Education Columns

By James E. Hougas, III, MD, FAAFP

The creation of a new colonoscopy program at the family medicine residency brought many challenges. Only the newest teaching faculty (TF) had the privileges and experience to perform the procedure. The first plan was to recredential another faculty member who had previously performed colonoscopy but had not done so in years. Teaching an experienced faculty learner (EFL) is a unique situation. The EFL had almost quadruple the years of clinical experience and twice the years of teaching experience compared to the TF.

Skill Assessment

Many procedures can be taught in a specific order with an expected progression. In colonoscopy, each subskill builds on the prior skill, and the learner takes on more and more of the procedure.

Differences with EFL:

The EFL may experience mastery of skills earlier than expected. EFL confidence and nonlinear skill acquisition may mask areas where skill refinement is needed because of inaccurate assumptions by the TF.

Approach to the EFL:

An initial assessment was conducted by the TF with supervised colonoscopy simulation. The TF and EFL coconstructed an accelerated training plan based on the EFL’s self-reflection. The TF elicited EFL’s opinions on the training, progress, and next direction frequently. The TF reevaluated procedural competencies regularly.

Style Differences

Learners regularly adopt practice styles similar to their TF. The shared style allows the TF to predict the learner’s actions and efficiently correct skills. This happens through a shared vision of each skill.

Differences with EFL:

The EFL previously trained with different TF and has a preexisting style.

Approach to the EFL:

The TF has a responsibility to evaluate the EFL’s current approach and offer alternatives while maintaining safety. After the EFL demonstrated the ability to recognize their limits, the TF gave them ample opportunity to struggle and troubleshoot a skill. The TF would offer their approach and allow the EFL to independently assess the merits of that style.

Hierarchy/Readiness to Assume the Role of the Learner

The majority of learners in graduate medical education have less clinical and procedural experience than their TF. Based on their level of training, the learner has a concept of decisions they are allowed to make independently and which require consultation with the TF.

Differences with EFL:

The EFL has been practicing independently longer than the TF and is distant from residency. The TF and EFL are also peers in a larger university-based, full-spectrum practice.

Approach to the EFL:

The TF leveraged the EFL’s experience with the procedure to allow the EFL the first chance to determine the support they needed. The EFL’s insights allowed the TF to evaluate competency and offer guidance. Because of the EFL’s capability, the TF would ask more questions like “How can I help you?” and “Where were you getting hung up?” Guidance was delivered with “What I would do here…”, “You could consider…”, or “How about you try… .” In debriefs, the EFL could better articulate what training they needed next. Conflict was generally avoided because of the previous cocreation of the training plan.

Final Thoughts

The process of teaching an EFL is a unique one. Because of the EFL’s own teaching abilities and experience, the TF was able to have direct and well-articulated feedback on the TF’s teaching style. The TF frequently requested this feedback, which also helped maintain the peer relationship.