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Frontline learning of medical teaching: “you pick up as you go through work and practice” Hartford, W.; Nimmon, L.; Stenfors, T. Sep 19, 2017

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RESEARCH ARTICLE Open AccessFrontline learning of medical teaching: “youpick up as you go through work andpractice”W. Hartford1* , L. Nimmon1,2 and T. Stenfors3AbstractBackground: Few medical teachers have received formal teaching education. Along with individual andorganizational barriers to participation in teacher training programs, increasing numbers and altered distribution ofphysicians away from major teaching centers have increased the difficulty of attendance. Furthermore, it is notknown if traditional faculty development formats are the optimal learning options given findings from existingstudies document both positive and negative outcomes. There is a gap in research that explores how medicalteachers learn to teach and also limited research regarding how medical teachers actually teach.The purpose of this study was to provide insight into how physicians describe their teaching of trainees, and thenature of their teaching development and improvement to inform faculty development programs.Methods: Semi-structured interviews were conducted with 36 physicians, with a broad range of teachingexperience, purposefully selected from five disciplines: Internal Medicine, Pediatrics, Psychiatry, Surgery, and FamilyMedicine. A qualitative, inductive approach was used to analyse the data.Results: Teaching was described as being centered on the needs of individual trainees, but was dependent on patientpresentation and environmental context. For this group of physicians learning to teach was perceived as a dynamicand evolving process influenced by multiple life experiences. The physicians had not learnt to teach through formaleducation and then put that learning into practice, but had learnt to teach and improve their teaching through theirtrial and errors teaching. Life experiences unconnected with the medical environment contributed to their knowledgeof teaching along with limited formal learning to teach experiences. Teaching practice was influenced by peers andtrainees, feedback, and observation. The findings suggest these medical teachers learn to teach along a continuumlargely through their teaching practice.Conclusion: The findings suggested that the participants’ major resource for learning how to teach was informalexperiential learning, both in and out of the workplace. This may have implications for faculty development strategiesfor medical teaching education.Keywords: Physician, Faculty development, Qualitative research, Feedback, Peer observation* Correspondence: wendy.hartford@ubc.ca1Centre for Health Education Scholarship, University of British Columbia,Vancouver V6T 1Z4, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Hartford et al. BMC Medical Education  (2017) 17:171 DOI 10.1186/s12909-017-1011-3BackgroundFew medical teachers have received formal teaching edu-cation [1–3] despite the recognition of teaching as a coreprofessional attribute [2, 4]. Traditionally, faculty devel-opment units associated with universities offer trainingprovided in a variety of formats such as workshops,short courses, university accredited awards, and on-linewebinars etc. [1–3, 5–7]. However, the difficulty of en-couraging physician attendance has been increased withthe higher number and altered distribution of medicalteachers away from major teaching centers [8–10]. Inaddition, there are several other barriers, both individualand organizational in nature, for physician participation infaculty development programs some of which are lack ofprotected time, underestimation of the need for furthertraining, and lack of personal motivation [5, 11, 12]. Further-more, it is not known if traditional faculty development for-mats are the optimal learning options as learning alsooccurs in informal real life contexts [2, 3, 6, 7, 13], andthrough social mechanisms such as hidden curricula [5, 13].Few studies have assessed the effect of intensive teachertraining on the performance of medical teachers [2, 3, 5].Findings from existing studies are mixed, suggesting bothpositive outcomes: improved teaching ability [12, 14], andnegative outcomes: decreased teaching effectiveness [13].The field of medical education encourages self-directedand life-long learning [5, 7, 15, 16]. Being part of the med-ical culture medical teachers may, themselves, considercontinuous development and improvement essential [12].Although the importance of professional development forcontinuous development and maintenance of competencyis well established there is a gap in research that exploreshow medical teachers perceive their teaching and learningto teach. Filling this gap may provide insight into thenature of physicians’ teaching development [2, 17].MethodsFor this research we explored how physicians 1) describethe process of teaching trainees, and 2) describe theprocess of learning to teach and how they would go aboutbecoming better teachers of trainees. Five disciplineswhich represent the top five selections of Canadian med-ical graduates and top five available Canadian ResidentMatching System (CaRMS) [18] match residencies, wereselected for this study for their significant representationof medical teachers and trainees, and potential for teachingopportunities. Four were Royal College specialties: InternalMedicine, Pediatrics, Psychiatry, and Surgery. These disci-plines also provide a variety of inpatient and outpatientcare. The fifth discipline family medicine, while not a RoyalCollege specialty, is conceived using a similar frameworkto the Royal College of Physicians and Surgeons of Canada[19]. We used a qualitative approach and conducted semi-structured interviews with 36 physicians. Ethical approvalfrom the University of British Columbia’s Behavioural Re-search Ethics Board was obtained for the study. This re-search was part of a broader exploratory study that wasdesigned to investigate physicians’ conceptions of theirteaching practices and their development as teachers oftrainees as well as their conceptions of teaching and learn-ing to teach their patients [20, 21], and their understandingand application to teaching trainees of the Canadian Med-ical Educational Directives for Specialities (CanMEDS)framework. In addition, the investigation explored howphysicians perceived power relations within their patientand trainee relationships which has been reported on else-where [22]. Approximately 40% of the interview questionspertained to physician interactions with trainees. For ex-ample: Can you describe to me your approach to teachingdifferent trainees in order to teach them well? and, Canyou tell me about how your teaching of trainees hasevolved over time?Context, population, sample, and data collectionThis study took place at the University of British Columbia.The Faculty of Medicine teaches undergraduate medicalstudents and postgraduate residents at a main campus andthree regional campuses. All clinicians who teach medicalstudents and postgraduate residents hold a faculty appoint-ment. Academic clinicians are salaried with formal expecta-tions and protection for research and teaching; clinicalfaculty are funded for sessions in which they teach whilethey deliver patient care. Participants in this study weredrawn from university-affiliated academic health sciencescenters, community hospitals, and clinics in the main site.We used purposeful sampling to provide us with physicianswho collectively represented a broad range of teaching ex-perience. An email introductory letter that described thelarger study was sent to all colleagues identified by thestudy’s co-investigators. On average 4 out of 6 of those phy-sicians initially contacted in each discipline were interestedin participating, and were subsequently sent a consent formprior to the interview taking place. To recruit the additionalparticipants we used a snowball sampling technique whichinvolved asking those interviewed to provide names andemail addresses of colleagues who fit our recruitment cri-teria. An introductory email describing the study was sentto the additional potential participants. The interviews wereheld either in person at the participant’s office or on thephone and averaged 1 h in duration. Participants received agift certificate.The interviews were conducted by WH and LN (au-thors) with six interviews conducted by a Family Medicineresearch associate. All interviews were audio recorded,transcribed and given a unique identifier based on special-ity and number: Family medicine is identified FAM, In-ternal medicine as IM, Pediatrics as PED, Psychiatry asPSYCH, and Surgery as SURG. After interviews had beenHartford et al. BMC Medical Education  (2017) 17:171 Page 2 of 10conducted in three specialties all transcripts were readand LN and TS reviewed and revised the initial interviewprotocol which was based on two pilot interviews. Sincethe purpose of the interviews was to explore aspects ofthe learning process in respect to teaching trainees, mostquestions were followed by probing and follow-up ques-tions to deepen the respondents reflexive thinking aboutlearning [23].Data analysisThe audio recordings of the interviews were transcribedverbatim and the transcripts were analysed by WH, LN,and TS using QSR NVivo Version 10 (QSR InternationalPty Ltd., Doncaster, Victoria, Australia). The inductiveanalysis approach consisted of organizing the data,immersion in the data, generating categories and themes,and coding the data using a category system codingscheme [23]. The initial data organization was guided bythe research questions: 1) How do medical teachers de-scribe teaching trainees? and 2) How do medical teachersdescribe learning to teach and becoming better teachers oftrainees? As analysis progressed, categories and themeswere identified and discussed by the research team. Dur-ing the final stage of analysis, TS and WH brought theseveral themes together to create an overall structure ofthe main patterns.We used investigator triangulation to strengthen thequality of the study. The mixed backgrounds of the in-vestigators, medical education (TS), adult education(WH) and social science (LN), provide suitable andcomplimentary lenses through which to analyze the data,and may increase trustworthiness by lessening the prob-ability of common unified assumptions that can occurwithin a small research team [24].ResultsThe findings reflect participants’ descriptions of howthey taught trainees, and how they learnt to teach. Thisgroup of physicians approached teaching trainees invarious ways. In general, teaching was reported to becentered on the needs of individual trainees, but at thesame time was dependent on the patient presentationand environmental context. For this group of physicianslearning to teach was described as a dynamic and evolv-ing process influenced by multiple life experiences: acontinuum of learning. The physicians reported learningto teach and improving their teaching through theirpractice of teaching. Life experiences unconnected withthe medical environment were perceived as contributingto their knowledge of teaching along with limited formallearning to teach experiences. Interactions with peersand trainees were also cited as being influential to theirteaching practice. Rather than present the findings sepa-rated according to our two research questions we havemerged the findings to acknowledge the continuum oflearning [1] to teach through teaching.We present the findings as two themes: 1) Physicians,trainees, context, and teaching, and 2) Respondents’ ex-periences of learning to teach.Physicians, trainees, context, and teachingIn this section we describe the physicians, their trainees,their sites of teaching, and their teaching.The physiciansIn total 36 physicians were interviewed from five special-ties: 12 FAM (7 male, 5 female), 6 IM (1 male, 5 female),6 PED (2 male, 4 female), 6 PSYCH (3 male, 3 female)and 6 SURG (6 male). The length of time in clinicalpractice ranged from 5 to 41 years with an average of19 years, and the average length of time teachingtrainees was approximately 16 years.Not all physicians had wanted to teach and the partici-pants identified various reasons for taking on a teachingrole such as familiarity with the program and:“There wasn’t really anybody else to teach” (F3 FAM).“I didn’t want to teach. I didn’t think that was me atall. But after getting into it, we teach every day. And Ilike it a lot more than I thought I would” (F2 FAM).There were indications that these physicians perceivedteaching trainees as a necessary part of their work. Positiveteaching experiences re-enforced their motivation toteach. These medical teachers identified and shared a var-iety of motivators for teaching such as: giving back to themedical community, watching trainees grow in knowledgeand confidence, seeing trainees become good cliniciansand colleagues, passing on knowledge and experience tothe next generation to ensure better patient care, learningfrom learners, social interactions and professional collab-oration with trainees, capturing the interest of trainee ei-ther in their specialty or approach to practice, and theyouthfulness and enthusiasm of trainees.“I think I really enjoy watching residents and studentsgrow their knowledge and confidence and just becomereally good clinicians” (F1 FAM).“…it’s about making sure that the trainees become goodquality physicians that end up taking care of patients”(M3 IM).Approximately one third of the participants describedtheir active involvement in research.“But the research hasn’t been in terms of training. It’sbeen more clinical research” (H1 PSYCH).The traineesThe majority of physicians taught a range of trainees from1st year medical students to residents. Some physiciansalso taught fellows and acted as supervisors for doctoralstudents. In most instances physicians received one or twoHartford et al. BMC Medical Education  (2017) 17:171 Page 3 of 10trainees at a time with the duration of placement depend-ing on the level of trainee and the program requirements.Physicians also taught trainees from different specialties.For instance, F6 FAM taught a mix of family practice andpsychiatry 1st and 2nd year residents, and H4 SURGtaught medical students through to fellows from a varietyof specialties as well as other health professionals such asnurses. Several physicians variously taught seminars togroups of trainees, and taught around trainees learninggoals during residency and career paths.ContextAll of the medical teachers reported that most of theirteaching occurred in clinical settings such as roundingon patients, and consultations at the hospital or officedepending on where they practiced. The study partici-pants described teaching trainees as being context andenvironment dependent, case based, and patient-orientated which was identified by one physician as:“…learning off [sic] what walks through the door” (F3FAM), and as:“…is dependent on what they see and that is unpredict-able. It’s not like we have a prescriptive patient loadevery three months to meet their teaching needs in a per-fect way” (H2 SURG).Several physicians indicated that their practice wasfee-for-service. Teaching trainees reduced the number ofpatient consultations, reduced income, increased costs,such as operating room expenses, and had an impact onconsultation and medical procedure wait lists.“Financial return. Because it takes a lot of time. And some-times– taking on too my residents for sure will slow downour practice. And then we suffer financially” (F6 FAM).Physicians described balancing trainee education whilemanaging busy practices and ensuring patient care wasnot adversely affected. Although patient consultationswere reduced, physicians perceived the time withtrainees was less than optimal.“The balance of education and service in our teachinghospital is always an ongoing struggle. And if there’s justsimply too much to do for patients in a set number oftime” (F3 PED).Physicians describe their teaching of trainees“And you have to be able to be looking for, in every en-counter you have with a patient where a trainee’s in-volved, as to how can I provide value to the trainee inthis encounter” (H3 SURG).The majority of medical teachers identified using “a littlebit of everything” (H2 PSYCH), and variously described avariety of formal and informal teaching methods, didacticteaching, lecturing, homework, and discussions and conver-sations. Some physicians indicated that they did not teachthrough lecture and seminars as much as through informalforms of teaching that arose during clinical practice.“…it’s quite informal…there are different places I teach,so I’ll teach them on the ward, at the bedside. I thinkthat’s the best learning experiential…” (F2 PED).More than half of the physicians described their teach-ing as evidence based, referring to medical/clinical scien-tific evidence for what they taught rather than how theytaught. Virtually all participants indicated, either expli-citly or implicitly, that they tailored their teaching to thelearning objectives and goals of trainees. Tailoring wascharacterised as requiring an understanding of thetrainee’s background, considering different levels ofcompetency, grading responsibility, and providing in-creasing autonomy with increasing learner ability.“They will then observe, and then I will– then they willdo it, I will guide them, and then they’ll do it all bythemselves [sic] with me watching. And we’ll recap on itlater” (M6 FAM).A role modeling approach to teaching trainees was de-scribed by almost two thirds of the participants particularlyin relation to integrating learning around non-medical skills:“…along the way, we talk about…we talk about theother skills of being a physician” (H1 PSYCH).In order to teach well, several of the medical teachersreported using various tools for teaching such as rele-vant literature, educational material, websites, and dia-grams. Others explicitly referred to providing timelyfeedback as part of their approach to teaching trainees.The majority of medical teachers referred to the import-ance of creating learning environments in which traineesfelt comfortable and safe to answer questions.“So I think there has to be that environment of learningand warmth and nurturing where people can feel quitesafe” (F2 PED).All of the physicians perceived that lack of time toteach adversely impacted their teaching of trainees.“I think again sometimes we just have so many patientsand it’s so busy clinically that you really just don’t havethe time to sort of sit down for half an hour and chatabout this particular topic. So I think time is a limitingfactor” (F1 PEDS).Respondents’ experiences of learning to teachOur analysis identified four distinct processes and expe-riences described by the respondents regarding how theylearned to teach and improve their teaching practices:learning through experience, formal training, receivingfeedback, and peer observation.Learning through experienceThese physicians explained how they learned to teachbased on three types of experiences: from outside ofclinical practice medicine, from being a trainee or aHartford et al. BMC Medical Education  (2017) 17:171 Page 4 of 10student themselves, and from teaching experience intheir role as physicians.Learning through experiences outside clinical practice“I think life experience changes the way you teach. Sowhen I first started off I was married but without chil-dren. Now I have three kids. So I think having kids– a lotof my residents learn about children through my kids. Orjust through my stories about my kids…sleep training,feeding, behavioural stuff…that’s when you bring in yourlife piece into teaching” (F1 FAM).Several of the physicians reported that their motivationand ability to teach had been influenced in some way byearlier life experiences. For example, life experiencesoutside of medical practice which had influenced teach-ing practice included experience as a girl-guide leader,an English as a second language teacher, a life-guard in-structor, having parents who were teachers, and becom-ing a parent. Three physicians referred to drawing ontheir experiences teaching in other parts of the worldand two participants cited involvement with governancebodies such as the Royal College and teaching commit-tees as influencing their teaching practice.Learning through experiences as a trainee“And I recall once…being mauled by an unpleasant se-nior physician when I was a student. And I vowed I’dnever do that to anyone myself” (M6 FAM).Several physicians spoke about their personal negativetraining experiences which had influenced their teachingpractice. Another physician reflected that she hadlearned as a trainee from less credible teachers that sheneeded to teach in an “evidenced based manner” if shewas to be credible and earn her trainees’ respect. Morepositively, several physicians referred to learning to teachfrom supervisors who had spent time helping them.Learning through experiences as a teacherSeveral physicians referred to learning to teach throughthe experience of teaching other trainees during theirown training.“To some degree you learn it in school, you know, tosome degree you learn it through supervisors …But mostof it, I think, you pick up as you go through work andpractice” (M4 PSYCH).A principal theme that emerged from our data was thatof learning through the practise of teaching trainees. Thephysicians variously reflected that experience and practicebrings expertise, wisdom, calmness and a greater confi-dence in their teaching skills and knowledge, and a deeperunderstanding of the characteristics associated with beinga good teacher. These characteristics included acquiringgood communication skills, and the ability to engagelearners, being honest with feedback, building trust andpatience, and having the ability to provide trainee learningopportunities.Experience was also reported as bringing an awarenessof self, teaching skills and approaches to teaching. Manyof the physicians described their learning of good teach-ing skills as an evolutionary and lifelong learning processthrough the experience of teaching trainees.“So I don’t think you can ever say you will always haveone teaching style or you shouldn’t. I think in order toevolve your teaching will evolve” (M3 IM).Physicians variously identified how teaching experi-ence had enabled them to become what they perceivedas better teachers. For example, teaching experience ledto feeling less pressured “to teach everything at once”(F5 IM), development of a teaching style and personality,becoming more learner centric, tailoring learning totrainees needs, and practising more evidence basedteaching, and moving from didactic teaching to morecase based teaching.A few physicians suggested that self-reflection on teach-ing practices provided motivation to become a betterteacher and required admitting both to self and traineesthe limits of their knowledge, acknowledging strong andweak teaching points, and identifying what was notworking.“So I had a lot of time to think and reflect on it andhad the same groups over and over again, like, the samesubject groups but with different students. So I would justtry different things and try to figure out what worked.”(H1 IM).Other physicians alluded to honing skills, fine tuninginformation, and/or being “up-to-date” as ways to im-prove teaching.Formal training“I didn’t know how to teach. They didn’t tell us how toteach…So it was a few years after that that I started go-ing to the train the trainers– the teacher’s toolbox. And Ithought, oh, my goodness, there’s way more to it than Ithought there was… I think I’m a much better teacherthan I used to be ‘…cause I know more about what I’msupposed to do” (F2 FAM).The majority of physicians had received little or noformal teaching education or basic training courses priorto their first trainee teaching experience, and some hadno basic training even after many years of teaching. Afew of the physicians had received some training teach-ing other students or residents as part of their overallmedical training. Several of the physicians had engagedin learning to teach opportunities provided by variousinstitutions such as the Canadian Pediatric Society, anduniversity courses. Opportunities included formal work-shops, courses such as the One Minute Teacher, ABCHartford et al. BMC Medical Education  (2017) 17:171 Page 5 of 10Primer and Train-the-Trainer, formal courses, andundertaking a fellowship. Bringing in internationalspeakers to give rounds and workshops was identified byone respondent as another method used to improveteaching practice. A perceived benefit of taking courseswas improved focus on teaching. Several physiciansidentified conferences, and courses on adult learningtheory, stages of learning, and acquiring teaching skillsas opportunities for continued learning.“…if I get an opportunity I will go to any workshop thatwill improve my teaching skills” (M3 PSYCH).Several of the medical teachers identified, and hadsought out opportunities for improving their teachingskills and knowledge base; such as, learning how to im-prove their communication skills, their ability to provideconstructive criticism and feedback, and how to encour-age critical thinking.“It’s like I realize I have a hard time giving negativefeedback so if I’m going to do better, I have to work onimproving those skills.” (F1 IM).To improve teaching efficacy, a few physicians identifiedorganising acquired knowledge into structured teachingpractices as well as “setting up a more solid infrastructure”(M4 PSYCH) for trainees. Two physicians identified aneed for more teaching related faculty developmentcourses, and other physician suggested discussion groupswith a panel of excellent medical teachers would provideopportunities for improving teaching skills.“I think I would like to probably work on sort of havinga more organized approach to sort of, you know, teachingaround particular topics” (F1 PED).However, although many of the physicians knew aboutvarious teaching courses, some physicians indicated thatthey would not engage in learning to teach opportunitiesciting lack of motivation, no perceived need to learnmore about how to teach, and time constraints as con-tributing factors.Learning about teaching through the process of receivingfeedback“So if you were to ask me right now what specific skill set Iwas short of, I would have to say I don’t know. But that’snot because I know all the skill sets. It’s probably just ‘causethere’s some things that I’m not aware of” (F8 FAM).Respondents described how receiving feedback fromboth trainees and peers identified teaching skills thatcould be improved which helped them to improve theirteaching and develop as teachers.Learning through receiving feedback from trainees“Yeah, and I also sort of try and get feedback from resi-dents and students on how to improve things. Becausethey are the one who sort of are really judging me, ob-serving me. So they are the best critics, right” (F4 PED).More than a third of participants indicated that receiv-ing feedback from trainees had influenced their teachingpractice in a variety of ways such as by inspiring change,confirming good teaching, and enabling medical teachersto develop programs that would better suit the needs ofthe trainees.“What I would like is ongoing, more robust feedbackfrom trainees about the strengths and the weaknesses”(H2 SURG).One third of the medical teachers cited that receivingfeedback from trainees which identified strengths andweaknesses, and areas for improvement would inspirethem to improve their teaching. However, these physiciansperceived current evaluation systems as inadequate andthat a better evaluation system, that provided frequent,timely, and helpful feedback which identified a teacher’sweaknesses, and how teachers could better serve trainees’learning needs would assist medical teachers in becomingbetter teachers. Some of the physicians perceived the needfor more time to schedule feedback sessions with traineesand an environment that was conducive to providingtimely feedback. However, several participants suggestedthat fear of recrimination may prevent or made it difficultfor trainees to give negative feedback which potentiallyrendered evaluation reports unhelpful.Learning through receiving feedback from peers“…we do periodic assessment from an outside observer ofteaching, through the university. So I have that periodic-ally” (H6 SURG).While only two physicians referred to having receivedfeedback from their peers several other physicians indi-cated they would be receptive to the practice of peerevaluation. These physicians considered that receivingpeer feedback and evaluation would make a significantcontribution to teaching improvement by identifyingweaknesses and should not be avoided.“And I should probably get a peer to supervise myteaching and to give feedback” (H2 PSYCH).However, only one physician identified a formal peerfeedback and evaluation mechanism, and another re-ferred to the absence of such a mechanism. One phys-ician commented that despite the desire for feedbackand evaluation in practice this may not occur as physi-cians often worked in autonomous silos.Learning from peer observation“I think it always helps to see how other people teach, soI think I would spend time with some of my colleagues tosee what their approach to teaching is and what theyallow people to do and how that relationship works…”(H3 SURG).Hartford et al. BMC Medical Education  (2017) 17:171 Page 6 of 10Various participants described how peer observation hadinfluenced their teaching practice. These medical teachersdescribed how informal observation of colleagues and ex-cellent teachers interacting with trainees, and observingand listening to more experienced teachers with differentteaching methods had provided learning experiences. An-other physician considered that to develop as good teachersphysicians required early exposure to good teachers withgood communication skills who had the ability to provideconstructive criticism to learners. Notably, however, twophysicians suggested that observation of poor teachingskills had also served as a learning model.“And frankly, if we’re good or bad at it, they’re learningone or the other. So, you know, and when I was a trainee,when I saw people who are poor collaborators, I learnedjust as much from that experience as I did from a goodcollaborator” (H2 SURG).Although peer observation was valued as a learningexperience, difficulties with this practice were identifiedby two participants since “we work in silos” (F2 FAM).DiscussionDespite the differences in these medical teachers’ charac-teristics, their descriptions of teaching trainings and oflearning to teach were remarkably similar. The samplesize was too small to draw any conclusion regarding dif-ferences between specialties. The data also suggests thatsites of practice played a significant, and potentially pre-ferred role in these participants’ informal teaching andlearning to teach activities. Although these medicalteachers reported limited formal teaching training, theydescribed competent teaching practices, despite teachingin environments which they perceived to be less thanoptimal for learning.Physicians describe their teaching practiceThe Canadian Medical Education Directives for Special-ists (CanMEDS), a competency framework that has beenadopted internationally, identifies teaching as a signifi-cant part of the Scholar role with a number of compe-tencies that medical teachers are expected to achieve [1,4]. Our descriptive data suggests that the physicians inthis study may practice many of these competenciessuch as the use of formal and informal curricula, learnerassessment, needs assessment, optimization of the learn-ing environment, role modeling, providing feedback,supervising and grading responsibility, the use of evi-dence based techniques, and the need to tailor teachingto trainees’ requirements. Srinivasan et al. [1] present ateaching competency framework with six core compe-tencies which also emphasises the acquisition of thesesame skills as desirable for a medical teacher.Learning from experienceThe physicians in this study mostly considered theylacked formal teaching training and described learningto teach predominantly through their lived experience ofteaching trainees. This finding is congruent with litera-ture concerning formal learning to teach education forphysicians [1–3], and workplace and experiential learn-ing which have been identified as significant and valu-able approaches for providing learning opportunities [2,3, 6, 7, 25, 26]. Workplace learning provides a contextualand authentic experience as medical teachers can learnfrom each other through the practical application of theprograms they teach [6, 7, 25, 27], and may have greaterrelevance to learners than formal programs and textbook learning [27].These medical teachers described learning to teach asan ongoing interactive process which was influenced by amultitude of life experiences outside of medical practiceand through learning in the roles of both a trainee andmedical teacher. The concept of learning to teach traineesas an ongoing process is reflected in the literature whichsuggests that learner physicians are influenced by bothpositive and negative learning experiences throughouttime such as specific lectures, particular bedside teachingmoments, behavior of their preceptors, and relationships[3, 5, 6, 26].Learning from experience is a reflective process [28].However, although our participants appeared to be quitereflective about learning to teach few of our participantsexplicitly described engaging in reflective practices ontheir life and work experiences.Learning from formal learning experiencesIn our study participants who engaged in formal facultydevelopment programs identified their experiences asbeneficial. This supports the literature which suggests thatparticipants are usually satisfied with programs, find thecontent relevant and useful, gain in knowledge and skills,and experience positive changes in attitude toward teach-ing [7, 11, 12, 17, 26, 29]. However, although research con-cerning the effects of faculty development programs onteaching and student learning is limited [2, 3, 5, 13], trad-itional formats may not bring about teaching improve-ment, may not be engaging, and may be disassociatedwith reality [14]. Not all of the study physicians were mo-tivated to participate in faculty development programs cit-ing several perceived barriers such as lack of time and noneed to learn more about teaching, which also reflectswhat has been identified in the literature [5, 11, 12, 29].That only two physicians identified a need for more med-ical teacher training courses was perhaps a reflection ofperceived barriers, or possibly lack of self-awareness of theneed to improve teaching skills which is considered a sig-nificant barrier to learning [11].Hartford et al. BMC Medical Education  (2017) 17:171 Page 7 of 10Learning from feedbackAs has been observed in the literature [3], receivingfeedback from both trainees and peers was highly valuedby this group of physicians. Also in accordance with theliterature [7, 30–33], the frequency and reliability offeedback received from trainees was reported to be inad-equate and although many physicians were receptive tofeedback, peer evaluation and feedback seldom occurred.Several physicians indicated that the environment inwhich they taught was not always conducive to receivingtimely and reliable feedback: since trainees may fear re-crimination; and because physicians often work aloneand are not in an environment that is favorable to re-ceiving peer evaluations. Feedback may lead to reflectionon practice which is considered an important compo-nent of learning [2, 6, 7, 25, 31, 34–37].Learning from peer observationsSeveral of the physicians either explicitly or implicitly re-ferred to learning from observing teaching practices of theircolleagues and teachers even when the teacher may notshow expertise in a particular professional behavior, such ascollaboration. Peer observation is considered necessary tophysician learning and self-improvement [2, 3, 5, 7, 16, 32–35, 38], but learners need to differentiate between positiveand negative behavior traits [17, 35, 36, 38].Obstructions and influences for teaching and learning toteachThe last, but not insignificant finding refers to organizationalstructures which inhibited teaching of trainees and the influ-ences which motivated these medical teachers to continueto teach despite various obstructions. While adequate remu-neration, particularly for the medical teachers practicingwithin the fee-for-service structure, may allow for schedul-ing adequate time for teaching trainees, the potential fornegative impact on patients such as increased wait times forconsults and/or procedures may remain. Several authorshave suggested that it is necessary to identify and addressorganizational practices and structures which promote orimpede successful workplace experiential learning [2, 3, 5, 7,12, 14, 25, 34]; for example, the challenge of working in iso-lation [5]. Our findings suggested that organizational prac-tices such as intermittent and unhelpful trainee feedback,perceptions of working in isolation, and lack of peer evalu-ation may not organically generate informal learning in theworkplace. As with previous studies [2, 3] the medicalteachers in this study appeared to derive personal satisfac-tion from teaching trainees which motivated them to teach.In addition, it can be inferred from the data that for thesephysicians teaching was, to some degree, an inherent part oftheir medical practice.Implications for practiceLearning from experience and practice in the workplace hasa major role in medical teacher development [2, 3, 6, 7, 25,26]. However, workplace learning appears to be an under-utilized resource for faculty development programs [6]. Infor-mal learning, like formal learning, can be intentional andplanned [2, 25, 34] and it is feasible that informal faculty de-velopment programs could be implemented in the work-place. It is likely that medical teachers’ learning needs andorganizational structures vary. For instance in our studymany, but not all, of the medical teachers practiced within afee-for-service structure. Therefore, it may be necessary totailor faculty development programs to fit the requirementsof specific teaching and learning communities. Finally, teach-ing skills and knowledge acquired through formal learningprograms may not easily be transferred in a stable way to thereal teaching environment [3, 6, 13, 14, 25, 39]. Situated cog-nition theory proposes that doing and knowing cannot beseparated, and that the context and culture within which anactivity occurs constructs and re-constructs knowledge [39,40]. Accordingly, learning in situ may support acquisition ofknowledge and provide medical teachers with enriching prac-tical learning opportunities [39, 40], such as regular peer ob-servation, evaluation, and feedback, [2, 3, 6, 7, 14, 17, 32],which may help physicians develop a range of teaching skills.Strengths and limitationsThe findings of this study provide new insight into med-ical teachers’ perceptions of their approaches to teaching,and of their experiences of learning to teach. However, therespondents’ descriptions of their teaching practice werenot supported by field observations and may not reflecttheir actual teaching practice. This is a single centre studylimited to medical teaching in Canada. In addition, partici-pants only represent the five most frequently chosen med-ical specialties and their respective teaching cultures.Suggestions for further researchWe identified four areas requiring further research. Fewparticipants explicitly described their reflective practices.However, reflection on practice through “structured crit-ical reflection and analysis” is an important and crucialcomponent of learning and development [28, p. 264].Research which explicatively investigates how medicalteachers use reflection and reflective practice as an aidto learning to teach and what that practice looks likemay expand existing literature [41–45]. Secondly, studieswhich specifically investigate how medical teachers re-ceive feedback, and how that feedback benefits develop-ment of their teaching practice may contribute to theapparently limited literature concerning feedback andworkplace learning.Thirdly, organizational structures, including cultural dif-ferences across specialties and sites of training, have theHartford et al. BMC Medical Education  (2017) 17:171 Page 8 of 10potential to inhibit medical teaching and learning oppor-tunities. More research in this area may identify character-istics of supportive learning communities [28]. Lastly, lackof self-awareness of the need to improve teaching may bea significant barrier to learning [11]. Research which expli-catively investigates medical teachers’ self-awareness ofteaching skills may identify individual traits and/ororganizational structures that contribute to heightenedself-awareness of teaching skills.ConclusionMedical education requires an increasing number of appro-priately trained and experienced medical teachers. Thisstudy sought to add to and fill a gap in the existing litera-ture by exploring how medical teachers perceived teaching,and how they described learning and development of teach-ing medical trainees. The findings may have implicationsfor faculty development programs as they suggest that theparticipants’ valued informal teaching practices, and theirpredominant resource for learning how to teach was infor-mal experiential learning, both in and out of the workplace.Further research which investigates medical teachers’reflective practice, feedback opportunities, supportiveorganizational structures, and self-awareness of teachingskills may contribute to their learning needs and provideadditional insights into faculty development needs.AcknowledgementsThe authors would like to thank the respondents for their participation, and Drs.Joanna Bates, Ian Scott, Ravi Sidhu, Paris Ingledew, Summer Telio, and MattiasBerg the co-investigators on the larger study, from which this data was derived.FundingThis research was funded by a 2013 Royal College CanMEDS Research andDevelopment Grant. This grant program is supported by the Royal College ofPhysicians and Surgeons of Canada and the Associated Medical Services, Inc. (AMS).Availability of data and materialsThe datasets generated and analysed during the current study are not publiclyavailable due to the sensitive nature of the raw data on which the conclusionsof the manuscript rely. Please contact the authors for further information.Authors’ contributionsTS conceived of and designed the study. LN and WH collected the data. WHconducted the analysis and literature review, with contributions fromTS. TS and WH drafted the manuscript. TS and LN were also involved inediting the manuscript and revising for intellectual content. All authors readand approved the final manuscript.Ethics approval and consent to participateThis study received approval from the University of British Columbia on May29th, 2012. Reference number H12–00022. All participants consented toparticipating in this study.Consent for publicationNone required.Competing interestsTS is a section editor on the editorial board of BMC Medical Education.WH and LN declare they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Centre for Health Education Scholarship, University of British Columbia,Vancouver V6T 1Z4, Canada. 2Department of Occupational Science andOccupational Therapy, Faculty of Medicine, University of British Columbia,Vancouver, Canada. 3Department of Learning, Informatics, Management andEthics, Karolinska Institutet, Stockholm, Sweden.Received: 16 February 2017 Accepted: 13 September 2017References1. Srinivasan M, Li ST, Meyers FJ, Pratt DD, Collins JB, Braddock C, Skeff KM,West DC, Henderson M, Hales RE, Hilty DM. Teaching as a competency:competencies for medical educators. Acad Med. 2011;86(10):1211–20.2. 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Aukes LC, Geertsma J, Cohen-Schotanus J, Zwierstra RP, Slaets JPJ. Thedevelopment of a scale to measure personal reflection in medical practiceand education. Med Teach. 2007;29(2–3):177–82.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Hartford et al. BMC Medical Education  (2017) 17:171 Page 10 of 10

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