Fellows as Teachers: Supporting Future Educators

After completing this article, readers should be able to:

1. Identify the various teaching roles embodied by fellows throughout their training.

2. Analyze reasons for developing teaching skills as an essential part of any fellowship training.

3. Evaluate the barriers to facilitating the growth of fellows as teachers and apply strategies to mitigate these challenges.

4. Explore essential educational foundations and innovations that guide and support the design of curricula for fellows as teachers.

The word doctor is derived from the Latin, docco, which means “to teach.” Teaching represents a core aspect of the physician’s role. As with all other vital skills required for this position, dedicated efforts to develop medical trainee teaching skills are essential. Trainees in subspecialty fellowships are particularly poised to develop and use their teaching skills to educate a diverse learner audience. Fellows transmit their knowledge to other trainees, staff, and patients’ families in roles as teachers, team leaders, and consultants to other specialties, with the goal of optimizing the quality of care delivered to patients. Because of these roles, the Accreditation Council for Graduate Medical Education and American Board of Pediatrics expect fellows to develop skills as competent teachers based on the subspecialty milestones. (1) However, formalized efforts to help fellows progress along the milestones are variable. Enhancing the teaching skills of neonatal-perinatal medicine (NPM) fellows would not only benefit fellows in training, but also their institutions, other learners, patients, patients’ families, and the greater field of neonatology. While there are challenges in doing so, strategies also exist to support training programs and their fellows in this endeavor.

Engaging in roles as both learner and teacher may be challenging as fellows balance their own learning with that of their learners. Despite this challenge, teaching has been shown to help physicians broaden and deepen their clinical skills and knowledge acquisition, as well as practice more thoughtfully as they justify their decisions based on the underlying evidence to their learners. (2) Fellows who have participated in a “fellows-as-teachers” program noted improvements in their teaching skills and a deepened understanding of neonatal pathophysiology as the most valued outcomes. (3) By teaching more junior trainees, such as residents and students, fellows solidify their knowledge and practice by explaining nuanced physiology to other medical professionals. By teaching families, fellows learn the art of explaining scientific information in more easily understood terms. By teaching other health care professionals and ancillary staff, fellows have the opportunity to strengthen their multidisciplinary relationships and improve the teamwork culture of the unit. Thus, learning how to teach effectively can help fellows’ careers by building a strong knowledge base, improving their communication, and cultivating leadership skills.

The benefits of family-centered care and shared decision making with families are well-established. (4)(5)(6) The skills needed to effectively communicate complex medical information and lead discussions about potential treatment plans with caregivers resemble those needed to teach effectively, breaking down information and assessing for understanding. Understanding a neonate’s medical condition can help parents comprehend the importance of certain aspects of NICU care, such as skin-to-skin time, minimal noise in the unit, and infection prevention strategies. In this way, supporting fellow teaching skills may translate into improved quality of care for infants and their families. In addition, family education is especially critical at the time of discharge to increase parental understanding and confidence in their child’s care. (7)

Learner education is a primary goal of all training programs. Research suggests that fellow participation in fellows-as-teachers curricula help develop their skills as effective teachers and enhance resident and medical student education. (3)(8) In 1 study, residents reported that fellows were “very important” to their education, and they rated their overall satisfaction with their NICU experience higher after implementation of a fellow-as-teacher curriculum. (3) Because fellows have recently progressed through medical school and residency, they likely have a better understanding of trainees’ learning needs. (9) In a study by Woodfield and Sullivan, 89% of medical students reported a preference for teaching by clinical teaching fellows over attending physicians. (10) Students identified fellow teaching as being more approachable, consistent, and well-suited to their level of learning. In addition, faculty have reported that they were able to focus on teaching residents more advanced topics, knowing that the fellows had covered the more basic foundations. (3) When fellows provide bedside teaching or formal didactics, they also role-model the importance of teaching and fostering an effective learning environment.

A focus on fellow teaching skills can benefit the division’s educational culture by fostering an environment in which teaching is valued. Recommendations include incorporation of medical education topics into conferences, providing faculty development opportunities, and highlighting educators’ work within a division or department. (9) Together, fellows and faculty can cultivate a collaborative learning environment to meet the needs of rotating learners, staff, and families. Creation of a positive learning environment supports wellness and protects against burnout. (11)(12) In addition, incorporation of a robust teaching culture can promote interest and innovation in education that may add to the academic productivity of a neonatal division and aid long-term recruitment of clinician educators. (9)

Strengthening the teaching skills of fellow physicians promotes the development of strong future educators and patient advocates and may have important effects on the growth of neonatology as a field. For instance, pediatric residents identify subject matter, role models, lifestyle factors, and teaching as key drivers in making career choices. (13) Of these, the opportunity to teach is significantly more important to those pursuing subspecialties than general pediatrics. Mentorship is also an important factor influencing resident career choice. (14) Fellows who exhibit strong skills as teachers and engaged role models for more junior learners may similarly influence their learners’ career choices. Furthermore, clinician-educator tracks have increased in graduate medical education programs, (15) with an increasing trend seen in physicians choosing education tracks to promotion. (16) Taken together, it is important for the field of neonatology that fellowship programs develop and emphasize their education programs to attract and retain physicians within the field.

One of the biggest challenges to improving fellow teaching skills is the lack of time to acquire and practice these skills. (17) NPM fellowship responsibilities include a multitude of clinical and nonclinical demands. With competing priorities, it is important to capitalize on opportunities that already exist for fellow skill development, such as incorporating medical education topics into fellowship curricula and providing observation and feedback of fellow teaching skills by faculty while on patient rounds (Table).

It can be equally challenging to devote time to teach. For instance, there is a fine balance between leading patient rounds so that patient management can proceed efficiently while ensuring rounds are educational for junior learners, such as medical students and residents. Learning techniques that facilitate teaching “on the fly” may be particularly useful to overcome this barrier (Table). Teaching in short increments is also supported by research that suggests that learners can focus best during shorter sessions. In addition, learners themselves experience competing demands with limited time for neonatology-specific teaching and procedural skill acquisition as they balance patient care, their own didactics, and other responsibilities such as attending continuity clinic. Thus, scheduling protected time for teaching before beginning patient rounds may be an effective strategy. This could be a case discussion of an overnight admission or review of new radiology studies.

Fellows are actively engaged in building their own knowledge base, clinical expertise, and procedural skills. As a result, they may lack the confidence to transfer knowledge they themselves are still solidifying. They need time to study, attend their own teaching sessions, and integrate what they have learned into practice. For these reasons, fellows may experience difficulty balancing their own learning with the needs and expectations of their learners. Some may not believe they have much knowledge to offer or feel they lack the tools to teach effectively. Others may find it uncomfortable to realize and identify their own knowledge limitations while teaching. Mentorship and targeted instructional tools and resources provided by faculty to support fellow teaching may help alleviate some of these challenges (Table).

Performing procedures presents a specific conundrum as decreased duty hours, the presence of other trainees and providers, and changes in clinical care and resuscitation practices limit available opportunities for attaining procedural experience. These factors lead to a conflict of interest wherein fellows must assess and balance their own progression toward competency in required procedures with the training and maintenance requirements of other learners and providers. Resuscitation of very-low-birthweight or extremely low-birthweight infants is another common area to attain proficiency, but opportunities for practice may be limited. (18) Clear guidelines from program administration dictating priority for the fair distribution of procedural opportunities can help alleviate some of this tension. Several procedures also provide opportunities for multiple learners to actively participate or observe, such as placement of umbilical lines and chest tubes. Tools such as video laryngoscopy enable multiple learners to visualize relevant anatomy and learn procedural steps, regardless of the operator. Simulation-based learning experiences may also be a helpful strategy to improve procedural confidence and competence (Table).

Fellows often serve as supervisors for more junior learners, and balancing patient safety with trainee education is another challenge that may arise. (17) Discernment of subtle findings on the history or physical examination, interpretation of laboratory and imaging results, and management decisions can have a negative impact on patient outcomes. Faculty guidance may be particularly useful as fellows practice balancing learner autonomy with patient safety. In addition, fellows may experience difficulty providing learners with the opportunities to perform procedures on patients while ensuring patient safety. For example, guiding residents through their first intubation may be challenging, based on various learner, patient, team, and instructor factors. These include learner experience, instructor teaching skills, team communication, and known or unknown patient factors that may influence the success of a procedure. Some of these factors could be mitigated by specific instructional and learner assessment methods such as just-in-time teaching, (19)(20) coupled with a simulation-based readiness assessment. (21) Learner preparation through paired briefing and debriefing, as used in surgical specialties, may also be beneficial. (22)

Within a given day, NPM fellows may find themselves providing some form of education to residents, medical students, nurses, advanced practice providers, respiratory therapists, other physicians within or outside their specialty, parents, and other individuals (Fig). These groups bring their own unique knowledge base and clinical expertise, and there may be differing dynamics related to experience and interpersonal factors at play. Fellows may find it awkward and challenging to serve in a teaching role in some circumstances, such as with more senior advanced practice providers. However, exploring and understanding the scope of an individual and profession’s training can help fellows develop relationships that allow them to both teach and learn from individuals with different expertise. In addition, fellows who are new to an institution experience the extra hurdle of navigating a new hospital system and culture while developing rapport with trainees and staff. (17) Lack of training and confidence in navigating these situations may result in missed opportunities for improving interprofessional team-based care and learning. Strategies for navigating the multiple teaching roles of the fellow include introducing fellows to the various groups with whom they will work and creating opportunities for collaboration and teaching early on (Table).

The current approach to improving fellow teaching skills often relies on self-directed, independent learning. Fellows learn to teach by teaching or by observing effective teachers. Although experiential learning can be highly valuable, this could be improved with timely instruction and access to resources. In addition, although there are structured programs and resources directed at improving resident and faculty teaching skills, (23) relatively few programs target fellows. (3)(17)(24)(25)(26)(27)(28)(29) One study of 183 medical subspecialty fellows revealed that fellows expressed a strong interest in teaching and that the majority believed it would be part of their future career. (23) However, although 67% had training in education during residency, only 33% reported receiving such training during fellowship. There is opportunity to create a continuum throughout training by laying a foundation of key medical education principles and building a stepwise gradient for fellows to improve their skills. Without this foundation, it can be difficult to appropriately assess and align education with the learner’s knowledge base and learning style. Similarly, fellow experiences in receiving real-time feedback on their teaching methods is variable and limited. In the same study, only 29% of fellows reported having their teaching observed during fellowship. Only 12% reported having received monthly feedback on their teaching, (23) similar to another study reporting only 10% of fellows receiving frequent feedback on their teaching. (30)

Institutional resources and commitment to educational excellence may significantly influence the development of fellow teaching skills. Access to educational resources and faculty mentors who are experts in medical education or who have undergone formal training in medical education is inconsistent among departments and institutions. With limited instruction time and many required training objectives to meet, fellowship leadership must choose and prioritize what material to cover. Likewise, departmental and institutional support for these programs depends on priorities and available resources. Pooling resources across divisions, departments, or even institutions, in the form of regional or national curricula, may mitigate the financial strain of developing fellows-as-teachers curricula (Table). Simply emphasizing the importance of teaching in fellowship may be an important first step. (23) Educational collaboratives that promote fellow and faculty development can elevate and enhance the education culture to which fellows are exposed.

Neonatology fellows are developing their foundation of knowledge as they are concurrently refining their preferred teaching approaches to disseminating this knowledge. This flexibility offers fellows the opportunity to practice different teaching strategies that fit various learning styles and individual learning needs as they proceed through their training. Part of determining which teaching styles will work best for a given fellow will depend on personal preferences, learner characteristics, topics, and specific learning objectives. While it has been noted that “good clinical teachers” should have characteristics such as bidirectional teaching, emotional activation, generativity, self-awareness, and competence, (31) neonatology fellows functioning as teachers must also be adaptable to the needs of their various audiences.

The development of effective teachers can be assessed across 4 thematic categories: personal attributes, educational theory and principles, core clinical teaching skills, and mentored instructional activities. (32) These areas complement each other as trainees gain more experience with teaching and develop their own teaching style. Within NPM, these skills can be nurtured in a formal didactic environment, in a real-time teaching environment such as patient rounds, and through simulation. The medical education community has developed several approaches to simultaneously help foster trainee education and trainee development as teachers. Although a comprehensive recipe to successfully hone teaching skills does not exist, we discuss herein some of these approaches to medical education for fellows.

Building effective teaching skills during fellowship requires motivation from both fellowship program leadership as well as fellows. Given how vital it is for fellows to be effective teachers, we should focus on giving them the tools and resources to improve their instructional skills. Core topics may include andragogical principles, how to facilitate various types of teaching sessions (such as small group or simulation), and training in learner assessment and feedback. Effective teaching strategies are constantly evolving due to ongoing research in this arena. Advances in medical education resulted in a shift of the pendulum from traditional didactic lectures to innovative instructional methods promoting active learning, including gamification, problem-based learning, flipped classrooms, and application-based learning. (33)(34)(35) Once fellows are familiar with basic education theory and teaching skills, they can begin to incorporate these strategies into their teaching sessions.

Learners' comfort, motivation to learn, enthusiasm to engage in educational activities, and overall perception of learning are all significantly influenced by the learning environment. (36) Thus, cultivating a positive learning environment is crucial. This encompasses important characteristics that include, but are not limited to, the physical and emotional safety of learners; teachers’ understanding of learners, their needs, cultural backgrounds, and expectations; open and safe communication styles; a positive rapport between the teacher and the learner; and a culture of empowering learners with ownership of their education. (37) Self-reflection by teachers on their teaching philosophy and the learning environment they create is vital. Challenges to constructing an effective learning environment include a lack of awareness of the positive impacts of a safe learning environment, significant overlap of work and learning, learners' critical thinking abilities in a busy work setting, and willingness to modify teaching styles. (38)

Rotations in the NICU can be physically and emotionally daunting for residents and medical students. NPM fellows can create a positive learning environment by meeting with trainees ahead of their rotation or during the first few days of their rotation to understand their backgrounds, communication styles, and learning expectations. These interactions also provide an opportunity for fellows to establish a collegial rapport and a safe, nonjudgmental environment with their learners. Fellows can further model and contribute to a positive environment by acknowledging, listening to, and answering questions posed by learners, patients’ families, and staff during daily medical rounds. A conscious effort to create a positive learning environment and to monitor and adapt to the changing needs of learners is essential to creating an environment conducive to learning.

The importance of active learning and a learner-centered approach to teaching have been extensively researched and published. (39)(40) In a learner-centered approach, learners are empowered to take responsibility for their education, which further promotes engagement and higher order thinking. Case-based learning, problem solving, simulation, games, and technology-enhanced learning are techniques that promote active learning. Incorporating these principles requires teachers to transition their teaching strategies and consider those that facilitate active learning. Asking open-ended questions, providing the learners the time and space to respond, ensuring learner accountability, and allowing learners to guide discussions are some key techniques to foster active learning.

NPM fellows can encourage active learning and facilitate discussions during patient rounds by directing residents and students to evaluate evidence and review literature to aid their clinical decision making. Using short “chalk-talks” to discuss core concepts of neonatal physiology and encouraging learners to give brief presentations at the end of their rotations on common neonatal conditions also facilitates learner involvement. Using established curricula to conduct NPM fellow-led simulations on neonatal stabilization and resuscitation during a rotation encourages learner participation and promotes active learning. Simulation is a popular education strategy with extensive research supporting its use as an adjunct to clinical experiences and classroom instruction. Simulation also offers a safe environment to practice difficult clinical scenarios that require critical thinking. (41)

The National Neonatology Curriculum Committee has used the concept of the flipped classroom, an instruction model in which learners review assigned videos and complete supplemental readings before the instructor-facilitated session, saving class time for more active discussion and learning activities. (42) Learners have the unique advantage of learning asynchronously at their own pace and later applying core physiology concepts to engage in in-depth instructor-facilitated group discussions to solve clinical problems. (43) This format appeals to adult learners who are known to be internally motivated and value self-directed learning, solving problems, and gaining knowledge they can directly apply to their work. (35) It also facilitates collaboration with other learners, including the opportunity for peer-to-peer learning and the establishment of a learning community in which the instructor also benefits. (44)

Teachers in a clinical setting experience the unique challenge of educating multigenerational learners. Learning styles and learner needs vary significantly across generations with baby boomers preferring classroom instruction, whereas millennials and generation Z learners inclined toward technology-enhanced educational methods. (45) Differences in learning styles have been explored by various adult learning theories, including self-directed learning and experiential learning. These theories are unique in their characteristics, such as different ownership of learning, timing of learning, and their ability to fit the needs of various learning styles. An understanding of these theories and their potential application in day-to-day teaching will help promote effective learning. (46)(47) A teaching approach blending different strategies such as direct instruction versus open questions and group problem-solving is warranted in a clinical practice setting such as medical rounds when there is a possibility of teaching learners from across generations.

Innovative educational strategies with a learner-centered approach using technology are the future of medical education. Flipped classroom models, simulation-based education, and use of digital texting platforms to foster education are just a few innovative strategies gaining attention in the field of neonatology. Ubiquity of portable electronic devices, including smart phones and tablets, complement the use of technology in medical education. Portable electronic devices, when coupled with universal access to the internet, not only assist rapid exposure to enormous amounts of educational content, but also aid the use of technology in medical education. Digital flashcards, interactive visual aids, and audience response systems are all convenient options due to portable electronic devices.

Gamification is another popular mode of instruction to facilitate adult learning. The scope of gamification in medical education has gained significant attention in the past decade. Peer competition, teamwork, and point-based scoring systems effectively aid learning by motivating individuals and teams to work together to improve their performance. Kahoot! (Kahoot! Oslo, Norway), Bookwidgets (Kidimedia, Kortenberg, Belgium), and Gimkit (Gimkit, Seattle, Washington) are a few examples of software programs that may be used to enhance learning using gamification. Higher levels of engagement and concentration, as well as a more relaxed learning environment, are some unique advantages of gamification.

The COVID-19 pandemic challenged educators to innovate beyond the traditional classroom setting to incorporate remote learning strategies. Innovations included the American Academy of Pediatrics Section of Neonatal-Perinatal Medicine Trainees and Early Career Neonatologists (TECaN) virtual journal clubs, and ethics and quality improvement seminar series. TECaN also uses group chat applications to bring fellows from across the country together for board review, clinical case questions, and various special interest groups. The Organization of Neonatal-Perinatal Medicine Training Program Directors developed the Online with Experts series and the “Megaflip” classroom. (48) On-demand learning is also facilitated by the availability of several neonatology-specific podcasts and educational videos on the MedEd On The Go (NSCI Group, Inc, Washington Crossing, PA) smartphone application.

NPM fellowship programs have a responsibility to ensure that their trainees are prepared to be teachers and leaders within the field. For trainees to graduate with strong teaching abilities, a focus on fostering this skill set should begin as soon as fellows enter their neonatology training program. Creating new curricula can be time-consuming and costly and may not be possible for individual institutions because of limited resources such as education experts. A potential solution for NPM fellows is the development of regional or national medical education foundations curricula with curated and centralized resources that fellowship programs could access and use to supplement their own efforts.

Neonatology fellows engage in formal and informal teaching daily in the NICU. They are entrusted with educating parents, providers, and students on a broad range of topics and are often the primary source of information for these learners. It is essential that NPM fellowship programs incorporate formal training in teaching to equip fellows with the necessary teaching skills. These programs should train fellows to effectively educate others in various clinical learning environments, regardless of their future career goals. Building fellows’ toolbox and flexibility to use different educational strategies based on learners’ needs and learning objectives will benefit fellows, their future learners, and the field of neonatology.