|Year : 2019 | Volume
| Issue : 2 | Page : 65-71
What constitutes excellent teaching: A survey of the perceptions of AAVMC distinguished veterinary teacher award winners
Kenneth D Royal1, Todd Zakrajsek2, Keven Flammer1
1 Department of Clinical Sciences, North Carolina State University, Raleigh, NC, USA
2 Department of Family Medicine, University of North Carolina, Chapel Hill, NC, USA
|Date of Web Publication||5-Nov-2019|
Dr. Kenneth D Royal
Department of Clinical Sciences, North Carolina State University, 1060 William Moore Dr, Raleigh, NC 27607
Source of Support: None, Conflict of Interest: None
Background: Although researchers have attempted to discern the characteristics of good teachers and good teaching, no one has attempted to solicit the perspectives of instructors recognized for their teaching effectiveness in veterinary medicine. Thus, the purpose of this study was to survey national award-winning educators, namely recipients of the AAVMC Distinguished Veterinary Teacher Award, in an effort to gain insights about the beliefs, characteristics and behaviors of proven, outstanding educators. Methods: This mixed-methods study utilized survey and grounded theory methodologies to analyze quantitative and qualitative data. Results: Although most award-winning educators did not possess any formal training in education, each demonstrated a high-level understanding of modern learning theory and effective pedagogical techniques. Although opinions varied on some issues, there was virtually a consensus on the importance of issues such as emphasizing clinical relevance, focusing on core concepts, avoiding minutiae, offering opportunities for application, and illustrating how concepts are related. Further, most educators embraced backward design principles and were highly intrinsically motivated to perform their instructional duties well. Award-winning educators tend to believe developing expertise in teaching is just as important as developing expertise in one's academic discipline/content area. Conclusion: Continual and increasing efforts to promote faculty development are warranted in veterinary medical education.
Keywords: Academic affairs, assessment, curriculum, educational methods, outcomes, skills, knowledge, and attitudes, student affairs
|How to cite this article:|
Royal KD, Zakrajsek T, Flammer K. What constitutes excellent teaching: A survey of the perceptions of AAVMC distinguished veterinary teacher award winners. Educ Health Prof 2019;2:65-71
|How to cite this URL:|
Royal KD, Zakrajsek T, Flammer K. What constitutes excellent teaching: A survey of the perceptions of AAVMC distinguished veterinary teacher award winners. Educ Health Prof [serial online] 2019 [cited 2020 Jul 6];2:65-71. Available from: http://www.ehpjournal.com/text.asp?2019/2/2/65/270291
| Introduction|| |
An extensive body of research spanning virtually every academic discipline has studied the topic of excellent teaching. The vast majority of studies have attempted to understand the qualities and behaviors of excellent teachers in an effort to improve teaching practice. Although the approach for investigating excellent teaching is often quite variable, research demonstrates clearly that disciplinary expertise and excellent teaching are related, but independent constructs. The expectation of dual expertise presents a unique challenge for college and university faculty as higher education is predicated on the concept that disciplinary expertise must be taught through a carefully designed curriculum spanning years of rigorous training, whereas excellent teaching is assumed once content knowledge is acquired. As a result, faculty members from essentially every discipline receive little, if any, formal training in pedagogy. Faculty in veterinary medical programs are no exception.
In an effort to better understand how faculty develop teaching expertise, Oleson and Hora  conducted interviews with 53 faculty members. Results indicated that teaching strategies and approaches were derived from several areas (e.g., prior classroom experience and trial-and-error approaches, interactions with faculty colleagues, ways that respondents learned as students, and participating in faculty development workshops), but no mention was even made of formal training in education prior to beginning as a faculty member. There is a growing recognition of the importance of effective teaching as a key aspect of educational reform. It has been well documented that working at becoming a better teacher, often through faculty development activities, is an important aspect of enhancing student learning.,
Although researchers have attempted to discern the characteristics of good teachers and good teaching, no one has attempted to solicit the perspectives of instructors recognized for their teaching effectiveness in veterinary medicine. To that end, the purpose of this study was to survey national award-winning educators, namely recipients of the AAVMC Distinguished Veterinary Teacher Award, in an effort to gain insights about the beliefs, characteristics and behaviors of proven, outstanding educators. It is hoped that this information will assist faculty who are currently teaching in veterinary medicine programs.
| Methods|| |
The AAVMC Distinguished Veterinary Teacher Award was first awarded in 1992. Each year, veterinary colleges in the U.S. (and more recently the Caribbean) select the top teacher in their college for the Distinguished Teaching Award. From this pool of college-level outstanding educators, individuals are nominated for the national AAVMC Distinguished Veterinary Teacher Award, with one winner selected each year. At the time, the present study was conducted 25 individuals had previously won this prestigious national award. A list of award winners was acquired from the AAVMC website, and contact information was obtained for each individual through an online search. The online search revealed one individual was deceased and one person had retired and could not be located. Thus, 23 previous award winners were invited to participate in the study. Fifteen individuals agreed to participate, resulting in a 65.2% response rate.
With respect to demographic characteristics, 9 (60%) participants were males and 6 (40%) were females. Fourteen of the fifteen participants were 55 years of age or older. The number of years of teaching experience ranged from 25 to 42, with a median of 33 and a mean of 33 (standard deviation [SD] = 4.7). Participants receiving the AAVMC award indicated the following academic ranks: 2 (13.3%) were Assistant Professors, 5 (33.3%) were Associate Professors, and 8 (53.3%) were Full Professors. With respect to the number of years of teaching within each DVM program year, 8 (53.5%) participants indicated teaching in 1st year courses, 10 (66.7%) for the 2nd year courses, 7 (46.7%) for the 3rd year courses, and 8 (53.5%) for the 4th year courses.
Procedures and instrumentation
In the fall of 2016, the Institutional Review Board approval was granted to conduct the study. Participants were contacted in January 2017 and asked to participate in a study investigating what separates an excellent teacher from simply a good teacher. Two E-mail reminders were sent and the survey window remained open for approximately 3 weeks.
Participants were asked a series of questions about topics such as the importance of various pedagogical practices, previous training and experience in education, influences and mentors, continuous improvement practices, talent origins, incentives to teach, and more. All items were generated by the research team and inspired by extant education research and theory. Item formats included a combination of the rating scale and open-response options.
In addition to the open-ended questions, AAVMC award winners were asked to complete the 23-item teaching perspectives scale, which measured the perceived importance of various educational practices. Items were selected for inclusion in the survey based on a combination of extant education research and general curiosity. For example, the Teacher Behavior Checklist  identified teacher qualities and behaviors that previous research has identified as critically important. Items that were deemed most important in previous studies were modified accordingly and included in the study. The research team recognized participants may not make full use of a traditional 4- or 5-point rating scale, as many (if not most) items likely would be rated as important. In an effort to better distinguish differences between items, we utilized a 10-point visual analog scale (1 = Not important; 10 = Extremely important). The Cronbach's alpha reliability estimate for the 23 items was 0.804, indicating “moderately” reliable scores.
| Results|| |
Importance of various teacher qualities and behaviors
Because of the small sample and the lengthy rating scale, a frequency distribution offered little utility. Thus, a variety of descriptive statistics (e.g., sum of raw score ratings per item, median, mean, SD, minimum and maximum ratings) were produced for a more thorough inspection of the data [Table 1] and [Figure 1].
|Figure 1: Mean (± standard deviation) item responses using a 1–10 Visual Analog Scale|
Click here to view
Formal training in pedagogy
Given the relatively limited formal training in teaching strategies in higher education, and the importance of effective teaching to learner success, we sought to determine what prior training award-winning teachers had in the areas of teaching effectiveness before actually teaching in the field of veterinary medicine. Of the fifteen participants responding to the survey, seven participants noted they received no formal training in education whatsoever. Three participants noted they did have university-level courses related to teaching, but the amount varied considerably. One award winner held a Ph.D. in an education discipline in addition to a Ph.D. in a veterinary discipline, one participant had received training to be a biology teacher as an undergraduate, and one participant noted taking an education course at the undergraduate level and a course on principles of college teaching at the graduate level. The remaining five participants noted they learned about educational theory and strategies while engaging in their teaching duties, attending workshops and visiting the institution's teaching and learning center.
Are excellent teachers born or made?
It is well-documented that most anyone can improve the quality of his or her teaching with sufficient dedication and training. Yet, there remains considerable variation among instructors' teaching effectiveness. This has led some scholars to question whether excellent teachers are born or made., We presented this question to participants to solicit their perspectives on the matter. Responses were evenly split with 7 (50%) noting they believe the best teachers are born, and 7 (50%) noting they believe the best teachers are made. One participant did not answer this question.
Modeling from mentors
The research on faculty socialization has long noted the influence of mentors on shaping the attitudes and behaviors of faculty colleagues., We asked participants if they modeled certain aspects of their teaching from a mentor or someone they thought was an excellent teacher. Nine participants noted they modeled a great deal of their teaching from observations of former teachers and/or fellow faculty members. Two participants noted they worked directly with mentors who influenced their teaching. Interestingly, with respect to teaching, four participants noted they did not have any mentors nor were they influenced by others.
Influences that affected award winners' teaching
Research has indicated a variety of factors influence effective teaching. We asked participants to note the most significant influences affecting their teaching effectiveness. Responses largely fell into three themes. Seven participants noted they held a deep love for the subject matter and a strong desire to share it with others. Six participants noted they primarily were motivated by a personal commitment to motivating, mentoring and otherwise helping students achieve their potential. Two participants noted their primary motivation was to do a great job for the students and not disappoint them.
Incentives to improve teaching
The topic of incentives often is discussed as an essential motivator for teaching excellence. Participants in the current study were asked if they had received any incentives (e.g., more designated time for teaching, supplemental salary) to improve their teaching prior to winning the AAVMC award. One participant noted s/he had previously received a teaching award from students, but the 14 other participants noted they did not receive any incentives. When asked what types of incentives and/or resources they believed would be effective for improving teaching, 9 participants responded, falling into one of three themes. Four participants noted the existence of a learning community (e.g., teaching academy) where educators could come together and learn how to improve their teaching skills. Three participants said simply being recognized, even at the school level, would provide a great incentive to improve teaching. The other two participants stated an institutional culture that recognized and rewarded teaching excellence (e.g., promotion and tenure pathways) and refused to accept poor teaching would be a strong incentive.
Focus on strengths, weaknesses, or both?
In recent years, fields such as positive psychology, organizational psychology, and leadership have embraced strength theory. In short, strength theory dictates that people have a greater potential for growth and improvement if they focus on improving their strengths, as opposed to fixing their weaknesses., We were curious how excellent teachers invest their time and energies with respect to making improvements in teaching. Specifically, do excellent teachers spend more time and energy attempting to improve existing strengths or overcome current weaknesses? Of the 15 participants, 4 (26.67%) noted they focused primarily on their strengths and sharpening those skills, 2 (13.33%) focused primarily on their weaknesses and improving any deficiencies, and 9 (60%) noted they focused equally on their strengths and weaknesses.
The role of reflection
Extant literature in medical education has frequently cited the role of reflection on quality teaching. All 15 participants noted they continually reflected upon their teaching in an effort to make improvements. When asked what kinds of changes have actually resulted from these reflections, the participants presented a number of personal examples. Seven participants noted they reviewed their lecture recordings to identify areas, in which content was taught in excessive detail; they altered subsequent instruction to reduce emphasis on minor details. Two participants emphasized the importance of focusing on student understanding, as opposed to student memorization, and teaching in such a way that understanding is emphasized (acknowledging that it often takes longer). Two participants noted they continually find ways to make the material more clinically relevant. Other responses included identifying how to better provide feedback (e.g., not giving too much feedback at once and ensuring that whatever feedback is provided is done so in an encouraging way); faithfully responding to comments made on teaching evaluations; and reviewing examination items with a significant number of incorrect answers and identifying how the content was taught and what could be done to better teach it in the future.
Key pieces of advice for veterinary educators
The value of good advice is immeasurable, and hence, we asked award-winning educators what key pieces of advice they have for other veterinary educators. The following key selections were identified to serve as examples of the types of powerful statements made by national award winning teachers.
“Be enthusiastic about your topic. Ask yourself what students need to know for their career with emphasis on entry-level DVM competence. Look for opportunities to actively involve students in problem solving activities versus simple lecture format. Get to know your students as people!”
“Start with the program and course objectives in mind. Make sure that what you are teaching is relevant and the relevance is demonstrated. Don't try to teach everything. Prioritize the information for the students so they know what is most important.”
“Seek to learn about teaching and learning in the same way you pursue knowledge and practice in your research and clinical activities. It's not just about knowing your material, it's also about understanding pedagogy, your students, and the context of your teaching.”
“Seek mentors and a community of practice. Don't be afraid to experiment with your teaching.”
“Remember your students are individuals, and remember that everyone (even the most intelligent) has a subject that is difficult for them; for some of your students, that subject might be yours.”
“Try to learn names–it shows respect and individual interest, and helps build confidence in your students.”
“Be enthusiastic. Avoid trivia. Avoid requiring memorization and help students to problem solve, primarily through teaching with cases. Make the material clinically relevant and remember that they won't remember much of what you say so you need to teach them how to learn on their own.”
“(1) Start with the end in mind; become clear on what you want your students to do at the end of your course and use “backward design” to align your course goals, with your assignments, learning objectives, and assessments. (2) Find out what level of preparation students coming into your course have. Review what they should have known in a relevant way to introduce your subject and relate your subject to what they will need to know to succeed in the profession. (3) Engage students deeply using proven pedagogies such as team based learning, cooperative learning, collaborative learning, problem based learning, etc., preferably with the support of a teaching center, faculty learning community, educational technology group, etc., and find out how you can bring good teaching into scholarship so you can succeed professionally.”
“(1) Engage the students both in and outside of the class room. Some of my best teaching is in small groups, informally outside the classroom. (2) No question should go unanswered at the time it was asked. It is okay not to know the answer, but totally unacceptable not to care about the answer. (3) Lighten up and laugh a little bit with the students but never ever at the students. (4) Respect your students.”
“Don't try to cover too much information/details; focus on teaching core principles in several different ways. Attend classes/presentations by other teachers (good and bad) in a topic outside your discipline and notice what works for you as a learner (and what does not). Help students understand relevancy of your subject/topics, why it matters and practical application.”
“(1) Show the students that you care. (2) If you don't care about teaching please quit doing it. (3) Focus on skills and how to find information when the students need it. This means you can focus less on an endless list of factoids.”
“(1) Don't try to “cover everything” just because it has been handed to you. (2) Be totally transparent about what you feel is critical for students to learn, write it down, and be congruent about testing/assessing the students on that knowledge/skills. (3) Remember that when you walk into a classroom you are not just delivering information, you are shaping the development of future veterinarians and veterinary technicians. These students will remember something you said or some piece of wisdom you conveyed long after you have forgotten you said it. Those words will live on long after you have left the classroom and the university. Never lose sight of the impact you have. You are shaping the future professionals, scientists, leaders, and poets for tomorrow. You shape the future by how you teach today.”
“Determine the key skills and concepts you want your students to master and focus your teaching on these. Make a list of all of the important details you teach, then take the list and remove all of them from your lectures.”
“Establish or join a group of teaching peers to expand your knowledge and access new approaches to teaching. Have yourself peer-reviewed by faculty who are recognized for instructional excellence. Meet with faculty members to ensure integration and relevance of teaching material.”
| Discussion|| |
Award-winning faculty had a number of excellent insights about what constitutes excellent teaching. There was a virtual consensus on several items of the teaching perspectives scale, as five items had mean ratings ≥9. These items included emphasizing clinical relevance, focusing on core concepts, avoiding minutiae, offering opportunities for application, and illustrating how concepts are related. These findings converge with best practices in modern pedagogy (e.g., the Scholarship of teaching and learning literature).
With respect to feedback, instructors reported student feedback (M = 8.60, SD = 1.59) was rated as more important than peer feedback (M = 7.13, SD = 2.53) or alumni/employer feedback (M = 6.33, SD = 2.94). Cohen's d effect size estimates were calculated to discern the practical significance between each of these values. First, an effect size of 0.69 indicates the practical significance between student and peer feedback was “medium” in magnitude. An effect size of 0.96 indicates the practical significance between students and alumni/employer feedback was “large” in magnitude. Finally, an effect size of 0.34 indicates a “small” practical difference between peer and alumni/employer feedback. We are unsure why student feedback was rated more important than peer feedback, especially given the enormous literature that has called into question the validity of student evaluations of teaching results. It is possible, however, that peer feedback offers only limited utility given faculty peers typically have very limited exposure to their colleagues' teaching, whereas students frequently observe this behavior.
Interestingly, award-winning faculty rated required class attendance as least important among the 23 items presented. For many college and university faculty, class attendance is a very sensitive subject and many hold strong opinions that in-person attendance is valuable (e.g., development of social and cultural outcomes, professional expectations). However, award-winning faculty indicates that it is not important to require class attendance. Given the prevalence of recordings and various instructional technologies, it is possible that multiple instructional modalities largely mitigate this concern.
With respect to formal training in the education sciences, most award-winning instructors did not have any formal educational training before beginning their veterinary school teaching. However, it is abundantly clear that these teaching award-winning instructors became very knowledgeable of modern learning theory and advocate faculty colleagues take education as serious as they do their primary area of expertise. The sample was divided on whether excellent teachers are born or made. Some believe a natural proclivity may be necessary to reach a level of excellence, whereas others believe a natural proclivity is not necessarily a pre-requisite for becoming an excellent teacher.
There has long been conjecture that most college and university faculty tend to carry forth the same instructional techniques they experienced when they were students. This phenomenon was apparent with award-winning instructors, as most noted a specific individual that inspired them and modeled what effective instruction should look like. However, it is not enough simply to borrow many of the same qualities and practices from others. Virtually every participant noted being an excellent instructor requires continuous efforts to improve. Critical to these efforts is the role of reflection and taking stock of what has worked well and what has not. There was less consensus about whether one should focus on improving one's existing strengths or improving one's current weaknesses, although most instructors felt it was a good idea to focus on both.
There is an old adage that a poor physician harms one person at a time, but a poor teacher harms many. This is a rather sobering perspective as it clarifies the responsibility instructors have to teach well. Award-winning instructors were very cognizant of this considerable responsibility. Specifically, several instructors noted they primarily were motivated by a desire to do a good job for their students. Other displays of selflessness were also apparent with regard to how instructors design their courses. Whereas (arguably) most instructors in medical education programs design their courses using a forward-design approach (a faculty-centric approach, in which an instructor first decides the breadth and depth of what to teach based on what they think students ought to know and then subsequently constructs assessments to measure learning), most all award-winning instructors emphasized utilizing backward design  principles (a student-centric approach, in which instructors begin by considering the outcomes they hope students will achieve and construct course content and assessments accordingly).
Finally, with respect to incentives, responses to the item pertaining to advice for veterinary educations, most of the award-winning instructors appeared to be intrinsically motivated and found student learning to be a sufficient incentive to teach well. This finding is particularly noteworthy, as extant research has identified intrinsic motivation to be the strongest motivator for improving teaching. Although there is a pervasive assumption that offering teaching awards and other incentives will lead to an increased faculty commitment to teaching, extant research does not necessarily support this notion. Research by Ward  found institutional reward systems to have only a minimal impact on efforts to improve teaching. While it is ideal that every educator takes teaching very seriously, invariably some educators will not despite the incentive.
First, it is important that all faculty charged with teaching responsibilities recognize the true magnitude of that responsibility. In addition to potentially impacting future patient outcomes in some limited way, instructors also may impact future generations of learners. That is, not only are instructors teaching current students but also they are indirectly influencing others who someday will learn from these future veterinary professionals. Second, given the tremendous responsibility and network of influence, it is critical that colleges of veterinary medicine train faculty in modern pedagogy. Perhaps, an obvious forum to offer this training is a teaching academy, which many veterinary schools already have in place or are planning to develop. Third, quality teaching has repeatedly been shown to be the most influential factor for student success., Yet, for many institutions across all health professions teaching remains a lesser priority. Perhaps, it is time for accreditors to begin to focus more intently on teacher quality, thus giving institutions an additional incentive to improve education quality. Finally, incentives can be an effective motivator for some instructors. Institutional leaders need to continually identify the factors that will best motivate instructors to improve teaching quality and work to offer these incentives to deserving educators.
Limitations and future research
This study possesses a few limitations. First, and perhaps most obvious, is the inescapably limited sample size. Second, this study sought the perspectives of national award-winning instructors who have demonstrated excellence in teaching. However, it should be noted that there are many excellent instructors in the field of veterinary medicine, many of whom have not received the national AAVMC Distinguished Veterinary Teacher Award. The insights gleaned from this study may or may not be representative of the views of those winning other teaching awards or those who are excellent teachers in general.
There are a number of avenues for future research. First, there may be value in identifying award-winning instructors across colleges of veterinary medicine and replicating the present study with a much larger population of excellent veterinary instructors. Second, there may be value in investigating the types of instructional materials and resources excellent veterinary instructors obtained that helped improve their instruction, as these same resources may also be beneficial to others. Finally, the influence of mentor/mentee relationships can be both traceable and measurable. However, little work has attempted to understand the epidemiology of good teaching, namely, the reach and depth of one's influence on future generations of learners.
| Conclusion|| |
Although most award-winning educators did not possess any formal training in education, each acquired a high-level understanding of modern learning theory and effective pedagogical techniques. Some had formal training before teaching, but most appeared to have a strong desire to identify how to best teach well. Although opinions varied on some issues, there was virtually a consensus on the importance of issues such as emphasizing clinical relevance, focusing on core concepts, avoiding minutiae, offering opportunities for application, and illustrating how concepts are related. Further, most educators embraced backward design principles and were highly intrinsically motivated to perform their instructional duties well. Award-winning educators tend to believe developing expertise in teaching is just as important as developing expertise in one's academic discipline/content area. Continual and increasing efforts to promote faculty development are warranted in veterinary medical education.
Financial support and sponsorship
Conflicts of interest
Both authors are editors for Education in the Health Professions. Thus, peer-review was initiated and performed by an independent editor (Rinaldo) associated with the journal.
| References|| |
Oleson A, Hora MT. Teaching the way we were taught? Revisiting the sources of teaching knowledge and the role of prior experience in shaping faculty teaching practices. Higher Educ 2014;68:29-45.
Bowen WG, McPherson MS. Lesson Plan: An Agenda for Change in American Higher Education. Princeton, NJ: Princeton University Press; 2016.
Brown J, Kurzweil M. Institutional Quality, Student Outcomes and Institutional Finances. Washington, D.C: American Council on Education; 2017.
Condon W, Iverson ER, Manduca CA, Rutz C, Willett G. Faculty Development and Student Learning: Assessing the Connections. Bloomington: Indiana University Press; 2016.
Bain K. What the Best College Teachers do. Cambridge, MA: Harvard University Press; 2004.
Keeley J, Smith D, Buskist W. The teacher behaviors checklist: Factor analysis of its utility for evaluating teaching. Teach Psychol 2006;33:84-91.
Royal KD, Hecker KG. Understanding reliability: A review for veterinary educators. J Vet Med Educ 2016;43:1-4.
Pinsky LE, Monson D, Irby DM. How excellent teachers are made: Reflecting on success to improve teaching. Adv Health Sci Educ Theory Pract 1998;3:207-15.
Ross S. Are influential teachers born or can they be taught? Med Educ 2015;49:1056-8.
Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall Inc.; 1977.
Eiland LS, Marlowe KF, Sacks GS. Development of faculty mentor teams in a pharmacy practice department. Curr Pharm Teach Learn 2014;6:759-66.
Bradforth SE, Miller ER, Dichtel WR, Leibovich AK, Feig AL, Martin JD, et al.
University learning: Improve undergraduate science education. Nature 2015;523:282-4.
Rath T, Conchie B. Strengths Based Leadership: Great Leaders, Teams, and why People Follow. New York: Gallup Press; 2009.
Buckingham M, Clifton DO. Now, Discover Your Strengths. New York: Gallup Press; 2001.
Guskey TR. “It Wasn't Fair!” Educators' Recollections of Their Experiences as Students with Grading. San Francisco, CA: Paper presented at the American Educational Research Association's Annual Meeting; 2006.
Wiggins G, McTighe J. Understanding by Design [Monograph on the Internet]. Expanded 2nd
ed. Alexandria, VA: Association for Supervision and Curriculum Development; 2005.
Smith MC. Selecting and rewarding best teachers in U.S. schools of pharmacy. J Pharm Teach 1994;4:31-9.
Ward B. Improving teaching across the academy: Gleanings from research. In: Neal E, Richlin L, editors. To Improve the Academy: Resources for Faculty, Instructional, and Organizational Development. Vol. 14. Stillwater, OK: New Forums Publishing Group; 1995. p. 27-42.
Hecker K, Violato C. How much do differences in medical schools influence student performance? A longitudinal study employing hierarchical linear modeling. Teach Learn Med 2008;20:104-13.
Royal KD. Quality teaching matters more than innovative curricula. Am J Med 2017;130:e167.