Six Strategies to Stimulate Resident Learning

1. Apply “Adult Learning Principles”

The most important principles to keep in mind when teaching residents are summarized in four principles: relevance, goals, active involvement and respect. These principles form the basis for the other five strategies. Adults must believe what they are being taught is relevant to their immediate future. If they do not, they simply will “turn off ” and not learn the material.

The resident must believe that the learning will lead to some goal, perhaps passing their board examination or becoming a competent surgeon. Sometimes you should reinforce the relevance of the material and exactly what goal will be achieved. Adults must be actively involved in their learning. A straight lecture with passive participants results in poor learning retention. Lectures can be designed for improved effectiveness and alternatives to faculty lectures should be encouraged. These could include residents giving the lectures themselves, case studies with group discussion, case studies with online discussion (as simple as email!), literature searches, etc.

Finally, adults should be treated with respect. I call this the “positive learning environment”. You should encourage active discussion and questioning to enhance learning. Teaching activities should be positive, motivating and aimed at increasing confidence, never punitive or intimidating. A poor learning environment inhibits effective learning.

2. Perform a “Needs Assessment”

All too often, we assume what a resident knows based on their post-graduate year of training or progress through the training program. It is important to ascertain where the resident is in mastery of the material. A “needs assessment” determines the level of knowledge or skill an individual resident possesses. This may be achieved by simply asking several questions, observing skill during a procedure or reviewing past evaluations.

The needs assessment will help you teach at a level appropriate to the learner. If you teach at too low a level, the material will not be relevant and is a waste of time; if you teach at a too advanced a level, the resident may have difficulty with the concepts or skills, and learning will be adversely affected. Performing and acting upon a needs assessment will ensure that the material is relevant.

3. Provide “Goals and Objectives”

Adults need to feel that their learning leads to a goal, so you shouldn’t keep this goal a secret! Tell the learner from the outset what you expect, whether you are lecturing or teaching in clinic or operating room. The goal of the teaching intervention can be thought of as the big picture of desired learning.

Objectives are more discreet, measurable items that can be considered the goal’s building blocks. If you achieve the objectives, the goal will be met. For example, prior to a clinic teaching session, I might tell a first year resident, “Today, I want to be sure that you are able to detect a relative afferent pupillary defect and describe its significance.” This is the goal of the teaching intervention. To reach this goal, objectives might be that resident should be able to:

1. Recite the anatomy of the pupillary light reflex
2. Perform a swinging flashlight test
3. Identify a relative afferent pupillary defect in at least three patients.

By providing these simple goals and objectives you establish a framework for learning and testing. The resident will have a clear understanding of what you deem to be important.

4. Improve Lecture Effectiveness

The formal lecture is still widely used to impart information to residents. Unfortunately, learning retention is very poor when students passively listen.

You should be providing goals and objectives at the beginning of every lecture to orient the student and let them know what they should be getting from it. Ideally, you should also get the audience thinking and involved, perhaps by using a case study, pre-test, or by asking a stimulating question. These approaches orient and engage the audience.

The difficult part is maintaining attention in the body of the lecture – adults lose attention after just 10 minutes of passive listening. This is where interactivity should play a role. Frequent questioning of the audience, using case studies, brainstorming, varying audiovisual aids and emphasizing relevance will help keep the audience attentive and participating.

To wrap up the lecture, be sure to have a conclusion that summarizes the key points. Post-testing is also valuable as both you and the students will see that learning has occurred (hopefully!).

5. Give Good Feedback

Feedback may be formative or summative. Formative feedback can be thought of as behavior modification – you are trying to change bad habits and reinforce good behavior. Another word for formative feedback is teaching! Summative feedback is the grade on a test or whether one has passed or failed a rotation.

From a teaching standpoint, formative behavior is crucial for improving knowledge and skill. Good formative feedback should be timely: if your dog pees on the rug, you don’t scold your dog a week later – you do it right away or the dog doesn’t know why they are being scolded! It should also be frequent, specific (hopefully based on first-hand data) and should be designed to improve performance. Terms such as “good case” or “you are not doing right” are not helpful as the resident doesn’t know what was good or how to “do it” right. Be specific about what exactly was good about how the case was done. Tell the resident exactly how to do it right.

Good feedback should point the resident in the right direction and improve performance. Remember that feedback should be used not only to help the struggling resident improve but to make a good resident great. You should use formative feedback every day!

6. Use a Rubric

I define a rubric as an explicit set of criteria used to assess a particular skill. This provides you with a tool that can help you to give timely, specific, structured feedback. Rubrics can be used to assess virtually any skill including piano playing, lecturing, and surgical procedures.

Good rubrics consist of three parts: dimensions, for example, steps of a surgical procedure; levels, for example, scores of 1 through 5, or novice to expert; and descriptors, that is, what it means to perform at a certain level for any of the dimensions. Valid and (sometimes) reliable rubrics have already been published for ophthalmic patient examination (1,2), phacoemulsification (3,4), small incision cataract surgery (5), strabismus surgery (6) and the lateral tarsal strip procedure(7).

Rubrics should be given to the resident in advance so that they serve as both a teaching and assessing tool. The resident can read the rubric in advance to learn what is required to be competent in various stages of the procedure. The rubrics should be completed by you immediately after the case and then reviewed with the resident to provide that structured, timely and specific formative feedback described above. Additionally, the rubric allows you to more objectively assess the resident’s performance, allowing areas of deficiency to be identified and remediated.

In summary, we should always strive to improve our teaching effectiveness, with the goal of stimulating resident learning. Utilize adult learning principles in your teaching and try using some of the strategies described. Good Luck!

Karl C. Golnik is Director for Education of the International Council of Ophthalmology and Professor, Department of Ophthalmology, University of Cincinnati and the Cincinnati Eye Institute, OH, USA.