Does clinical teacher training always improve teaching effectiveness as opposed to no teacher training? A randomized controlled study

Teacher training may improve quality and professionalism of teaching and is therefore widely employed in faculty development programmes [1–9]. However, training may have the paradoxical effect of reducing actual performance. Research on expertise development suggests that the integration of new strategies could result in deterioration of performance until higher levels of competence are reached. As a result of new learning, current routines, procedures, and organization of knowledge, which had worked quite well before the training, may be called into question. In particular, meta-cognitive components of training may make learners aware of their potential for further development [10–12]. This awareness may reveal one’s own deficits to the trainee, and may therefore cause insecurity [13].

Furthermore, developing and integrating new strategies into a routine requires considerable time, re-training and practice [14], often referred to as deliberate practice [15]. As a consequence, during an intermediate time the training might therefore lead to detrimental effects. Evidence exists that such U-shaped developments occur while new information or new skills are being worked into an existing teaching routine: When new paths are entered, some drawbacks in performance are to be expected. In the field of clinical teacher training however, this potential phenomenon has not yet been clearly addressed. We therefore wanted to explore the impact of clinical teacher training at an early time point after intervention. To measure quality and effectiveness of teaching we chose teachers’ performance in an intensive course in emergency medicine. Using a prospective randomized controlled design, the investigators were blinded towards teacher training and teachers were blinded towards the final purpose of the study. At present, the Objective Structured Teaching Exercise (OSTE) is the most extensively studied instrument to assess teaching quality [16]. However, we preferred to use a different outcome parameter since the ultimate goal of teaching in emergency medicine is to improve students’ skills and the outcomes for patients. With these goals in mind, we chose practical resuscitation skills as the primary outcome parameter. We assessed:

In August 2006 eighteen clinical teachers from emergency medicine and anaesthesiology were matched with respect to their clinical experience and teaching experience, and then randomly assigned to a session of teacher training lasting two days (‘trained group’) or no training (‘untrained group’). In anticipation of organizational shortcomings within the department, we planned one additional pair of teachers as backup. From October 2006 to June 2007, all of the teachers in the sample were routinely scheduled to teach emergency medicine to 3^rd year students. [In Germany, medical students start their curriculum after 13 years of school. Their first two years at university predominantly cover basic science].

In this study none of the measured parameters of teaching performance was found to be superior in the group of trained teachers. This finding specifically refers to the primary endpoint (practical skills of students), where two domains even revealed a significantly worse performance in the trained teacher group. Looking at the two other domains more closely (chest compressions and AED use), it has to be considered that students reached very high scores. This might indicate a ceiling effect, which can mask potential differences. On the other hand teachers might have strongly focussed on these core competencies in resuscitation, since they hold the highest evidence level in international resuscitation guidelines.

The secondary endpoint ‘theoretical knowledge’ (MCQ) also showed no advantage of the trained group with a tendency towards inferior test results for the group of trained teachers. Evaluation of teaching quality by students revealed significantly lower ratings for trained teachers, with analogous trends for the sub-domains ‘teaching structure’ and ‘interaction’.

As stated at the beginning of this article, the most likely explanation for these negative results are difficulties in newly trained teachers putting acquired theoretical concepts into practice. After a two-day training with plenty of information and a generally strong shift in attitudes (from teacher- to learner-centeredness), teaching performance was assessed when the learners had not yet been given time to practice the newly-learned techniques. Thus a ‘confusion effect’ may have occurred, making it impossible to adequately integrate the contents of the training, resulting in poorer teaching performance. This hypothesis may be supported by the self-perception of trained teachers, who did not feel more satisfied with their sessions although they reported higher levels of competence and self-confidence. A similar phenomenon was described in the field of business school education, where business school students performed inferior to untrained controls, when they had to transfer their substantial knowledge to practical applications [13, 23].

One might speculate that teaching quality would have improved if it had been assessed at a later time. Unfortunately re-evaluation of teachers was not possible because some of the teachers had since left the institution.

Our findings indicate that duration and timing – the “dosage” – of teacher training need to be considered carefully. Other training programmes of longer duration have been proven to be efficient [5, 24], and even some shorter programmes have improved teaching performance [6, 9, 25]. However, these programmes were predominantly designed for resident and clerkship teaching, and teaching quality was assessed at a later time point long after training, offering considerable practical opportunity to integrate new competencies.

Another aspect might be the distribution of training over time. While many courses are run as one or two-day seminars or workshops, Morrison et al. spread their training of only 13 hours over 6 months and substantially improved the score in an objective standardized teaching examination [3]. In this light, shorter training units might be more “digestible”, hence in our two-day training we might have administered an “overdose”. However, whether teaching performance might have improved over time remains an open question.

In this prospective study, outcomes after clinical teacher training teaching were not found to be superior compared to untrained controls. For a number of study end points, results even turned out to be significantly worse. A potential reason could be that trained teachers experienced difficulties in integrating new teaching competencies into their teaching practice at this time point. Further research is warranted to clarify the underlying mechanisms.

JB was clinical educator in anaesthesiology in association with Dieter Scheffner Center for Medical Education at Charité – University Medicine Berlin, Germany and is now coordinator at the Vice Deanery of Education of the Medical Faculty at the University of Zurich, Switzerland. JS is a former student at the dept. of anaesthesiology, now a physician in radiology at Vivantes Hospitals, Berlin, Germany. CL is a former student of the dept. of anaesthesiology, now a physician at the Dept. of Cardiology, Hospital of the German Red Cross, Berlin-Westend. HG is full professor of educational science, Head of the Department of Educational Science, University of Regensburg, Germany.