Teaching Medical Students to Teach: Primary Care Considered

PRIMARY CARE CONSIDERED: The SLC Blog

Welcome to Primary Care Considered, the blog of the Student Leadership Committee (SLC) at the Harvard Medical School Center for Primary Care. Featured monthly in the Center’s newsletter, this section will highlight the projects, activities, and past successes of the SLC. Please join us at our events and share your thoughts!

Teaching Medical Students to Teach

In this post, SLC member Lydia Flier shares her experiences with the current state of near-peer teaching on the wards, and what can be done to improve it. Working with faculty from the Center for Primary Care, Lydia’s Scholars in Medicine project involved the development and implementation of a pilot fourth year elective that saw senior students teaching first-year medical students in a primary care setting. She shares the impetus for this program, and preliminary results from the pilot program evaluation. 

Although modern medical education has long since moved past the assembly line approach of “See one, do one, teach one,” effective teaching remains essential to the practice of medicine. The integration of teaching into clinical care—seeing, doing, and teaching on hospital rounds, intraoperatively, or during an ambulatory assessment and plan—is as old as medicine itself. In this environment, attending physicians, residents, and medical students alike must be able to educate peers, students, and patients.

Unfortunately, it has been apparent during my clinical training that, in spite of the central role of teaching in the practice of medicine, not all residents are equally adept at assessing my level of knowledge, relaying information clearly, or giving meaningful feedback. In fact, the difference between a great or less-than-ideal resident usually has less to do with their medical knowledge, or even their skill working with patients, than with their teaching ability. Most often, less-than-ideal residents are such because they fail to treat me as an adult learner and do not optimize learning in the clinical setting. Fortunately, such residents are rare, but they can nevertheless create a profoundly negative working environment. Given that our task as third year students is, for the most part, to learn, this can have significant consequences.

How can we better prepare residents to teach? It has to start early, perhaps as early as medical school. With the first year of residency focusing on managing patients, it is no surprise residents have little time to develop educational skills. While ACGME accreditation for Internal Medicine residencies requires evaluation of residents in “teaching skills involving peers and ­patients,” (1) the amount of explicit instruction residents receive regarding how to teach varies widely, usually does not start until after intern year, and is understandably of secondary importance to the delivery of high-quality patient care. I can only imagine the trepidation of finishing intern year and being newly expected to manage a team, oversee the care of 20 patients, and educate others in earlier phases of their training. Unless someone is already adept at teaching, it is easy to see why this aspect of the job all too frequently falls by the wayside. ­

Medical students receive little preparation for this teaching role. There are no national requirements outlining teaching competencies for undergraduate medical education. Until last year, Harvard Medical School (HMS) only offered one course in how-to-teach for senior medical students, which prepared them to teach the physical exam in a standardized setting, but never evaluated their teaching skills.

Emphasizing teaching at this stage of training could have a significant impact down the line. A growing body of literature demonstrates the value of teaching medical students to teach. Reviews by Soriano, Pasquenelli, and Yu, for example, highlight many programs of medical students-as-teachers and the benefits of “near-peer” instructors (2–4). Topping defines the latter as “people from similar social groupings who are not professional teachers helping each other to learn and learning themselves by so doing” (5). According to this definition, both students and their near-peer instructors stand to benefit from the experience. However, few if any of the programs described using near-peer teaching in a true patient-care or outpatient setting. Most offered only tutorials or taught solely discreet skills such as the physical exam.

Keeping this data in mind, and recognizing that few teaching options were available at HMS, I set out in my Scholars in Medicine project to develop a new course in primary care medicine and medical education, with the belief that the senior years of medical school are an appropriate time to begin building not only advanced clinical knowledge but also teaching competencies.

The project grew out of an initial plan my classmate Colleen Farrell and I devised as part of our work on the Student Leadership Committee at the Harvard Medical School Center for Primary Care. We originally wanted to create a primary care “Grand Rounds,” teaming up with expert primary care faculty to guide fourth-year students in how to make a high-quality case presentation. However, recent changes in the HMS curriculum presented an opportunity to establish an even a wider-ranging course designed for the “Advanced Phase” of the curriculum. (“Advanced Phase” refers to the combined MS3/4 block after the new MS2 clinical year.) To test our idea, we designed a pilot course with the assistance of Medical Education faculty at the Center, including Drs. Kristen Goodell, Sara Fazio, and Barbara Ogur. The resulting “Elective in Primary Care Medicine and Teaching” pilot was intended for senior medical students who had completed their core clerkship year and wanted the opportunity to develop their teaching skills in a longitudinal primary care setting, with support from expert primary care faculty while doing so.

Beginning in the early months of 2015, we developed the learning objectives and requirements of the course. The core component involved placement in an outpatient primary care office. Senior students serve as near-peer teachers of the history and physical exam to MS1s learning this information for the first time during their primary care longitudinal placement. Near-peer teachers were expected to attend at least 6 clinic sessions between October and March. They also worked in teams to lead a Grand Rounds presentation and to make a digital concept video on a topic in primary care. Seven evening didactic sessions for the senior students covered “Adult Learning Theory,” “Giving Feedback,” “Evidence-Based Medicine,” “Ambulatory Teaching and the 1-Minute Preceptor,” “Effective Lecturing,” “Making a Concept Video,” and “Endings and Transitions with Patients and Students.” This evening curriculum served to educate the fourth-years on adult learning theory, which they could begin to put into practice during clinic sessions.

Nicole de Paz, one of the fourth-year students at HMS who participated in the pilot course, commented: “It’s been really rewarding to be involved in this experience [with] the first-years, especially to be in a role where we can give them direct feedback and help them feel more comfortable in the clinic. I’ve enjoyed working on my own teaching skills through the didactic sessions, and I’m excited to keep applying these skills as a resident next year.”

Certain components of this course have been piloted or offered through different avenues at HMS in the past. However, they have never been previously combined with the goal of training students in both the primary care specialty and medical education simultaneously. Not only does the course explicitly address the need to improve teacher training in medical education, but it also addresses a second key need at the school, by helping close the gap in primary care education at HMS.

In the past, most students in New Pathway (the outgoing HMS curriculum) had their first and only primary care exposure through a year-long Primary Care Clerkship (PCC) placement in the third year. Today, Pathways (the new curriculum beginning in 2015-2016) pairs students with a primary care preceptor and clinic early in first year, providing more opportunities for close mentoring and valuable early exposure. The Advanced Phase of the curriculum is already benefitting from several courses training and integrating advanced students as near-peer teachers, and new opportunities will likely develop over time. At this time, ours is the only one in a primary care or outpatient setting; as this phase is still relatively undefined, now is the time to shape its primary care and medical education offerings.

We are almost at the completion of the first pilot program, which has been running with 8 senior medical students since October 2015. The didactics have been well-received by participating students, and the near-peer preceptor experience has been positive for senior students and faculty alike.

We are cautiously optimistic about expanding enrollment next year and seeing where this program may go. In the meantime, there is still a significant amount of assessment and improvement to be done. To prepare for future iterations of the course, we will be reviewing all of the feedback from participants, including near-peer teachers, MS1s, and faculty preceptors who were involved.  As the curricular reform at Harvard reaches students in their senior years, we envision that this course will be an opportunity for current MS1s to return to the clinic where they first learned the H&P and begin the process of growing as teachers as well as independent clinicians, preparing them for residency and beyond.

 

We would like to acknowledge all of the faculty and staff at the Harvard Medical School Center for Primary Care who contributed to the development and support of the course. Thank you!

 

  1. American College of Graduate Medical Education. Program Requirements for Graduate Medical Education in Internal Medicine. [Internet]. 2013. Available from: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/140_internal_medicine_07012013.pdf
  2. Soriano RP, Blatt B, Coplit L, CichoskiKelly E, Kosowicz L, Newman L, et al. Teaching medical students how to teach: a national survey of students-as-teachers programs in U.S. medical schools. Acad Med. 2010;85(11):1725–31.
  3. Pasquinelli LM, Greenberg LW. A review of medical school programs that train medical students as teachers (MED-SATS). Teach Learn Med [Internet]. 2008;20(1):73–81. Available from: http://www.tandfonline.com/doi/abs/10.1080/10401330701798337
  4. Yu T-C, Wilson NC, Singh PP, Lemanu DP, Hawken SJ, Hill AG. Medical students-as-teachers: a systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract. 2011;2:157–72.
  5. Topping KJ. Trends in Peer Learning. Educ Psychol. 2005;25(6):631–45.