dramatic result of the theme day approach has been an enhanced sense of pride in the program by residents. Our residents regard the Theme Day approach to AHD as a unique strength (and selling point) of the residency program.

A number of important elements of AHDs proved more difficult to incorporate. While the team approach to presentation quickly caught on, use of faculty content and teaching coaches has been slower and less consistent. Even when teams did identify a content coach, the coach was often minimally involved in the planning and direction of the content. Attendance by content coaches has been poor. The main obstacles have been the limited number of faculty to take on this role and lack of experience in working with coaches.

Use of objectives for both the overall session and individual presentations has increased and appears to be gradually improving, but has been inconsistent. In the 2003-04 academic year, only 10 of 16 Theme Days included overall objectives. Even when provided, objectives are not well written. We have now added to the summer sessions on teaching and learning a session on how to write objectives, but further work is

Page 5 of 9 required. Once fully implemented, the teaching coach should provide guidance and feedback on the development of objectives.

Over time there has been a tendency to revert to fewer and longer presentations, which are more general, comprehensive, and detailed. This was particularly evident in the year when we reduced teams to three residents.

Resident feedback on theme weeks showed that they appreciated the opportunity to focus their attention on a specific content area over a longer period and felt that this approach enhanced learning. Interest was piqued and sustained over the week. The following are examples of specific comments from the first evaluation: “very helpful and informative”, “do this again next year”, “definitely continue these sessions next year”, “very good concept – it works, keeps up curiosity throughout the whole week”. “Excellent - would like to see more of these theme weeks” and “my interest was sustained throughout the week”. When directly asked, a few residents agreed that there was some redundancy between presenters but they thought the redundancy actually supported their learning.

Conclusion AHDs are a common educational strategy in postgraduate training programs but there is little scientific literature describing their development and implementation. Without a foundation of training in effective teaching skills and supervision by faculty we found that our AHD was highly ineffective and held in poor regard by residents. A systematic attempt to organize and base AHD on sound educational principles similar to those reported in the literature1 resulted in a dramatic improvement in the educational quality of AHD. High quality AHDs seem to require ongoing effort. Residents can be highly effective presenters and AHD provides a venue that allows them to develop and refine their presentations skills and to receive formative feedback that encourages improvement, an aspect of our AHD that is different from Zweifler et al1. Our strong AHDs (with Theme Days and Weeks) seem to have helped create high morale and pride in the program. There is a definite need for more research and scholarly activity in this area.

Page 6 of 9 Table 1 CanMEDs roles and content targeted for incorporation into AHD Role Content areas identified for presentation in AHD Medical expert Common or important medical topics Physical exam skills Communicator Consultancy skills Collaborator Roles of allied health professionals in managing common medical problems Manager Resource utilization, practice management Health advocate Health maintenance and prevention Scholar Study skills, teaching skills, research methodology Professional Ethical issues, medical legal issues

Table 2. Example Theme Day

Theme: Cystic Fibrosis for Internists

Content areas Basic Science Genetic basis Pathogenesis Clinical presentation / course Lung disease Pancreatic disease

Microbiology Microorganisms Antimicrobial therapy Physiotherapy Techniques and devices Presented by CF therapist Lung transplantation When should patients be referred? Criteria for transplantation Pregnancy Fertility Counseling issues

Table 3: Example Theme Week

Theme: Medical Legal Issues in Medicine

Monday What a physician needs to know about the legal system: An introduction to the legal system. Presenter: lawyer specializing in medical issues Tuesday Session 1 - 60 minutes I’ve been asked to be an Expert Witness – now what? Presenters: Lawyer, experienced expert witness (MD) Session 2 - 30 minutes Reflections of an encounter with the legal system: a personal account of a physician defendant in a malpractice suite (discussion of psychological impact etc.)

Page 7 of 9 Wednesday Session 1 (Grand Rounds – 60 minutes) Duty to Disclose – Disclosing Medical Error Presenter: Physician from CMPA (Canadian Medical Protective Association) Session 2 (Noon Rounds) Duty to Inform (Informed Discharge) Presenter: Physician from CMPA Thursday Extended session (4 hours) Mock trial Participants: Judge, lawyers, physicians Friday The Complaints Process: How to avoid and respond to a complaint to the College of Physicians and Surgeons Presenter: Physician Manager of the Provincial Complaints Committee

References

Page 8 of 9 1Zweifler J, Ringel M, Maudlin RK, Blossom HJ. Extended Educational Sessions at Three

Family Medicine Residency Programs. Acad. Med. 1996;71:1059-63.

2CanMeds Roles

3D’Eon M. Evaluation of a Teaching Workshop for Residents at the University of

Saskatchewan: A Pilot Study. Acad. Med. 2004;74:791-797.