Faculty Development: Tools for Working with Residents

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ACGME Citation

II.B.2. Faculty members must.

II.B.2.c) demonstrate a strong interest in the education of residents;^(Core)

II.B.2.d) devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities;^(Core)

II.B.2.e) administer and maintain an educational environment conducive to educating residents; ^(Core)

II.B.2.f) regularly participate in organized clinical discussions, rounds, journal clubs, and conferences; and,^(core)

II.B.2.g) pursue faculty development designed to enhance their skills at least, annually: ^(Core)

II.B.2.g).(1) as educators; ^(Core)

II.B.2.g).(2) in quality improvement and patient safety; ^(Core)

II.B.2.g).(3) in fostering their own and their residents’ well-being; and, ^(Core)

II.B.2.g).(4) in patient care based on their practice-based learning and improvement efforts; ^(Core)

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Introduction

Faculty development is required by the ACGME for the teaching faculty for the surgery residency program.  The categories of this faculty development are in medical education, quality improvement, wellness and in patient care.  How this is offered, taken, and recorded for the faculty is up to the individual program.  On site visits, and in the WebADS, this is usually documented by including a list of faculty development courses or seminars offered by the institution, school of medicine, or at national meetings.  This usually get more onerous for the core faculty that are at affiliated institutions.  

Faculty development programs can look different depending how you want to approach it with your teaching faculty.  They can be department sponsored and very elaborate like faculty coaching programs, a regimented didactic program, to being a list of resources that faculty should take or review annually.  

 ‘Most faculty have limited or no training to equip them to be successful teachers unless they have sought additional training in education or have improved their skills through experience, reflection, and personal assessment.  Thus, fulfilling these ACGME requirements can be challenging for the surgical educator and program.’  (Deal SB, Alseidi AA, Chipman JG, Gauvin J, Meara M, Sidwell R, Stefanidis D, Schenarts PJ.  Identifying Priorities for Faculty Development in General Surgery Using the Delphi Consensus Method.  J Surg Educ. 2018 Nov;75(6):1504-1512.

The learning modality that surgery faculty seem to desire:

The topics that faculty seem to desire:

Following this guide to Faculty Development for Surgery Faculty, below are a few resources (with links associated with the title) framed by topic.  How you utilize them in your program can be molded to fit your institutional and department culture.

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Faculty Education

Coaching programs

1. The overall framework for teaching residents through a coaching lens has best been described by Rassbach et al. 
   1. Resident groups are targeted for coaches at certain PGY’s (2-5 for surgery) and usually one coach assigned longitudinally to 5-7 residents.  
   2. Coach training
      1. Initial training
      2. Quarterly coach meetings (around teaching topics) with peer mentoring
      3. Coach assessments intermittently
   3. Coaches are taught using the following framework

1. 4. Coaches should be non-voting members for the Clinical Competency Committees (information to the committees and assist in deficit areas only.
   5. References:
      1. Rassbach CE, Blankenburg R.  A Novel Pediatric Residency Coaching Program: Outcomes After One Year.  Acad Med. 2018 03;93(3):430-434.
      2. Rassbach CE, Bogetz AL, Orlov N, McQueen A, Bhavaraju V, Mahoney D, Leibold C, Blankenburg RL.  The Effect of Faculty Coaching on Resident Attitudes, Confidence, and Patient-Rated Communication: A Multi-Institutional Randomized Controlled Trial. Acad Pediatr. 2019 03;19(2):186-194.
      3. Min H, Morales DR, Orgill D, Smink DS, Yule S. Systematic review of coaching to enhance surgeons’ operative performance.  Surgery. 2015;158:1168–1191.

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Clinical Teaching

1. Servey J and Wyrick K. One-minute clinical precepting model. MedEdPORTAL.
2. Hodgson CS, Wilkerson L. Faculty Development for Teaching Improvement. Faculty Development in the Health Professions. Springer; 2014, 29–52.

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Structured operative teaching

Consider implementing the BID model (Briefing, Intraoperative teaching, and Debriefing) (Roberts et al):

1. Briefing
   1. This will be a short (2-3 minute) interaction at scrub sink designed to help identify the learner’s needs.  E.g. “Tom, you’ve probably done 100 laparoscopic cholecystectomies. What do you have left to learn in the performance of this procedure?” “I want to work on my efficiency. I end up having to reposition the instrument in my left hand too often, so I want to work on positioning of the fundus grasper.”
2. Intraoperative Teaching
   1. The discussion and didactic during the operation should not merely be rote talk but directed education towards the goals identified at the scrub sink briefing.  This does not preclude the use of teaching scripts but simply directs and focuses them to allow the learner to achieve their self-directed gorals. E.g. “Tom, can you talk me through your decision-making process as you position your left hand? What will help you with your goal of working on efficiency?” “I need to choose a spot with the left-handed grasper to be able to expose the triangle of Calot adequately, but still be able to see the other areas for dissection.” Later: “So how many times have you had to reposition your left hand?” “Only three times–that’s really good for me.” “That’s great. What do you know now about how to do the initial positioning?” “It needs to be low enough to be able to expose the triangle of Calot, but the positioning needs to allow me to start dissecting the liver bed without moving it too many times.”
3. Debriefing
   1. At the end of the operation (e.g. during closing), debrief about the encounter.  The debriefing should consist of four elements:  
      1. Reflection: The learner reflects on their performance and whether they achieved their objective.  E.g. “Tom, how do you think you did with your goal of positioning your left hand appropriately?” “I think I did well this time. Just focusing on it seemed to help.” “I agree. Your time to complete the case was very good, which was, in part, because of your efficiency with positioning.”
      2. Rules: Identify rules to guide future practice.  E.g. “What will you remember to help you position your hand appropriately in the future?” “Grab low enough on the fundus to expose the triangle, but at a place where I can move the fundus back and forth to dissect the liver bed.”
      3. Reinforcement:  Identify what was done right to guide future replication and prioritization of effort.  E.g. “Focusing on positioning at the outset seemed to provide great exposure for dissection without disruptive changes of the grasper position.”
      4. Correction:  Correct technical mistakes but especially identify and correct mistakes in thinking (the underlying reasons for the identified technical fallacies). E.g. “Make sure you consider the friability of the tissue. This gallbladder wasn’t heavily inflamed so it could tolerate more torque during retraction. With friable tissue you may have to reposition more frequently to avoid tearing.”
         1. Gardner AK, Timberlake MD, Dunkin BJ. Faculty Development for the Operating Room: An Examination of the Effectiveness of an Intraoperative Teaching Course for Surgeons. Ann Surg. 2019 Jan;269(1):184–90.
         2. Boillat M, Bethune C, Ohle E, Razack S, Steinert Y. Twelve tips for using the objective structured teaching exercise for faculty development. Med Teach. 2012;34:269–273. 20. 
         3. Roberts NK, Williams RG, Kim MJ, Dunnington GL. The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg. 2009;208:299–303
         4. Trowbridge RL, Snydman LK, Skolfield J, Hafler J, Bing-You RG. A systematic review of the use and effectiveness of the Objective Structured Teaching Encounter.  Med Teach. 2011;33:893–903.
         5. Yang RL, Esquivel M, Erdrich J, Lau J, Melcher ML, Wapnir IL.  PREDICT:  Instituting an Educational Time Out in the Operating Room.  J Grad Med Educ. 2014 Jun;6(2):382-3.

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Giving Effective Feedback

1. Directed feedback 
   1. Ramani S, Könings KD, Ginsburg S, van der Vleuten CP. Feedback Redefined: Principles and Practice.  J Gen Intern Med. 2019 May;34(5):744-749.
   2. Ramani S, Könings KD, Ginsburg S, van der Vleuten CPM.  Meaningful feedback through a sociocultural lens.  Med Teach. 2019 Dec;41(12):1342-1352.

2. Setting the educational environment
   1. Gannon SJ, Law KE, Ray RD, Nathwani JN, DiMarco SM, D’Angelo A-LD, et al.  Do resident’s leadership skills relate to ratings of technical skill?          J Surg Res. 2016 Dec;206(2):466–71.

3. Using recorded video for teaching and learning
   1. Vaughn CJ, Kim E, O’Sullivan P, et al. Peer video review and feedback improve performance in basic surgical skills.  Am J Surg 2016;211(2):355–60.
   2. Hu Y-Y, Mazer LM, Yule SJ, Arriaga AF, Greenberg CC, Lipsitz SR, et al. Complementing Operating Room Teaching With Video-Based Coaching.  JAMA Surg. 2017 Apr 1;152(4):318–25.
   3. McQueen S, McKinnon V, VanderBeek L, McCarthy C, Sonnadara R.
      Video-Based Assessment in Surgical Education: A Scoping Review.  J Surg Educ [Internet]. 2019 Jun 5. Sheahan G, Reznick R, Klinger D, Flynn L,
   4. Zevin B. Comparison of faculty versus structured peer-feedback for acquisitions of basic and intermediate-level surgical skills. Am J Surg 2018

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Mentorship

1. Definitions, goals, and objectives
   1. Healy and colleagues define mentorship as, “a process whereby an experienced, highly regarded, empathetic person (the mentor) guides another (usually younger) individual (the mentee) in the development and re-examination of their own ideas, learning, and personal and professional development.”
   2. Ultimately a successful mentorship program allows the mentee to engage in successful personal growth and development, increase their access to professional networking opportunities, enhance their long term productivity, allow for career advancement and guidance, and improve career satisfaction.
      1. Healy NA, Cantillon P, Malone C, Kerin MJ. Role models and mentors in surgery. Am J Surg. 2012;204(2):256-261
      2. Kibbe et al.  Characterization of Mentorship Programs in Departments of Surgery in the United States. JAMA Surg. 2016 Oct 1;151(10):900-906.  
   3. Goals and Objectives Example:

Mentor Goals and Expectations

Mentor will be punctual and respectful of the mentee’s time

Mentor will focus their efforts on the mentee’s goals with no motives for opportunistic personal advancement

Mentor will help and guide mentee through a wide variety of decisions including but not limited to

• Career decision-making
• Research guidance
• Support in improving health and wellness, as well as burnout mitigation
• Study skills
• Team leadership

Mentor will maintain a safe space for the mentee to discuss any topic relevant to their personal development and wellbeing

Mentee Goals and Expectations

Mentee will be punctual and respectful of the mentor’s time

Mentee will follow up with any suggestions made by the mentor, and take initiative in implementing their advice with a plan of action

Mentee will attempt to understand their individual personal and professional goals and explore them with the mentor

2. Mentorship Models

Throughout the course of surgical training history, a variety of mentorship models have been developed for the surgical trainee

1. 1. Apprenticeship model: Prior to the current surgical residency paradigm, one-on-one training where a master surgeon would impart their knowledge to a pupil until the latter was ready for independent practice.
   2. Halstedian apprenticeship:  After the introduction of surgical residency, trainees underwent a Socratic dialectic method of education from a variety of surgical faculty/mentors.  “See one, do one, Teach one” was the teaching motif.  With increased residency hour restrictions and other modern limitation, many programs started to implement formal mentorship programs for directed trainee guidance with well-documented results. 
   3. Reverse Academic Mentoring Pyramid and/or Dyadic (one-on-one) mentoring:  The most experienced surgical faculty are mentors to those who are just starting their surgical careers.  Theoretically, senior faculty (who are nearing retirement) may have more experience to impart to juniors, and more time to dedicate to mentoring activities.
   4. Mosaic mentoring:  This model promotes the idea that each aspect of the surgical trainee’s goals should have a specific mentor eg. Research mentor, administrative mentor, resident mentor, subspecialty mentor, etc.
      1. Zhang et al.  “Formal mentorship in a surgical residency training program: a prospective interventional study.”  J Otolaryngol Head Neck Surg. 2017 Feb 13;46 (1):13.  PMID: 28193248
   5. Simulation lab:  This model directs the creation of a stress-free atmosphere to simulate not only technical skill acquisition but aspects of clinical and ethical care.
   6. Non-structured mentoring:  As a supplement to a formal mentorship program, surgeons use “teachable moments” to maintain growth such as at the scrub sink, in the OR, journal clubs, etc.
   7. Peer-group mentorship:  Residents may find benefit and find greater ease with opening up regarding their challenges when they can commiserate with those who are going through the same process or have recently done so.  This may optimize generational gap differences in approaches to learning and addressing challenges.  
   8. viii.Speed mentoring: Speed mentoring allows groups of mentors and mentees to meet for a focused period of time with no expectation for ongoing mentoring follow up.
      1. Ten Cate O, Durning S. Dimensions and psychology of peer teaching in medical education.  Med Teach. 2007 Sep;29(6):546–52.
      2. Ten Cate O, Durning S. Peer teaching in medical education: twelve reasons to move from theory to practice.  Med Teach. 2007 Sep;29(6):591–9.
   9. Tele-mentoring:  Off-site surgeons evaluate surgical activity to assess for adequate acquisition of new skills. 

1. 1. 1. Rombeau JL, Goldberg A, Loveland-Jones C. Surgical Mentoring: Building Tomorrow’s Leaders. New York: Springer; 2010.
      2. Economopoulos et al., Coaching and mentoring modern surgeons. Accessed: 2/3/2020
      3. Aylor M, Cruz M, Narayan A, Yu C, Lopreiato J.  Optimizing Your Mentoring Relationship: A Toolkit for Mentors and Mentees.  MedEdPORTAL 
2. Mentor evaluation by mentees
   1. Mentoring Competency Assessment:  Validated tool
      1. Fleming M, House S, Hanson V, et al. The Mentoring Competency Assessment.  “Validation of a New Instrument to Evaluate Skills of Research Mentors”  
      2. Cho CS, Ramanan R, Feldman M.  “Defining the ideal qualities of mentorship: a qualitative analysis of the characteristics of outstanding mentors.”  Am J Med. 2011 May;124(5):453-8.
   2. Mentee evaluation by mentors
      1. A variety of evaluation forms are used and are often home-grown.  The Mentoring Competency Assessment (MCA) for mentees may also be used.
      2. The goal is to assess to what extent the mentor is a fit for the mentee and how well the latter’s needs are being met through the relationship.
         1. UW Institute for Clinical and Translational Research. Mentor Evaluation Form Examples.  Accessed: 2/3/2020
   3. Mentorship Program Evaluation
      1. The formal program evaluation should be structured according to the individual program’s needs, goals, size, etc.
3. Practical Summation
   1. Implementing a formal mentorship program is a challenging yet important undertaking.  A formal, discussed plan of action coordinated with a high level of communication with all stakeholders can make the implementation much easier and successful.
   2. Consider forming a mentorship program subcommittee with interested, experienced faculty and residents.  This should allow for a coordinated formulation of the program’s goals and objectives and the general format of the program (eg. A mix of mosaic mentorship and peer mentoring).  Identify volunteer faculty mentors.
   3. Identify a standard manner of pairing mentors and mentees.  For example, at our previous institution (West Virginia University, Morgantown, WV) we elected to assign volunteer mentors to the new PGY-1 residents, but allowed other years to select their own mentors.  As the PGY-1s moved to their PGY-2 years they would have the option to keep their current mentors or identify new ones to transition to depending on their long term needs.
   4. Be clear at the outset that no feedback related to the program will be used for CCC evaluation of the resident.  All interactions are confidential within the program.  Nevertheless, it may be beneficial for the CCC committee to have access to the mentor-mentee assignments to communicate any identified issues to the relevant mentor for assistance.
   5. Identify a QI process to evaluate that:
      1. Mentors and mentees are meeting their goals and responsibilities
      2. Programmatic and individual evaluations are completed at a set frequency to allow program leadership to make changes on a yearly basis
      3. Mentors and mentees are meeting at an appropriate frequency.
   6. Frequent follow-up with the mentors will also ensure that any problematic interactions or previously unidentified individual mentee-related issues are not overlooked.
   7. Be clear at the outset that no feedback related to this program will be used for CCC evaluation of the resident.  All interactions are confidential within the program.

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Wellness

ACGME Citation

VI.C.1. The responsibility of the program, in partnership with the Sponsoring Institution, to address well-being must include:

VI.C.1.e) Attention to resident and faculty member burnout, depression, and substance abuse.  The program, in partnership with its Sponsoring Institution, must educate faculty members and residents in identification of the symptoms of burnout, depression, and substance abuse, including means to assist those who experience these conditions.  Residents and faculty members must also be educated to recognize those symptoms in themselves and how to seek appropriate care.  

1. Practical Summation
   1. Wellness is a mindset and a culture.  It is also essential to cultivate this culture to ensure a workforce that is dedicated to and caring for others; patients and one another.  It is also mandatory as stipulated in the ACGME general surgery program requirements.
   2. A formal program is not essential but recommended.
      1. A culture of coverage for patient care when residents are caring for their families or themselves must be established
      2. Skills session for faculty and residents on the recognition of burnout, fatigue, depression and substance abuse should be an annual event.
         1. Grand rounds for faculty and residents
         2. Skills session for residents
         3. Presentation at department, division, and/or section meetings for faculty
      3. Policies and department message that going to regular appointments is not only mandatory but encouraged
      4. Mental health services offered and widely publicized and encouraged
      5. Regular wellness functions outside the workplace
         1. For groups of residents
         2. Faculty and residents
      6. Skills session in leadership, teamwork, and communication
         1. For faculty
         2. For residents
      7. Resources for housing, childcare, exercise facilities, family and personal counseling, and emergencies to be compiled, coordinated, and offered
   3. Implementing a formal wellness program is a challenging yet important undertaking.  A formal, discussed plan of action coordinated with a high level of communication with all stakeholders can make the implementation much easier and successful.
   4. Consider forming a wellness program subcommittee with interested, experienced faculty and residents.  This should allow for a coordinated formulation of the program’s goals and objectives and the general format of the program (eg. Policies and components).  Identify volunteer faculty, residents, and mental health provider(s).
   5. Identify the components of the program.  For example, 
      1. Mentorship
         1. Informal
         2. Formal
      2. Physical
         1. Gym facilities
         2. Fitness challenges
         3. Fitness groups
            1. Races
            2. Yoga
            3. Boot camps
            4. Soul Cycle
      3. Mental
         1. Formal group counseling
         2. Individual counseling services offered
         3. Sessions
            1. Reflection – journaling, poetry (in groups or self-directed)
            2. Medication
      4. Social
         1. Group outings
         2. Residency-wide retreats
            1. Teamwork 
      5. Healthy Food
         1. Snacks 
            1. Workroom
            2. Off hours

1. 6. As you start a program consider obtaining survey data or hold discussions with your residents regarding their perceived primary sources of burnout.
      1. Your problems (and, therefore, solutions) are likely to be institution-specific and may or may not be amenable to a structured, published wellness curriculum.
         1. Consider using an “Inventory of Elements” to assess strengths and weaknesses related to your program’s current well-being activities and culture
            1. 2016 ACGME Annual educational conference.  Inventory of Elements of Your Program’s Resident Well-Being Plan. (n.d.). Retrieved February 25, 2020, from https://www.acgme.org/Portals/0/PDFs/Webinars/ProgramSpecificWell-BeingInventoryACGME2016.pdf
      2. Oftentimes burnout may be secondary to very specific EMR issues, specific floor issues, or inter-team conflict that cannot be affected interventions directed towards residents as individuals
         1. Identify these issues as soon as possible liaise with leaders and stakeholders of the relevant groups.  
         2. For example, residents may be paged for non-urgent electrolyte repletion issues often in the middle of the night or during high activity periods.  Mitigate these effects on resident burnout and improve patient care through validated nursing directed electrolyte repletion protocols.  Other strategies to decrease pages may revolve around charge nurses screening nursing concerns prior to contacting a physician
         3. Another example may be to meet with the institution’s medicine department to discuss, for example, holding off on non-urgent consults in the middle of the night when only a skeleton crew is present, until the next morning when more resources are available.
      3. Transparency is critical in the implementation of a wellness program with respect to expectations and end-goals.  The wellness program must NOT be a source of additional stress for the residents nor should they perceive that this is simply another box that the program needs to check.  Be clear as a leader of your program that although wellness initiatives in surgical programs are feasible, highly valued, and positively perceived by residents when implemented correctly, they have not been associated (as of this writing) with improved rates of burnout or resiliency in surgical residents.
   7. Salles A, Liebert CA, Esquivel M, Greco RS, Henry R, Mueller C.  Perceived Value of a Program to Promote Surgical Resident Well-being.  J Surg Educ. 2017 Nov – Dec;74(6):921-927.