Associations between teaching effectiveness scores and characteristics of presentations in hospital medicine continuing education

Hospital medicine (HM), which is the fastest growing medical specialty in the United States, includes more than 40,000 healthcare providers.[1] Hospitalists include practitioners from a variety of medical specialties, including internal medicine and pediatrics, and professional backgrounds such as physicians, nurse practitioners. and physician assistants.[2, 3] Originally defined as specialists of inpatient medicine, hospitalists must diagnose and manage a wide variety of clinical conditions, coordinate transitions of care, provide perioperative management to surgical patients, and contribute to quality improvement and hospital administration.[4, 5]

With the evolution of the HM, the need for effective continuing medical education (CME) has become increasingly important. Courses make up the largest percentage of CME activity types,[6] which also include regularly scheduled lecture series, internet materials, and journal‐related CME. Successful CME courses require educational content that matches the learning needs of its participants.[7] In 2006, the Society for Hospital Medicine (SHM) developed core competencies in HM to guide educators in identifying professional practice gaps for useful CME.[8] However, knowing a population's characteristics and learning needs is a key first step to recognizing a practice gap.[9] Understanding these components is important to ensuring that competencies in the field of HM remain relevant to address existing practice gaps.[10] Currently, little is known about the demographic characteristics of participants in HM CME.

Research on the characteristics of effective clinical teachers in medicine has revealed the importance of establishing a positive learning climate, asking questions, diagnosing learners needs, giving feedback, utilizing established teaching frameworks, and developing a personalized philosophy of teaching.[11] Within CME, research has generally demonstrated that courses lead to improvements in lower level outcomes,[12] such as satisfaction and learning, yet higher level outcomes such as behavior change and impacts on patients are inconsistent.[13, 14, 15] Additionally, we have shown that participant reflection on CME is enhanced by presenters who have prior teaching experience and higher teaching effectiveness scores, by the use of audience participation and by incorporating relevant content.[16, 17] Despite the existence of research on CME in general, we are not aware of prior studies regarding characteristics of effective CME in the field of HM.

To better understand and improve the quality of HM CME, we sought to describe the characteristics of participants at a large, national HM CME course, and to identify associations between characteristics of presentations and CME teaching effectiveness (CMETE) scores using a previously validated instrument.

METHODS

RESULTS

There were 32 presentations during the MCP conference in 2014. A total of 277 (75.2%) out of 368 participants completed the survey. This yielded 7947 CMETE evaluations for analysis, with an average of 28.7 per person (median: 31, interquartile range: 2732, range: 632).

Demographic characteristics of course participants are listed in Table 1. Participants (number, %), described themselves as hospitalists (181, 70.4%), ABIM certified with HM focus (48, 18.8%), physicians with MD or MBBS degrees (181, 70.4%), nurse practitioners or physician assistants (52; 20.2%), and in practice 20 years (73, 28%). The majority of participants (148, 58.3%) worked in private practice, whereas only 63 (24.8%) worked in academic settings.

CMETE scores (mean [SD]) were significantly associated with the use of ARS (4.64 [0.16]) vs no ARS (4.49 [0.16]; P=0.01, Table 2, Figure 1), longer presentations (30 minutes: 4.67 [0.13] vs <30 minutes: 4.51 [0.18]; P=0.02), and larger number of slides (50: 4.66 [0.17] vs <50: 4.55 [0.17]; P=0.04). There were no significant associations between CMETE scores and use of clinical cases, defined goals, or summary slides.

^{Figure 1}

Overall teaching effectiveness score distribution by audience response, number of slides, and presentation length. The boxes represent the interquartile range (IQR) (25th to 75th percentiles) with the median (middle horizontal line) and mean (triangle). The dashed lines extend to the last observation within a distance equal to 1.5*IQR from the top and bottom of the box. Any observations beyond that distance are plotted separately. Abbreviations: CME, continuing medical education.

The magnitude of score differences observed in this study are substantial when considered in terms of Cohen's effect sizes. For number of slides, the effect size is 0.65, for audience response the effect size is 0.94, and for presentation length the effect size is approximately 1. According to Cohen, effect sizes of 0.5 to 0.8 are moderate, and effect sizes >0.8 are large. Consequently, the effect sizes of our observed differences are moderate to large.[20, 21]

DISCUSSION

To our knowledge, this is the first study to measure associations between validated teaching effectiveness scores and characteristics of presentations in HM CME. We found that the use of ARS and longer presentations were associated with significantly higher CMETE scores. Our findings have implications for HM CME course directors and presenters as they attempt to develop methods to improve the quality of CME.

CME participants in our study crossed a wide range of ages and experience, which is consistent with national surveys of hospitalists.[22, 23] Interestingly, however, nearly 1 in 3 participants trained in a specialty other than internal medicine. Additionally, the professional degrees of participants were diverse, with 20% of participants having trained as nurse practitioners or physician assistants. These findings are at odds with an early national survey of inpatient practitioners,[22] but consistent with recent literature that the diversity of training backgrounds among hospitalists is increasing as the field of HM evolves.[24] Hospital medicine CME providers will need to be cognizant of these demographic changes as they work to identify practice gaps and apply appropriate educational methods.

The use of an ARS allows for increased participation and engagement among lecture attendees, which in turn promotes active learning.[25, 26, 27] The association of higher teaching scores with the use of ARS is consistent with previous research in other CME settings such as clinical round tables and medical grand rounds.[17, 28] As it pertains to HM specifically, our findings also build upon a recent study by Sehgal et al., which reported on the novel use of bedside CME to enhance interactive learning and discussion among hospitalists, and which was viewed favorably by course participants.[29]

The reasons why longer presentations in our study were linked to higher CMETE scores are not entirely clear, as previous CME research has failed to demonstrate this relationship.[18] One possibility is that course participants prefer learning from presentations that provide granular, content‐rich information. Another possibility may be that characteristics of effective presenters who gave longer presentations and that were not measured in this study, such as presenter experience and expertise, were responsible for the observed increase in CMETE scores. Yet another possibility is that effective presentations were longer due to the use of ARS, which was also associated with better CMETE scores. This explanation may be plausible because the ARS requires additional slides and provides opportunities for audience interaction, which may lengthen the duration of any given presentation.

This study has several limitations. This was a single CME conference sponsored by a large academic medical center, which may limit generalizability, especially to smaller conferences in community settings. However, the audience was large and diverse in terms of participants experiences, practice settings, professional backgrounds, and geographic locations. Furthermore, the demographic characteristics of hospitalists at our course appear very similar to a recently reported national cross‐section of hospitalist groups.[30] Second, this is a cross‐sectional study without a comparison group. Nonetheless, a systematic review showed that most published education research studies involved single‐group designs without comparison groups.[31] Last, the outcomes of the study include attitudes and objectively measured presenter behaviors such as the use of ARS, but not patient‐related outcomes. Nonetheless, evidence indicates that the majority of medical education research does not present outcomes beyond knowledge,[31] and it has been noted that behavior‐related outcomes strike the ideal balance between feasibility and rigor.[32, 33] Finally, the instrument used in this study to measure teaching effectiveness is supported by prior validity evidence.[16]

In summary, we found that hospital medicine CME presentations, which are longer and use audience responses, are associated with greater teaching effectiveness ratings by CME course participants. These findings build upon previous CME research and suggest that CME course directors and presenters should strive to incorporate opportunities that promote audience engagement and participation. Additionally, this study adds to the existing validity of evidence for the CMETE assessment tool. We believe that future research should explore potential associations between teacher effectiveness and patient‐related outcomes, and determine whether course content that reflects the SHM core competencies improves CME teaching effectiveness scores.