Open Access Original
Article
DOI: 10.7759/cureus.818
Does Faculty Follow the Recommended
Structure for a New Classroom-based, Daily
Formal Teaching Session for Anesthesia
Residents?
Anjum Anwar 1 , Pedro Tanaka 2 , Matias V. Madsen 3 , Alex Macario 4
1. Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University 2. Department of
Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine 3. Department
of Anesthesiology, Herlev and Gentofte Hospital, University of Copenhagen 4. Department of Anesthesia
H3580, Stanford University School of Medicine
Corresponding author: Anjum Anwar, anjum@stanford.edu
Disclosures can be found in Additional Information at the end of the article
Abstract
Background: A newly implemented 15-minute classroom-based, formal teaching session for
anesthesia residents is given three times daily by the same faculty. The faculty member was
provided a suggested template for the presentation. The template structure was developed by a
group of residents and faculty to include best teaching practices. The goal of the current study
was to measure how frequently the faculty teaching these sessions followed the template.
Methods: From February 20, 2015 to February 6, 2016, a research assistant trained in education
mapped a total of 48 teaching sessions to determine how frequently the teaching sessions
included each of the elements in the recommended template structure. The assistant was
chosen from outside the anesthesia department so as to minimize biases.
Results: It was found that 98% of the sessions used the teaching template's suggestion of using
computer slides (e.g., a Powerpoint presentation). We observed that 75% of the sessions
provided specific recommendations about patient care, 65% had reinforcement of learning
points, 56% had a test or a quiz, 49% provided references and directions for further reading,
44% provided take-home messages, and 31% used a clinical case vignette presentation to
introduce the keyword. The most common visuals were the use of a picture (38%) and a chart or
a graph (35%). We also saw that 65% of the sessions had active involvement of residents. With
respect to time and slide limitations mentioned in the template, we saw that 35% of the
sessions finished within the recommended time limit of 15 mins and 21% had the
recommended 10 or fewer slides.
Received 08/16/2016
Review began 09/12/2016
Review ended 09/27/2016
Published 10/06/2016
Conclusion: Compliance by the faculty to the recommended structure was variable. Despite
this, the sessions have been well received and have become a permanent part of the residency
curriculum more than two years after their implementation.
© Copyright 2016
Anwar et al. This is an open access
article distributed under the terms of
the Creative Commons Attribution
License CC-BY 3.0., which permits
unrestricted use, distribution, and
reproduction in any medium,
Categories: Medical Education
Keywords: best teaching practices, adherence to a template, reinforcing learning points, employing
attention grabbers in teaching, active learning
provided the original author and
source are credited.
Introduction
How to cite this article
Anwar A, Tanaka P, madsen M V, et al. (October 06, 2016) Does Faculty Follow the Recommended
Structure for a New Classroom-based, Daily Formal Teaching Session for Anesthesia Residents? . Cureus
8(10): e818. DOI 10.7759/cureus.818
A classroom-based formal lecture remains common in graduate medical education. The amount
of knowledge and number of skills that anesthesiology residents need to learn increase every
year as the specialty grows in scope. Since time available to learn both during direct patient care
and in the classroom is limited, optimizing the education yield is a priority for every program
director.
Two years ago, a new classroom-based formal teaching series was implemented when focus
groups with the house staff revealed that they wanted explicit instruction of keywords for the
American Board of Anesthesiology (ABA) exam [1]. The house staff also identified teaching
techniques they thought the faculty should use, which was complemented by input from
anesthesia faculty with expertise in medical education [2].
The new program consisted of a 15-minute time-limited session repeated three times daily by
the same faculty member. This format enabled almost all residents to attend, given the
constraints of their individual schedules. A predetermined presentation template developed by
the residents and faculty was provided to the lecturers to provide uniformity for how content
was delivered. This template included, for example, a brief clinical case scenario to introduce
the day’s ABA keyword topic and a multiple choice question to promote interaction between
the lecturer and residents.
The best teaching practice elements in the recommended template were similar to what had
been found in other studies. For example, a panel of experts found that a high-quality
presenter summarizes key concepts, uses audio and/or visual aids, presents material in an
organized fashion, monitors audience’s understanding of material, provides a conclusion,
clearly states goals of the talk, shows enthusiasm for topic, demonstrates command of the
subject matter, encourages appropriate audience interaction, and communicates the
importance of the topic [3]. Also, residents prefer teaching that is directly applicable to patient
care, evidence-based, short in duration, structured around clinical cases or questions, and
includes active participation [4].
The goal of the current study was to measure how frequently the faculty teaching these sessions
followed the structural elements recommended by the resident and faculty groups. These
elements included using computer slides, introducing the ABA keyword with a clinical case
vignette, reinforcing learning points, employing graphics or visuals, adding quizzes, providing
recommendations about patient care, incorporating references/directions for further reading,
eliciting active involvement of residents, listing take home messages, limiting the talk to a
maximum of 10 slides, and finishing the lecture within 15 minutes.
Materials And Methods
The Stanford Institutional Ethics Review Board deemed this study exempt from review. Since
this study was considered as a program evaluation, the requirement of signed consent forms
from participants was waived.
From February 20, 2015 to February 6, 2016, a research assistant trained in education attended
the lectures. The assistant mapped a total of 48 sessions to one of the 10 elements in the
recommended lecture structure. To address subjectivity in determining the presence or absence
of some of the elements, a pilot study period was conducted where a dozen sessions were
mapped and discussed with all the authors to standardize data collection. The assistant was
chosen from outside the anesthesia department so as to minimize biases.
The faculty in the Department of Anesthesiology, Perioperative, and Pain Medicine selected
topics for the lectures from the keyword list available at
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http://www.openanesthesia.org/category/aba-keywords/. Table 1 shows an excerpt from the list.
ABA Keywords Sample
Adrenal insufficiency: Lab finding
Cerebral aneurysm – Electrolytes
Advanced multiple sclerosis: Anesthetic drugs
Cerebral aneurysm – Transmural pressure
Aerobic vs. anaerobic glycolysis
Cerebral aneurysm clipping – Anes. management
Age-related P50
Cerebral autoregulation
Aging – CNS changes
Cerebral blood flow: Temperature effect
Aging: Cardiovascular physiology
Cerebral ischemia: Deep hypothermia
Aging: Pulmonary physiology
Cerebral vasospasm: Treatment
TABLE 1: ABA Keywords Sample
This table is an excerpt from the keyword list available at http://www.openanesthesia.org/category/aba-keywords/.
The following elements were included in the standardized slide template shown below in
Figure 1:
-- Presenting a clinical case vignette to set up a problem-based learning experience and to
introduce the keyword. The rationale is that the first moments of a presentation set the tone,
capture the learners’ attention, help with the learning climate, and place the session into
context.
-- Reinforcing learning points to strengthen the concepts.
-- Including specific recommendations on patient care and clinical applicability to emphasize
the relevance of the topic to the learners.
-- Using graphics and visuals as attention grabbers, including the use of video clips, a cartoon,
charts/graphs, or a picture. The number of images (e.g., PNG, JPEG, JPG, screenshot, or cartoon)
per lecture was counted as well.
-- Using a quiz as an attention grabber to help learners interact with content.
-- Actively involving residents in the teaching session. The conceptual framework presented by
Chi [5] described active, constructive, and interactive as types of overt learning activities
undertaken by students. This framework generates a hypothesis that active engagements are
likely to be better for learning [6]. We measured the active involvement by the number of
interactions during the lecture where a learner was involved. For this study, active engagement
between teacher and learner was defined as more than three engaging activities every 10
minutes of the formal teaching session. Those activities included residents asking questions,
responding to questions by the instructor, or development of a group discussion [7].
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-- Including references or directions for further reading.
-- Providing explicit take-home messages at the end.
-- Using no more than 10 slides
-- Limiting the lecture to 15 minutes
FIGURE 1: Keyword template
Results
Adherence to the template ranged from a low of 21% for not exceeding the number of slides
limitation to a high of 98% for using computer slides (one faculty used an erasable white board
instead of computer slides). These results are shown in Table 2 and also visualized in Figure 2.
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Template Element
Adherence Percentage
Computer slides (e.g., Powerpoint) presentation
98%
Clinical case vignette presentation to introduce keyword
31%
Reinforcement of learning points/repetition
65%
Specific recommendations patient care - clinical applicability
75%
Graphics and visuals:
- video clip
4%
- cartoon
2%
- chart/graph
35%
- picture
38%
Test or quiz
56%
Active involvement of residents
65%
References/directions for further reading/studies
49%
Take home messages
44%
Lecture duration of at most 15 min
35%
A maximum of 10 slides
21%
TABLE 2: Percentage of the Formal Teaching Sessions that Met Expected Structural
Elements as Recommended by the Faculty and Resident Work Group
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FIGURE 2: A visual display of data in Table 2
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The number of slides per lecture averaged 13.9 with a standard deviation (SD) of 4.2 and the
number of images per lecture averaged 3.3 with an SD of 4.2. It was observed that 74% of the
lectures had images. Other attention grabbers observed were brainstorming at 23% of sessions,
citations at 4%, personal anecdotes at 17%, challenges to the group at 19%, dramatic action
(such as imitating patients' breathing and extraordinary gesticulation) at 13%, and polls at 13%.
Please see Figure 3 for attention grabbers and Figure 4 for components of visuals.
FIGURE 3: Use of attention grabbers
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FIGURE 4: Components of graphics and visuals
Discussion
Compliance by the faculty to the recommended structure was variable. Despite this, the
sessions have been well received and have become a permanent part of the residency
curriculum more than two years after their implementation.
It is possible that the predetermined slide template structure was not explicit enough as to the
required elements. Furthermore, it could be the case that not all of the elements recommended
by the resident and faculty group were equally important. Efforts are underway to educate and
remind faculty to take advantage of all the suggested elements.
The purpose of presenting a case vignette is to activate the resident’s prior knowledge. The
conceptual framework is that prior knowledge is then built upon further as the residents at the
session interact, resulting in their initial mental model to be modified and refined. As
previously acquired knowledge is activated, the house staff can identify gaps in knowledge as a
part of the activation–elaboration notion. Also, situational interest exists in that either the
case or the test question creates a desire to find out more about the topic. This increases
concentration, focuses attention, and induces a willingness to learn, motivating the resident to
further inquire either with the faculty or literature until they are satisfied with their
understanding [8].
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Reinforcement of learning points occurred in 65% of the sessions. However, only 44% of the
sessions provided explicit take home messages. This is crucial as learner engagement alternates
between attention and non-attention in shorter and shorter cycles as a lecture proceeds [9]. In
addition, the human cognitive system has a limited working memory that can hold five to nine
pieces of information elements and can actively process up to two to four simultaneously.
We found that the faculty paid attention to mentioning the clinical applicability of the teaching
session. It was observed that 75% provided specific recommendations for patient care. As for
the use of attention grabbers, 74% of the lectures had one or more images. Research suggests
that attention grabbers help students to learn by helping to refocus their attention [10]. Other
attention grabbers included brainstorming in almost one-quarter of the sessions and a
challenge to the group or a personal anecdote, each observed in almost one-fifth of sessions.
Two-thirds of the formal teaching sessions employed active learning, often with a group
dialogue between faculty and residents. A study of 35-noon conferences with internal medicine
residents found that 52% of the sessions had interaction with the audience (not specifically
defined) and 17% included suggested reading [11]. These percentages are a bit lower than what
was measured in our study, 65% and 49%, respectively. The active design elements used in our
study are consistent with cognitive load theory. This framework for how people learn
acknowledges that human information processing includes information presented in a visual or
pictorial format and information presented in an auditory or verbal format. The lecture series
structure aims to provide multiple sources of information presented in visual form (e.g., a
written text and a diagram), in spoken form, and in group interaction so as not to overload the
visual processor.
Given that 75% of the teaching sessions were 18 minutes or less suggests that the presenters
stayed close to the recommended 15-minute time window. While only 21% of the lectures met
the 10-slide limit, we observed that 76% had 16 or fewer slides. Both of these observations are
encouraging as it is well-known that the audience attention span decreases significantly after
10 minutes [12].
Based on subsequent input by the trainees, a few more elements will be added to the
standardized template. These include (a) explicitly defining the learning objectives to help
establish expectations regarding the intended skills, attitudes, and knowledge for the learner
and (b) recommending that slides have no more than seven lines (which we defined as "overly
busy") [13-14]. We did relook at the slides of the 48 sessions and found that 42% of the faculty
did not use any overly busy slides.
Our study had certain limitations, including that it was performed at one institution and might
not be generalizable to other residencies. In addition, the teaching elements measured might
not reflect all aspects of what characterizes a successful formal teaching session, such as the
speakers' abilities to be engaging [15]. Furthermore, the adherence to the template might have
been adversely affected by the lack of formally required instructions about being compliant
with the template. It is well-known that residents also appreciate a safe learning environment,
which we were not able to specifically quantify [16]. This study also did not test how the
sessions affected learning retention, such as with a before-and-after written test, or a change in
resident anesthesia clinical practice.
Only a minority of the anesthesiology faculty have formal training in educating residents [17].
Most clinical faculties learn teaching techniques by primarily observing as a learner in someone
else’s lecture. As a result, ongoing faculty development efforts for teaching, including in the
classroom-based lecture format, are needed [18].
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In summary, the faculty were found to more commonly follow the best teaching practices of
mentioning clinical applicability, reinforcing main learning points, and active involvement of
residents. The template was less helpful in ensuring some other elements, such as the
presentation of a case vignette to introduce the ABA keyword.
Conclusions
In summary, the lecture template was very helpful in ensuring that the faculty followed the
best teaching practices of (a) mentioning clinical applicability, (b) reinforcing main learning
points, and (c) actively involving residents. The template was less helpful in ensuring some
other elements of the template, e.g., the slide limit and presentation of a case vignette to
introduce the ABA keyword. We conjecture that the template’s success in ensuring the best
teaching practices led to these sessions being well received. They have now become a
permanent part of the residency curriculum more than two years after their implementation.
Additional Information
Disclosures
Animal subjects: This study did not involve animal subjects or tissue. Human subjects:
Stanford Institutional Ethics Review Board issued approval N/A. Stanford Institutional Ethics
Review Board deemed this study exempt from review. Since this study was considered as a
program evaluation, the requirement of signed consent forms from participants was waived.
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