What's known on the subject? and What does the study add?
It has long been acknowledged that clinical expertise alone may not equip a surgeon to become a successful educator, and that medical educators may require additional teacher training to be able to teach effectively. To this end, many different faculty development training courses have arisen over the years including workshops, seminar series, longitudinal programmes, and fellowships. However, there is a lack of research into the effectiveness of these training programmes on long-term sustainable changes in teaching and learning, especially in the field of surgical education.
This article discusses the importance of faculty training within surgery and evaluates the existing faculty development programmes in terms of long- and short-term outcomes. Recommendations are provided that highlight the need for additional teacher training opportunities in surgery, the vigorous evaluation of the methodology and long-term outcomes of existing training programmes, and the need for better recognition and reward for teaching excellence within organisations.
To explore faculty training in the field of surgical specialities with a focus on the educational aspect of faculty training. Teaching is an important commitment for academic surgeons alongside duties of patient care, research and continuing professional development. Educating surgical faculty in the skills of teaching is becoming increasingly important and the realisation that clinical expertise does not necessarily translate to teaching expertise has led to the notion that faculty members require formal training in teaching methods and educational theory to teach effectively. The aim of faculty training or development is to increase knowledge and skills in teaching, research and administration of faculty members.
Materials and Methods
A range of resources, e.g. journal articles, books and online literature was reviewed to investigate faculty development programmes in surgery.
Various issues were addressed, e.g. the need for faculty development, evaluating the various types of training programmes and their outcomes, and exploring barriers to faculty training.
Recommendations were provided based on the findings.
There is increased recognition that faculty members require basic training in educational theory and teaching skills to teach effectively.
Most faculty training programmes are workshops and short courses, which use participant satisfaction as an outcome measure. However, there is growing consensus that longer term interventions, e.g. seminar series, longitudinal programmes and fellowships, produce more sustainable change in learning, behaviour and organisational culture.
Barriers to faculty development include lack of protected time, reward and recognition for teaching.
Recommendations are made including better documentation of faculty training interventions within surgery, further investigation into the effectiveness of long- vs short-term interventions, improved methodology, and increased recognition and reward for educational accomplishments.
The role of the surgeon as educator is an important, time-honoured concept. The obligation to pass on knowledge, skills and attributes takes special priority amongst the duties of a physician. According to the General Medical Council (UK) guidelines:
‘All doctors have a professional obligation to contribute to the education and training of other doctors, medical students and non-medical healthcare professionals on the team … and those who accept special responsibilities for teaching should take steps to ensure that they develop and maintain the skills' .
The role of the clinical teacher is diverse; including acting as facilitator, role model, information provider, resource developer, planner and assessor (Table 1) . Further to these roles, there is growing pressure on academic surgeons and medical educators to juggle their teaching duties with responsibilities of patient care, research and continuing professional development. An important issue highlighted in the above statement  is the development and maintenance of teaching skills in medical educators. Few medical academics have formal qualifications in teaching and educational theory, as greater merit is usually given to clinical and research achievements. It was once assumed that teaching ability may be innate to all qualified medical practitioners; however, there is increasing recognition that faculty training in preparation for teaching is vital. ‘Faculty’ or ‘teacher’ training or ‘faculty development’ promotes knowledge and understanding of effective teaching strategies. It can be defined as any planned activity that increases an individual's knowledge and skills in teaching, research and administration . It is an important component within medical education, a discipline in its own right that is concerned with the education and training of future and existing medical professionals. McLean et al.  have considered faculty training to be the vehicle that delivers the ultimate goal of medical education: ‘improving patient care by educating quality medical practitioners’; achieved through ‘developing professional teachers, educators, researchers and administrators’.
Table 1. The various roles of the clinical teacher. Adapted from Harden and Crosby .
Mentor, personal advisor or tutor to students.
Learning facilitator – facilitates teaching in various settings, e.g. small group problem-based discussions, integrated practical class sessions and teaching in a clinical setting.
Planning or participating in formal examination of students.
Curriculum evaluator – evaluates teaching programmes and teacher performance.
Curriculum planner – plays active role in curriculum planning committees.
Course organiser – planning and implementing new courses.
Production of study guides to support student's learning.
Developing learning resource materials, e.g. booklets, printouts, videos and Information Technology (IT) resources.
Teacher in a clinical or practical setting – a medical expert who can select and teach clinically relevant material in ward rounds, ward-based tutorials or clinics.
Lecturer in classroom setting – an expert in their clinical field who provides information in a lecture context, passing on knowledge appropriate to the level of understanding of the student.
Role model in a teaching setting – an excellent teacher who can kindle curiosity as well as better understanding of relevant clinical topics.
On-the job role model – provides an excellent example of professional attitude and standards of conduct in a clinical setting.
This article aims to explore faculty training in the field of surgical specialities with a focus on the educational aspect of faculty training. There will be discussion of the need for faculty training, available methods of training and effectiveness of outcomes, barriers to faculty development, and recommendations.
Do We Need Faculty Training?
Most clinicians with teaching appointments have had little formal teacher training [5, 6]. The notion that teaching is a part of being a doctor perhaps leads to the assumption that all physicians possess an innate ability to teach. Traditionally, clinical expertise was assumed to translate directly to teaching expertise; i.e. the dictum of ‘see one, do one, teach one’, where expert knowledge through observation and practice alone can translate to effective teaching [6, 7]. However, recent data support that in addition to content expertise; medical tutors require basic knowledge of educational theory and have expressed interest in acquiring formal training in how to teach effectively [5, 6, 8, 9]. Gibson and Campbell  surveyed 809 hospital consultants and found that only 34% had received formal teacher training, 57% felt that they needed training in basic teaching skills and many expressed interest in attending teacher training courses. Wall and McAleer  identified the learning needs of hospital consultants via a questionnaire; the top five themes for teaching were: giving feedback constructively, keeping up to date as a teacher, building a good educational climate, assessing the trainee and assessing the trainee's learning needs. A needs assessment carried out before implementing a surgical faculty training course entitled ‘Surgeons as Educators’ revealed that areas, e.g. developing programmes for faculty teaching, time and stress management and acquiring resources for faculty development, were deemed important but underdeveloped by the surgical faculty . Other surgical faculty members have expressed similar needs such as improving faculty teaching, developing strategies for marginal learners, conducting educational research and acquiring monitory resources and budget development [12, 13]. Thus, there is an increasing recognition that in addition to subject expertise, faculty members also require and request basic training in educational theory and teaching skills.
What Methods of Faculty Training are Available and What are the Outcomes?
A recent systematic review by Steinert et al.  identified 53 articles describing faculty development programmes with a focus on teaching skills between the years 1980 and 2002. Most faculty development courses took place in the field of family and internal medicine with only two articles relating to surgical specialties. Most activities described were in the form of workshops (46%); the rest were seminar series (19%), short courses (11%), longitudinal programmes, e.g. fellowships (10%), and ‘other’ (9%). Instructional methods that were used in the programmes included lectures, small group and interactive teaching, role plays and simulations, and the use of audio-visual aids.
Faculty development outcomes were measured using the Kirkpatrick scale , which states that the effectiveness of a training programme can be evaluated on four levels (Table 2):
Reaction, e.g. participant's reaction/satisfaction.
Learning, increase in knowledge, skills and attitude.
Behaviour, transfer of learning to educational environment.
Results, final impact on organisational culture.
Although the levels are not viewed as hierarchical, outcomes become more difficult to measure further down the scale from ‘reaction’ to ‘results’. Also, measures such as sustained learning, transfer of knowledge and organisational change are more meaningful and effective in evaluating training programmes than the short-term and superficial measure of participant reaction. In fact, a major criticism of the studies in the systematic review were that meaningful, long-term outcomes of faculty development such as improvements in learning and behaviour are seldom reported and most forms of evaluation include participant's satisfaction, which is the easiest to measure. However, in summarising the outcomes, there was overall high level of satisfaction, positive change in attitude towards teaching, increased knowledge of educational strategies and concepts, self-perceived changes in teaching behaviour (not always consistent with student evaluations) and changes in organisational practice (seldom reported) ranging from increased involvement in new educational activities and improved networking amongst colleagues.
Table 2. Levels of assessing outcomes of faculty training programmes. Adapted from Kirkpatrick .
This measures the participant's reactions and level of satisfaction with the training programme, including comments on negative and positive aspects. This is usually carried out through short questionnaires, evaluation forms or interview. Measuring reaction is important, as it provides valuable feedback and suggestions for further improvement. It is inexpensive, easily carried out and the least time consuming of the four measures.
This measures the extent to which participants have enhanced their knowledge, skills and attitudes during the training programme. Learning is evaluated both before and after the training programme via self, peer or formal means of assessment. Measuring learning is important as it means that there has been a change in perception and acquisition of new concepts and skills due to the programme.
This measures whether the knowledge and skills acquired during the training programme has been sustained and applied/transferred to the job setting and work practice. This requires a follow-up assessment and continuing evaluation, which may be more time consuming and difficult to carry out. However, measuring transfer is important as it indicates that learning has been put into effect in the workplace environment.
This measures improvement at an executive level that may include change in organisational culture and practice, development of new strategies and improvement in measurable outcomes (e.g. better student learning) that can be directly attributed to the training programme. This is the most reliable and long-term measure of the effectiveness of a training programme. However, there may be difficulties in forming a direct correlation between the intervention and the results and the process may be costly and time consuming.
Of the two interventions that took place in a surgical setting, one was described as a 1-day workshop entitled ‘Surgical Education: Principles and Practice’  and the other was a 6-day short course entitled ‘Surgeons as Educators’ . The former was developed by the American College of Surgeons to allow practicing surgeons to enhance their teaching skills in a clinical environment. The workshop consisted of five sections with educational objectives including understanding: the principles of adult learning, recognising the importance of needs assessment in teaching, questioning skills, feedback skills and performance evaluation. A range of activities were used, e.g. small and large group sessions, role-play situations, and group exercises with audio-visual aids. In all, 62 participants were involved and a follow-up survey was issued to all participants 4–6 months after the intervention. The survey had a 66% return rate and reported high participant satisfaction (78% rated the overall quality of the workshop as excellent); and a self-perceived change in teaching behaviour (88% reported that they had changed the way they taught based on the five educational objectives). The conclusion drawn was that a short, 1-day workshop designed to improve teaching skills of a surgical faculty can be well perceived by participants and show perceived changes in teaching behaviour; although further work is required to determine whether this will lead to measurable improvements in teaching.
The latter 6-day short course, ‘Surgeons as Educators’, was developed by the American College of Surgeons, Association of Surgical Education . A comprehensive needs assessment was conducted before implementation of the programme . The aim was to train surgical faculty in teaching strategies, educational programme administration and performance evaluation. Participants received a follow-up survey 3–6 months after course completion. More than half reported self-perceived changes in teaching behaviour and education-related actions related to curriculum development, teaching strategies and educational administration.
Although positive outcomes are reported, there are some limitations to be considered that can be generalised to most studies describing faculty development interventions. Firstly, the most popular type of intervention is short-term workshops and courses as described above. There is a view that short-term interventions may have fewer sustainable results and impacts on teaching behaviour and practice compared with long-term interventions, e.g. a seminar series or fellowship [14, 18]. However, shorter courses are more cost and time effective; many medical professionals cannot commit large amounts of time to these interventions. Thus, further research is needed to compare the effects of short- and long-term interventions in faculty training. Secondly, there is an overreliance on self-assessment and survey questionnaires to measure outcomes, e.g. participant satisfaction. Outcomes, such as change in attitude and learning behaviour, were often self-reported. Many authors have concluded that despite the growth of faculty development, more rigorous evaluation of meaningful outcomes is required, e.g. improved student performance and long-term organisational change [19, 20].
Thus, there is growing recognition that faculty development must develop beyond the traditional workshops and seminars to more rigorous and objective methods of teaching and assessment. The Objective Structured Teaching Encounter (OSTE) has been described as a faculty development tool to both teach and assess faculty members. The OSTE involves presenting clinical teachers with ‘standardised’ student learners and various ‘teaching scenarios’ in a controlled environment. The teacher then receives feedback from the standardised student and/or other faculty members based on their interactions and teaching performance with the student. The OSTE has been used as both a faculty development tool for improving teaching [21-23] and as a means of evaluating the effect of faculty development programmes on teaching skills [24-27]. A recent systemic review found that the OSTE may be a valid and reliable method for assessing teaching skills, reflecting realistic teaching scenarios and eliciting high participant satisfaction and improvements in self-perceived teaching performance . However, there were issues with assessing reliability as the rating instruments used were too variable across studies and there were concerns about the validity of student ratings. Also, there were criticisms about the lack of quantitative evidence that OSTEs actually improve teaching performance beyond self-perceived improvements reported by participants . Thus, methodological weaknesses exist with most faculty development programmes described. More long term and reliable assessment of outcomes is required.
What are the Barriers to Faculty Development?
Although there is increasing recognition of the importance of faculty development, some barriers still remain. Although most clinicians are enthusiastic about teaching; time and resource constraints can compromise high standards of teaching, especially when teaching duties compete with clinical and non-clinical commitments, e.g. administration, research, audit and continuing professional development [5, 29]. Interestingly, Callcut et al.  have found that the teaching ability of surgical faculty members was perceived to decline with career advancement and seniority, possibly due to increasing pressures to prioritise other commitments over educational development. As well as time constraints, teaching duties are often placed last amongst other clinical and non-clinical priorities, as teaching excellence is seldom recognised and rewarded on the same level as clinical and research excellence. Lowenstein et al.  noted that medical faculty are becoming less interested in their academic careers due to lack of effective faculty development programmes and lack of recognition and reward of teaching excellence. Steinert et al.  found that the reason faculty members did not participate in training programmes included increased time pressure and lack of protected time, as well as perceived lack of financial reward and recognition for teaching.
Perhaps the most significant barrier to faculty development is lack of institutional support. There is very little recognition and professional incentive or reward to encourage faculty members to seek qualifications in medical education [4, 20]. Most institutions place higher merit on clinical and research activities rather than teaching excellence; perhaps due to financial incentives or because an inherent teaching ability is assumed of medical professionals. In recognition of these difficulties, a task force was established by the Association of Surgical Education who suggested recommendations for improving faculty development based on research and findings from a survey issued to chairpersons in 140 surgical departments . Findings showed that only 69% of institutions used teaching and educational criteria during recruitment and only 66% reported awarding teaching excellence. Recommendations of the task force included ‘the need for appropriate recognition and support for surgery faculty members involved in education … through the development and implementation of appropriate systems for academic advancement and provision of adequate resources’. A hierarchical model called the ‘educational pyramid’ was developed, which classified faculty according to the level of skill attained in education (Fig. 1) , encouraging the documentation of educational contributions of surgical faculty and rewarding educational endeavours and accomplishments.
Based on the above findings, some recommendations for improving faculty training and development in surgical specialties can be made:
More research documentation of faculty development programmes and their outcomes within surgery
It is evident that there is a lack of description in the literature of faculty development programmes and their outcomes within surgical specialties. As with other specialties, the importance of faculty training within surgery is increasingly recognised. Blue et al.  have shown that the teaching quality of surgical faculty has an impact on student examination performance; surgical faculty teaching evaluation scores were associated with examination scores (P < 0.005). Despite the increasing recognition of the importance of faculty training within surgery, documentation of training programmes is poor. The systematic review by Steinert et al.  only revealed two training programmes in the field of surgery; both interventions were developed in the USA by the American College of Surgeons [16, 17]. In the UK, the Royal College of Surgeons of England (RSC Eng) have developed a training programme for surgical faculty entitled ‘Training the Trainers’, which aims to ‘provide surgical trainers with an improved understanding of educational theory underpinning formal teaching of knowledge and skills’; through lectures, group discussion and practical exercises . The importance of faculty development programmes has been highlighted by the RSC Eng who had begun to develop a four-stage strategy as part of the Intercollegiate Surgical Curriculum Project in 2005: (i) communicating the vision of faculty development programmes to deaneries and Trusts; (ii) developing courses and resources; (iii) developing local support for trainers at Trust level; 4) accrediting trainers and assessors . However, there have been no formal descriptions of these training courses in the scientific literature. Thus, it is recommended that descriptions of faculty development programmes within surgery must be improved with better documentation and evaluation of outcomes.
Further research into the effectiveness of long- vs short-term interventions
Research has indicated that there are advantages and disadvantages to both short- and long-term interventions; although most authors will suggest that long-term interventions produce more sustainable change in knowledge, skills and behaviour than short-term interventions [3, 14, 19, 20]. Short-term interventions, e.g. short courses and workshops, are easier and less expensive to run than long-term interventions, e.g. a seminar series or fellowship programmes. There have been reports that long-term interventions, e.g. fellowship programmes, are becoming increasingly unattainable due to lack of funding and time requirements [37, 38]. The above reasons may explain why short-term interventions are much more common than long-term interventions in faculty development [14, 20].
However, many authors have criticised short-term interventions in that they are not able to produce long term, sustainable change in learning, behaviour and organisational practice. Knight et al.  have reported continued teaching activities and sustained research comparing these two types of interventions is required to make definite conclusions.
Improved methodology and assessing long-term outcomes
Based on the evidence, we recommend that faculty training programmes should be targeted for methodological weaknesses and assess long-term and more reliable outcomes.
Many faculty training courses rely on questionnaire and survey methods to measure outcome. Few have used randomised controlled trials; for example, in the systematic review conducted by Steinert et al. , only 11% of the interventions reviewed were randomised controlled trials and most (89%) were quasi-experimental in design. Furthermore, increase in knowledge, skills and changes in attitude and behaviour were often self-reported by the participants via questionnaire or survey method. When questionnaires were used, few had been validated and psychometric properties of questionnaires were seldom reported. Thus, many authors have noted that more rigorous evaluation of outcomes via the use of sound qualitative and quantitative designs is needed [19, 20]. More objective means of evaluating the effectiveness of training programmes may be used instead of self-reported measures of outcome. Studies have described the use of OSTEs as a formal method of assessing teaching skills in a controlled environment that involves teaching scenarios with standardised students presenting with various learning needs [21-27]. However, there is a lack of standardisation of rating methods and lack of quantitative assessment of improvement in teaching skills in these studies . Thus, methodological weaknesses exist in the design and evaluation of faculty training programmes, improvements must be made in quantitative and qualitative designs and new methods of evaluating outcomes must be explored.
Another issue is that many studies have reported high participant satisfaction as a measure of outcome. This can be measured via short questionnaires and evaluation forms and is relatively inexpensive and less time consuming. However, although reaction and feedback from learners is vital for improving faculty training programmes, it does not provide a long-term picture of whether changes in learning and behaviour have been sustained and whether the programme has actually made an impact on organisational culture, teaching strategies and student learning. For instance, in the systematic review by Steinert et al.  with outcomes rated using the Kirtpatrick scale, only 19% assessed ‘results’ (i.e. long-term changes in organisational practise and improvements in learning of students). These outcomes are more time consuming and require greater resources, as they usually involve long-term follow-up assessments and continuing evaluation. Furthermore, it is difficult to directly attribute long-term improvements to the effect of the intervention due to lack of randomised controlled trials and too many extraneous variables. However, the recommendation is that faculty development programmes should strive to evaluate more long-term outcomes, such as increase in knowledge, skills and attitudes as well as changes in organisational practice and improved student learning through long-term assessments and continuing evaluations.
Better recognition and reward for teaching excellence and more protected time for educational development
There is a wide consensus that educational endeavours and teaching excellence deserve reward and recognition on a par with clinical and research excellence. It is evident from the literature that lack of protected time is a major deterrent for faculty to pursue educational training. Steinert et al.  reported that faculty members do not participate in training programmes due to work overload and lack of protected time to develop teaching skills. Motivation to pursue educational qualifications may be dampened by lack of financial reward and lack of recognition of teaching excellence in recruitment and promotion. The American Surgical Association has recommended that surgical academic departments should provide financial support for teaching programmes and compensate for time spent by faculty in educational activities; there should be requirements for faculty members to demonstrate knowledge of education and commitment to teaching and faculty development courses in teaching and education should be provided . Thus, recommendations are to increase recognition and reward for educational qualifications, providing more protected time and financial resources for faculty development and recognising educational achievements in recruitment and promotion.
There is increasing recognition that medical educators often require training in teaching skills and educational theory, as well as clinical expertise for effective teaching. Various methods, i.e. short- (short courses and workshops) and long-term (seminar series, longitudinal programmes and fellowships) interventions, used in the design of faculty training programmes have been discussed. The outcomes of different types of training programmes have also been evaluated. Long-term interventions have been shown to provide more sustained change in learning, transfer of skills to the educational environment and long-term organisational change. Barriers to faculty development have been discussed, including lack of protected time and resources, and lack of recognition and reward for educational endeavours by faculty. Recommendations have been made, including better documentation of faculty training interventions within surgery, further research into the effectiveness of long- vs short-term interventions, better methods and reporting of long-term outcomes and increased recognition and reward for educational accomplishments.