This study provides an insight into how neurological teaching in Germany is carried out from a residents’ perspective. Regarding the relatively short time period of five weeks and the exclusive addressing of university hospitals, a proportionately reasonable number of residents responded to the survey. (A brief note on the representativeness may be found in Additional file 2).
Although the authors believe that this is an important and thus far neglected topic, there is unfortunately little literature about teaching by neurological residents, which made it difficult to compare the data obtained in this study.
Teaching and workload
Most of the residents enjoy clinical teaching and are motivated in getting more involved in this field. The additional workload arising from the planning and implementation of a student course is relatively low, but needs to be done in addition to regular work. Due to the already existing workload of neurological residents with a high proportion of administrative activities and frequent overtime work , it has to be considered that the interest in teaching might decrease. Residents spend up to a third of their working time with teaching students [10, 11]. In addition, residents play a key role in the training of medical students, which has been shown in previous studies . However, apparently no concepts for a systematic teaching by residents exist in Germany. Overall, residents are apparently not given sufficient recognition for their work in teaching and do not receive enough feedback in this area , a fact which can be also shown in our data. Besides, they do not seem to be sufficiently informed about the learning objectives of their students: More than 60% of the participants do not properly know the curriculum and almost a third of them is not informed about the type or the expected horizon of exams in neurology. Regarding the aim of constructive alignment in neurological teaching, there is an urgent need for proper communication of the learning objectives in the departments themselves to ensure that goals of the curriculum are met and neurological teaching is done homogenously.
One possible reason for the lack of interest by superiours seems to be the allocation of funds. Funding is rather difficult to receive for teaching and the performance-based allocation of funds continues to predominantly reward classical clinical or laboratory-based research. The performance-oriented allocation of funds in teaching (LOM: Leistungsorientierte Mittelvergabe) is mainly regulated by the faculties themselves, and incentives such as awards for good clinical teaching do not exist at all university hospitals . As a result, this may also reduce the attractiveness of clinical teaching.
LOM points are weighted for each lecture, seminar, bedside course etc. depending on the time required, the number of students and the type of lesson. However, this does not always reflect the actual effort and importance of the teaching. For each LOM point, the respective department receives a financial equivalent. Nevertheless, the allocation of funds is still very heterogeneous among the various faculties [14, 15].
Residents participating in our survey had mostly not been informed about current developments in medical teaching in Germany (i.e. Referentenentwurf zur neuen Approbationsordnung, NKLM). Chair holders in particular should inform their employees about political developments in teaching and curricular changes and should encourage them to exert influence on it.
The importance of good teaching in order to recruit motivated employees still does not seem to be recognized at some places, which is reflected in the analyzed items B4-7 and C4-7 in our study. This is also shown by the fact that findings from educational research find their way into clinical teaching slowly, although the research and implementation of modern teaching methods is of enormous importance for our subject . With reference to the redesigning of medical curricular enforced by the COVID-19 pandemic, university hospitals in which a good teaching infrastructure and innovative, digital teaching methods already existed, had less difficulty adapting to the changes .
To teach is to learn!
Teaching improves one’s own learning. Also medical teachers may gain more knowledge by teaching than their own learners [18, 19]. Accordingly, the residents in our study stated to learn better by teaching. The question arises why teaching is not consciously used as a part of residents further training, since formats such as peer teaching and tutorials have been recognized as a teaching method at universities for decades. Despite the fact that 80% of final-year medical students state that they are interested in teaching  there are hardly any opportunities to receive didactic training in Germany. The fact that young residents benefit from teaching is even further neglected by the new version of the German licensing regulations, stating that young residents should not be given the opportunity to teach during the first three years of their postgraduate training at all. These circumstances make it significantly harder for residents to improve their teaching skills from the very beginning and they do not get access to improve their own knowledge by contributing to the curriculum. However, the fact that even residents at their very early stages of career are involved in teaching is—regardless of the new version of the German licensing regulations—a fact that incidentally cannot be reconciled with clinical reality, as shown in our study.
Positive effects of resident-as-teacher programs
64% of the neurology residents in our study have not yet participated in a teaching course at their university. However, the positive effects of resident-as-teacher programs have been proven in several studies by now , even if there is a lack of teaching-programs in neurology. In addition to the residents’ benefit from their own teaching , structured teaching programs increase job satisfaction  and lead to improved patient care .
Last but not least, teachers have a role model function for students and are often important advisors for their professional careers. Students who had experienced a good neurological teaching will possibly choose this subject as their later profession. Teaching-courses may also influence the decision of residents for future career choices . Therefore, excellent clinical teaching in neurology has a significant influence on the recruiting of future neurologists. And this is of main importance in times of demographic change and the growing therapeutical opportunities in our field.
In summary, the positive effect of residents as teachers overweighs potential disadvantages and can result in satisfied, enthusiastic residents contributing not only to young talent acquisition in this field, but also to improved patient care. However, this subject is still relatively neglected.
The myth that teaching (or teaching to teach) takes too much time has been refuted: Usatine et al. analyzed the time that an experienced teacher spends on teaching students at the bedside with the time that he or she needed alone with the patient. There were no significant differences as to whether teaching took place or not . In order to achieve this result, however, it is important to train teachers and especially residents in bedside teaching.
How should teaching be taught?
The question is how teaching by residents in neurology can be promoted and improved. In addition to improving the communication of learning objectives and exam content and political developments (e.g. new version of the licensing regulations for the medical education), medical didactic centers in particular should increasingly approach residents and offer didactics courses.
There are a number of resident-as-teacher activities that have also been integrated into an educational program for neurology-residents based on the 6 principles of adult learning theory (ALT) . However, as far as we know, there are very few purely neurological resident-as-teacher programs —and we do currently not have any information on such an existing program in Germany.
Nonetheless, some teaching methods that have been described are easy to train and can therefore also be used in German neurological clinics. These methods include the technique of the five-step Microskills Model [25, 26], or “One-Minute Preceptor”, which was developed in 1992. It has the goal to improve teaching efficacy and efficiency. The five-step structure contains: (a) get a commitment; (b) sample for evidence; (c) teach a general rule; (d) reinforce what was done well; and I correct mistakes  (Fig. 1).
Frank and Józefowicz also gave a good overview of different teaching methods in neurology (e.g. grand rounds, patient-oriented bedside-teaching, Case-based small-group teaching, work rounds etc.) and described how important enthusiasm and commitment are in neurological teaching .
It is also worthwhile to be informed about current teaching methods, i.e. by using platforms such as MedEdPORTAL  and the German Society for Medical Education (GMA) . It would also be desirable to have separate information websites for the respective medical faculties, for example through the department for medical didactics, and the existence of such a department is therefore of considerable value for each medical faculty.
Limitations of this study
One limitation of this study is that, in order to preserve anonymity, we did not explicitly ask for the location of the hospital/university and therefore cannot determine whether all university hospitals participated.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.