Otolaryngol Clin N Am

40 (2007) 1203–1214

Interactive Instruction in Otolaryngology

Resident Education
John M. Schweinfurth, MD
Department of Otolaryngology and Communicative Sciences,
2500 North State Street, Jackson, MS 39216, USA

Today’s academic faculty were typically trained under an education sys-

tem based entirely on didactic lectures. Because the choice of teaching
method is usually based on familiar methods, didactic lectures have per-
sisted. However, if the aim is to teach thinking or change attitudes beyond
the simple transmission of factual knowledge, then lectures alone, without
active involvement of the students, are not the most effective method of
teaching [1]. The goals of teaching as described by Isaacs are to (1) arouse
and keep students’ interest, (2) give facts and details, (3) make students
think critically about the subject, and (4) prepare students for independent
studies by demonstration of problem solving and professional reasoning [2].
Isaacs notes, however, that only two of these purposes are well suited to di-
dactic lectures. The problem then is how to organize lecture material so that
individual student’s learning needs are better addressed. Gibbs suggests that
lecture sessions contain a variety of activities designed to stimulate individ-
ual students to think, including small-group discussion, working problems
during lecture time, questions included in the lecture, and quizzes at the
end of lecture, among others [3].
The current article examines the feasibility of using these types of inter-
active learning techniques in an otolaryngology residency program. Other
possibilities include standard interactive lecturing, facilitated discussion,
brainstorming, small-group activities, problem solving, competitive large-
group exercises, and the use of illustrative cliff-hanger and incident cases.
The feasibility of these methodologies being effectively incorporated into
a residency curriculum is discussed.

E-mail address: jschweinfurth@ent.umsmed.edu

0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.07.002 oto.theclinics.com
1204 SCHWEINFURTH

Adult learning theory

As adult learners, physicians have many different learning styles, and any
planned education intervention should account for these differences. Mal-
colm Knowles is best known for the theory of andragogy, the art and science
of helping adults learn, as contrasted with pedagogy, the art and science of
helping children learn [4]. Knowles assumed that adults and children learned
differently based on five humanistic assumptions [4]:
1. As a person matures, his or her self-concept moves from that of a depen-
dent personality toward one of a self-directing human being.
2. An adult accumulates a growing reservoir of experience, which is a rich
resource for learning.
3. The readiness of an adult to learn is closely related to the developmental
task of his or her social role.
4. There is a change in time perspective as people maturedfrom future to
immediate application of knowledge; thus an adult is more problem
centered than subject centered in learning.
5. Adults are motivated to learn by internal factors rather than external
ones.
Compared with children, adults have significant experience and prior
knowledge from which they draw connections and parallels that help to de-
fine and categorize new knowledge. The more alike new knowledge is in or-
ganization and content to old knowledge, the more easily this knowledge
can be assimilated. On any given topic, learners differ greatly in the depth
and accuracy of prior knowledge. More than likely, the knowledge will be
fragmented and incomplete. In a standard didactic lecture, there is no op-
portunity for the lecturer to gauge prior knowledge of the learner and, there-
fore, the class’ learning effectiveness may be quite diverse. Some students
may reinterpret what they hear to fit preexisting misconceptions. It will be
necessary for some students, therefore, to unlearn some of what they already
know and reorganize their knowledge base. Thus the assessment of prior
knowledge is critical to the lecturer.
As adults grow and change in the learning experience, these changes
should be recognized, making feedback essential. The basis of andragogy
is often used in the teaching of adults. Putting this theory to work in the
classroom involves an awareness of the basic principles that underlie these
assumptions. The classroom should be a safe, comfortable environment
where facilitation, rather than lectures, is used as a teaching style. The facil-
itator should promote understanding and retention along with the applica-
tion of the material to the life experience of the students. The curriculum
should be problem centered whereas the learning design should promote in-
formation integration.
Life situations of physicians have a critical impact as well. McClusky,
who introduced the ‘‘theory of margin,’’ believed that adulthood involved
 INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY 1205

continuous growth, change, and integration, in which constant effort was re-
quired to manage the energy available for meeting the normal responsibili-
ties of living [5]. He envisioned margin as a formula, which expresses a ratio
or relationship between ‘‘load’’ (of living), and ‘‘power’’ (to carry the load).
Load is ‘‘The self and other demands required by a person to maintain
a minimal level of autonomy’’ and power ‘‘the resources, ie, abilities, posses-
sions, position, allies, etc., which a person can command in coping with
load.’’ For the learner to meet the demands of life, combined with learning
needs, power must exceed load. Thus, margin enables the individual to take
on more stimulating activities, such as educational opportunities, and inte-
grate them into his or her lifestyle. McClusky’s theory is appropriate
because it deals with events and transitions common to all adult learners.
Educators aware of this theory can more effectively create a learning envi-
ronment suited to the needs of the learner. Increased load due to unrealistic
work assignments, undue stress caused by uncertainty, and unresolved
social issues can affect how well the learner can cope. At the same time,
learning can provide surplus power, which can be a significant impetus in
achieving various goals.
Knox’s (1980) [6] proficiency theory also deals with an adult’s life situa-
tion. He defines proficiency as ‘‘the capability to perform satisfactorily if
given the opportunity.’’ This performance involves some combination of at-
titude, knowledge, and skill. The purpose of adult learning is to ‘‘enhance
proficiency to improve performance.’’ Central to this theory is the belief
that a discrepancy exists between the current and desired level of profi-
ciency. This discrepancy is the impetus that motivates the adult to seek
a learning experience that will increase proficiency. A model that represents
the theory would include the following interactive components: ‘‘the general
environment, past and current characteristics, performance, aspiration, self,
discrepancies, specific environments, learning activity, and the teacher’s role
[7].’’

Specific educational needs of otolaryngology residents and potential

barriers
Medical knowledge
Spread over 4 years, the otolaryngology residency is tightly packed with
didactic and self-directed learning in basic science and medical knowledge
and procedural skills training. A recent review of the American Board of
Otolaryngology’s medical knowledge content requirements revealed over
300 topics to be mastered before board certification. The requirement for
medical knowledge is tempered by the development of clinical skills through
other means such as practical experience as well as other obligations, includ-
ing research and community service. Owing to the nature of residency train-
ing, didactic instruction time in residency programs is limited. With the
1206 SCHWEINFURTH

advent of work-hour restrictions, most training programs lack sufficient lec-

ture time to thoroughly cover the curriculum mandated by the Accreditation
Council for Graduate Medical Education in the available training period.
Otolaryngology didactic sessions are therefore content heavy and must be
performed in a time-efficient manner to accommodate still further content
in other areas.

Motivation for change and learning

Much has been written about innovative teaching and learning tech-
niques in undergraduates. Physicians in training represent a substantially
different group of learners than undergraduates, however. Once a strong
professional identity has formedd usually after the first year of trainingd
resident learning may be described similarly to that of practicing physicians
by the ‘‘change model’’ of Fox and colleagues [8]. In interviews with over 300
practicing physicians, the authors found that the desire to learn and change
can come from professional, personal, and social reasons. In their experi-
ence, the most common reasons for change included a desire for general
competence or the recognition of a changing practice environment (eg, com-
petition, improved patient self-education, and Internet access). Resident
physicians are likely similarly motivated by a desire to strengthen profes-
sional roles and identity, gain competence, and deal with expected clinical
challenges. Geertsma and colleagues [9] identified three stages to learning
in practicing physicians: deciding on whether to take on a learning task to
address a problem, learning the knowledge and skill anticipated to resolve
the problem, and gaining experience in what has been learned. Residents
differ from practicing physicians under Geertsma’s model in that they do
not have the luxury of choosing whether to take on a new learning task:
all learning is new and therefore necessary. The limitation of the change
model is the mismatch between real and perceived learning need areas, an
observation that applies equally to both resident and practicing physician
learners. The instructor must nevertheless be aware of the need to link
learning experiences to the residents’ future practice in order to obtain the
necessary ‘‘buy-in’’ for whole-hearted participation.

Development of other skills in residency training

Part and parcel to residency training is functioning within a team, profes-
sional identification, and developing rapport with patients and other health
care workers. Thus, learning exercises that emphasize team building, inter-
personal skills, and leadership skills further the professional development
of young practitioners. Finally, upon graduation residents leave the nurtur-
ing training environment and go off into distant areas to practice and be-
come local and regional experts. Residents need to be encouraged,
therefore, to make the transition from passive to independent learning,
study, and professional development.
 INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY 1207

Needs assessment: focus group results

A focus group was conducted with otolaryngology residents in training to
discuss innovative learning strategies. In summary, residents (1) expressed
a desire to maintain the status quo and avoid complex exercises given the
available lecture time, (2) considered attempts at innovation as ‘‘too exper-
imental’’ or a ‘‘waste of time,’’ and (3) were concerned about extending the
topic outside the available lecture period into personal time. Finally, resi-
dents requested the inclusion of pictures, illustrations, and videos where ap-
plicable, as well as hands-on techniques. The general consensus was that
lectures should build on what has been seen or experienced clinically; resi-
dents may have difficulty learning in the abstract but are greatly interested
when they have experienced a clinical problem for which they are unaware
of or unable to find a solution.

Instructional methods
Didactic lectures
Lectures are the most widely used and accepted method of education. As
a tried-and-true method, lectures have many inherent advantages and ben-
efits. Lectures are time and resource efficient and cost effective, as a large
number of learners can be taught simultaneously with the same amount
of effort from one teacher. Lectures are familiar and comfortable to both
teachers and learners: owing to the lack of interaction neither is ‘‘put on
the spot’’ and the lecturer remains in complete control of the learning expe-
rience. In a survey of faculty at a large Australian university, Isaacs identi-
fied the reasons for the use of lectures: making students think critically
about the subject, demonstrating professional reasoning, making students
enthusiastic, explaining difficult points, and providing a framework for
self-directed learning [2]. The primary advantage of the use of didactic
lecturing for otolaryngology core resident education is that the faculty
member is a content expert in his or her respective area and is able to
distill the most salient points from the textbooks and literature and
demonstrate professional reasoning with an admixture of valuable real-
world experience not readily available elsewhere. As a group, the faculty
firmly believed that the presence of the teacher in the classroom, commu-
nicating and interacting with the students, is essential to the educational
experience [2].
Learning takes place along three dimensions: knowledge, skills, and atti-
tudes. The lecture format is appropriate only for addressing knowledge. De-
velopment of skills and attitudes by the learner requires more participation,
practice, and discussion than are available in the lecture format [10]. Within
the domain of knowledge there are different levels according to Bloom’s
taxonomy [11]. Realistically, lecturing can reach only the lowest two levels
1208 SCHWEINFURTH

of ‘‘knowledge’’ and ‘‘comprehension.’’ Higher levels of knowledge that in-

volve problem-solving skills (ie, analysis, synthesis, and evaluation) require
greater participation and practice and should be considered unattainable
from the lecture format [10].
From a practical standpoint, lecture preparation is time intensive for the
instructor, and the learner may be overloaded by content or bored and
subsequently ‘‘check out’’ or stop learning early on in the course of a lecture.
The ‘‘one-size-fits-all’’ approach of lectures is therefore insensitive to the in-
dividual needs of the learner. From the teacher’s standpoint, non-interactive
lectures lack feedback. The teacher is unaware of the student’s real-time
needs, reception, and degree of learning. One-way didactic lecturing does
not prepare learners for independent, self-directed learning and fails to
wean learners from passive roles. Finally, the lack of interactivity does not
promote interpersonal communication skills, leadership, and team building.

Interactive/active learning
Ramsden [1] and others in the area of teaching and learning in higher ed-
ucation distinguish three, essentially hierarchical, views of teaching: the
transmission of information, keeping the students active, and facilitating
change. The first of these views dovetails nicely with the idea that students
must, in the main, remember facts. The second takes a more instrumental
view of teaching: as long as students are active something good will happen.
The third is consistent with the idea that learning is personal to the student
and in a formal setting arises in the interaction with the teacher, student,
and subject matter, leading to learning for understanding or ‘‘deep’’ learn-
ing. The common wisdom is that deep learning requires that the student par-
ticipates actively whereby they ‘‘construct’’ knowledge for themselves [10].
Of course, this process cannot take place in the absence of knowledge; hence
students will need to have learned some facts. Interactions allow higher level
of understanding, higher ability in the analysis and synthesis of material,
easier transfer of material presented to other situations, and more effective
evaluation of the material presented [10,12,13].

Specific interactive techniques and their potential application

Questioning
Questioning the audience is the most commonly applied interactive tech-
nique (the Socratic Method) and is typically commonly used by many oto-
laryngology faculty in the form known colloquially as ‘‘pimping.’’ In
general, questions can be used to achieve several results (Box 1).
An essential role of questioning at the beginning of a lecture is to assess
the learners’ prior knowledge. This is an opportunity to identify specific gaps
in knowledge and misconceptions and bring all members of the audience
 INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY 1209

Box 1. Using questions as an interactive technique

 Focus attention
 Arouse interest
 Enhance inclusion by drawing out the reluctant learner
 Obtain feedback on the progress of the lecture
 Assess the level of understanding
 Assess the ability to apply learned concepts and knowledge
 Stimulate and guide thinking and reflection
 Explore different viewpoints
 Promote discussion and sharing
 Keep the discussion on track
 Summarize and consolidate learning

onto the same page before beginning the lecture. Intermittent questioning can
serve as a formative assessment of learning and the lecture modified
accordingly in real time to ensure that instructional goals are being met.
Questioning in a residency environment should be sensitive to the hierar-
chical structure of the training program and should avoid demonstrating
weakness in the knowledge base of senior residents in front of juniors.
Therefore, questions should be posed to the group as a whole and not to
individuals. It is also important to allow learners to question the teacher
during the lecture rather than waiting until the end.
Questions may also be posed to learners before the lecture. Learners will
avoid not knowing the answers to questions they are given in advance as
there is little excuse for not having tried. This technique serves to pique in-
terest, focus learning, and help the learner build on prior knowledge. Prepa-
ratory questions further serve to stimulate the development of new patterns
of self-directed learning such as reference and resource management which
residents will continue after graduation.

Discussion
Discussion is one of the most powerful tools of teaching and learning.
The transition from ‘‘lecturing to questioning to discussion’’ represents
roughly the move from the didactic to the rhetorical and then to the dialectic
mode of teaching and learning. All three modes are important, but for adult
learners, it is obvious that the latter two modes are more significant. Discus-
sion can be based on a provocative question, a case presentation, or a patient
management question, or can be learner initiated. To conduct a fruitful
discussion, the lecturer should
 Avoid imposing an opinion or conclusion on the class
 Listen actively
1210 SCHWEINFURTH

 Encourage participation with body language and verbal cues

 Keep the discussion on track and prevent domination by one or two
members
 Maintain a balance of differing viewpoints
 Correct factual errors
 Provide a wrap-up at the end of the session

Brainstorming
Brainstorming integrates aspects of both questioning and discussion.
Employed at the beginning of a lecture, brainstorming can be used to invite
everyone in the group to participate and put them at ease [13]. The teacher
can then alter the lecture based on the generated list (as a type of formative
feedback) because it demonstrates the learners’ previous knowledge and
educational needs. Brainstorming at different points in the lecture allows
learners to apply knowledge obtained earlier in the session or as a summa-
tion of the learning experience.

Small-group exercises
Most otolaryngology residency programs are already small groups. Yet
residents can be further divided by level of training or in half by juniors
and seniorsdor a mix of each. An innovative use of small-group activities
devised by the author involves pitting groups of residents against one an-
other. The competitive nature of surgical residents makes the use of ‘‘con-
test’’-oriented group exercises a good fit. Each postgraduate-year level can
serve as a two-person group, or for larger groups, junior versus senior res-
idents. Potential ‘‘prizes’’ include immunity from future questions, reduced
demands for activities in the future, or the power to determine tasks other
residents must perform.
The clinical orientation of cliff-hanger and incident cases makes them an
ideal jumping-off point for small-group breakout sessions. In the former,
residents are given a case outlining a complex situation that stops at the
point where a decision has to be made; in the latter, multiple correct deci-
sions must be made to obtain further information [10]. Residents can
work against the clockda diagnostic and management total-cost limitd
or each other to resolve each case. These are but a few examples of inter-
active small-group activities that can be implemented within a residency
training environment.

Interactive small-group activities and learning theory

The small-group structure outlined above can serve as the basic unit of
participation in the following types of activities: experiential and coopera-
tive learning, problem solving, case study, simulations, role playing, peer
 INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY 1211

teaching, independent study, and computer-based simulations [10,14–16].

The ‘‘expository model’’ creates a bridge between traditional and interactive
lecture styles. Content experts present material in a carefully organized,
sequenced and finished form. The major aspect in constructing the lecture
is to provide a framework to enable students to receive the most usable
material in an efficient manner, organizing knowledge into hierarchical
and integrated patterns, from general to specific, and completing the lecture
through reinforcement of the cognitive schema [17,18].
In one model of cooperative learning treatment described by Slavin [19],
learners are assigned to teams; each member is assigned a portion of the
material to be learned and designated as an ‘‘expert’’ for that portion.
Each is then responsible for teaching that material to the rest of the group.
The benefit of this activity is that it promotes team building through trust
and interdependence between members.
Gulpinar and Yegen [20] demonstrated that the use of an advance orga-
nizer, followed by a presentation of new material and reinforced by an in-
termittent, interactive task, best captured students’ attention and allowed
for recall of previous information, repetition of the material, and integration
of newly presented and previous information. Furthermore, they reasoned
that if new learning is not based on some prior knowledge, students may
learn new information as ‘‘isolated’’ bodies of knowledge and may therefore
face difficulties in applying and transferring the new knowledge in novel
situations. On the other hand, activation of prior knowledge promotes
reconstruction of already existing schemas and provides students with
a more fruitful conceptual framework for particular contexts [21].

‘‘Best-fit’’ techniques
According to Frederick [22], the lecture is here to stay. Although adult
learners may be eager to embrace change, faculty are not so readily retooled.
Therefore, interactive techniques that can be adapted to existing strategies
are most likely to be successfully adopted over the long-term. Of the afore-
mentioned techniques, questioning is the most readily usable by most fac-
ulty, and minor modifications to most curricula will greatly improve the
execution of this strategy. Some of the potential problems encountered by
the introduction of interactive techniques are listed with suggested solutions
in Table 1. Although not an exhaustive list, these problems are the most
commonly encountered ones when incorporating interactive techniques.
Slightly more involved techniques, such as discussion and brainstorming,
would be the next most adoptable solutions given their use in other formats
(eg, the multidisciplinary tumor conference or the morbidity and mortality
conference). Although likely to be disorganized initially, discussion em-
powers the residents (or other physicians) to direct their own learning
and, in turn, take responsibility for the conduct of the session, thus greatly
reducing the burden on the facilitator.
1212 SCHWEINFURTH

Table 1
Interactive lecturing problems and solutions
Challenges
Time available for lectures is reduced
Residents may feel cheated
Residents may feel overloaded if they are
asked to do some work in preparation
Residents may find it hard to participate if
they do not know enough
There may be a loss of clarity or focus
Lecturer may fear loss of control
Lecturer may be anxious about ability to
answer questions
Lecturer may be required to have particular
skills to construct appropriate
interactions and respond to comments
Some individuals may dominate
Residents may lack confidence in speaking
in large groups
Residents may be used to a culture of
passive learning in lectures
Residents want clear notes for examinations
Adapted from Young P. Interactive lecturing: problems and solutions. Social Policy and So-
cial Work Subject Center of the Higher Education Academy, November 2001. Available at:
(http://www.swap.ac.uk/learning/interactive3.asp).
Possible solutions
Reducing content may be useful
 Lecturer can make clear lecture notes
available
 Explanation of approach to learning and
teaching is important
 Keep advance work expected to minimum
 Can read short passages in the session
together
Choice of task may be important
Give a ‘‘map’’ to activities interactive
elements can be planned to enhance focus
 Can use bell or other device to change
mode
 Requires balance within session between
lecturing and interaction
 Residents can be referred to sources
 Unanswered questions can be dealt with
in a later lecture or through Web systems
 Can be viewed as part of a new culture
of learning
 Will need to develop skills by practice
 Start with simple interactions
 Can learn from others
 Ensure a variety of views are heard
 May need ground rules regarding air time
Can use paired work to build confidence
(or allow time to think on their own,
then share ideas in pairs)
 Need to build new culture (eg, by
reducing physical distance between
lecturer and students)
 Prepare students
 Explain importance of learning through
repetition of notes
 Lecturer can produce notes (eg, on the
Web)

The use of small-group breakout sessions poses more of a departure for

most otolaryngology faculty. However, the use of problem-solving and clin-
ical cases will greatly facilitate this transformation and improve the likeli-
hood of acceptance and ultimate success.
According to Tough’s [23] theory of self-directed learning, the best results
come from the skillful integration (with concerted efforts both by the
teachers and learners) of self-directed learning within formal instructional
 INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY 1213

programs. Therefore, techniques that combine the use of an advanced

organizer (from simple prelecture questions and outlines to the preparation
of formal presentations to be given to the rest of the group) with interactive
techniques integrated into the lecture session are most likely to provide
the best results. This format may be used with didactic, medical–
knowledge-based lectures as well as problem- or case-based sessions with
equal effectiveness.

Summary
The ideal teaching techniques for use with residents or other physicians
should combine the goals of development of medical knowledge, team build-
ing, or leadership skills with self-directed learning that provides a period for
reflection and personalization of learning goals for individual needs. This
approach would empower learners such that they are in control of their
own learning and allow them to pursue topics of interest. It would also pro-
mote independence and the means to discuss and defend one’s own ideas. In
short, the ultimate goal is internalization of the curriculum such that faculty
are merely facilitators of the learning process, and not its directors.

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