gms | German Medical Science

Both in German and English literature the term “tutorial” or “peer teaching” is used to describe a form of teaching where students or PhD students, so-called “tutors” or “peers” hold classes. In higher education, Topping & Ehly [26] described peer teaching as the “development of knowledge and skill through active help and support among status equals or matched companions”. Numerous studies document the advantages of teaching conducted by tutors, both at school and university level [4], [6]. In Germany the use of tutors was first introduced in 1951 at the Freie Universität Berlin [9]. For some 30 years tutors have also been used successfully in medical education, for example in anatomy during the pre-clinical phase. In medical studies, these are usually students of the same or more advanced years. Numerous studies demonstrate the positive effects of tutor-supported teaching on the academic achievements of medical undergraduate students [19], [21], [25], [27], [28], [29]. Through the relaxed learning environment, teaching content can often be taught more easily and practical skills are learnt and practised better. The tutors also benefit through their teaching activity. Their communication and teaching skills improve [2], they achieve better exam results at the end of their studies [31] and they are more successful in their careers [16].

In paediatrics the teaching of practical skills poses a particular challenge [23]. In medical undergraduate studies student tutors were successfully used in problem-oriented teaching of paediatrics [20] and graduate tutors in the core paediatrics curriculum [13]. Edwards et al [3] report on the successful use of graduate tutors in paediatric post-graduate specialisation in evidence-based medicine. The paediatrics clinic of the University of Tübingen introduced the concept of student tutoring in the paediatrics block work placement some years ago. More detailed analyses of this project have not been released to date.

The clinics for General Paediatrics and Child Cardiology at the University of Cologne showed, following the production of a compulsory learning goal catalogue [22] following the model of the “Swiss Catalogue of Learning Objectives for Undergraduate Medical Training“ [24], that none of the defined practical learning goals were adequately taught in any of the curricular activities [12]. This is confirmed by the results of the OSCE examinations introduced in 2006.

To tackle these deficits, a pilot project based on a concept of the University Paediatrics Clinic Tübingen was introduced during the first half of the 2008 summer semester, in which student tutors were trained who then proceeded to teach the practical learning content in the block work placement (BWP) in paediatrics. Following on from this pilot, this feasibility study looks at the 2008/09 winter semester to determine if this new, tutorial-supported concept achieves higher student and teacher satisfaction compared to the conventional course.

45 students in their 5th clinical semester took the conventional, week-long paediatrics BWP taught only by medical doctors during the second half of the 2008 summer semester on wards of the children’s hospital. In small groups, the students participated in the ward rounds and examinations and had, depending on the availability of ward doctors and senior physicians, the opportunity to examine children themselves under supervision and to discuss case files with the physicians. At the end of each BWP week feedback sessions were held with the ward physicians and the students about the current progress of the placement and the learning goals achieved.

A new teaching model was introduced in the 2008/09 winter semester for the BWP in paediatrics, which shifted demonstrations and practical exercises of paediatric examination techniques (such as throat inspections, otoscopy, abdominal examinations) and the teaching of individual teaching modules developed by physicians (such as urine diagnostics, infusion treatment, inhalation treatment) into the area of responsibility of student tutors. For this purpose, eight tutors were trained for a week by a team of assistants and senior physicians of the clinic prior to the start of the 2008/09 winter semester at the University Paediatrics Hospital Cologne. These were students who had successfully passed the BWP during the previous semester. Apart from theoretical training in paediatrics and examination techniques, learning content such as dealing with students, doctors and medical staff and motivating patients and their parents were taught (see Table 1 [Tab. 1]). The training course was designed by the primary author. The week-long practical and theoretical tutor training was carried out by the senior physicians and experienced specialised doctors at the children’s hospital and the primary author.

109 students in their 5^th clinical semester took the newly designed week-long BWP taught by student tutors in the 2008/09 winter semester. The practical skills specified in the learning goal catalogue for paediatrics were taught in the form of short seminars on child examination techniques and through practical instructions by the bedside on patient examination. In addition, as is the case in the conventional BWP, cases were discussed with the ward physicians. At the end of the BWP week, the same feedback sessions took place as on the conventional course. In both teaching events seminars with case demonstrations were taught by senior physicians during the afternoon. The content and progression of both teaching events is summarised in Table 2 [Tab. 2].

At the end of BWP, the students evaluated the BWP and assessed the practical skills they acquired via a questionnaire. The model for the questionnaire was the University Children’s Hospital Tübingen questionnaire, which had been developed and validated there as a result of the introduction of tutoring. Filling out the questionnaire was voluntary and not linked to the award certificate for the BWP. Of the 45 students in the 08 summer semester, 39 questionnaires were returned (response rate 87%) and of the 109 students in the 09 winter semester 85 questionnaires were returned (response rate 78%) and could thus be evaluated.

The evaluation part of the questionnaire contained five questions about the practical relevance of the BWP, on the comparison with the block work placements of other clinical disciplines, on gained confidence in dealing with children and the supervision by the ward and senior physicians (08 summer semester and 08/09 winter semester). The questions could be answered using a five point scale with grades from very good (1) to poor (5). The self-assessment part of the questionnaire contained three questions on the command of general medical skills in paediatrics (establishing medical history, documenting findings, discharge summaries) and eight questions on the command of important paediatric examination techniques and diagnostic measures. At the end of the week-long BWP in paediatrics, the students documented in the questionnaire whether they had completed and acquired the training modules and medical skills in the course of the placement during the 08 summer semester and the 08/09 winter semester. It was possible to distinguish between successfully completed and learned and not successfully completed and learned.

The statistical analysis of the evaluation part was performed using a t-test, assuming independent samples with an error probability of p <0.05 (SPSS 15 (SPSS Inc., Chicago, IL)).

The following hypotheses form the basis of the t-tests:

• H0: The mean grade in the 08 summer semester of the students (conventional approach) is no different from the grades in the 08/09 winter semester (tutor-based approach), i.e. the mean difference is zero.
• H1: The average grade in the 08 summer semester of the students (conventional approach) is different from the grades in the 08/09 winter semester (tutor-based approach), i.e. the mean difference is unequal to zero.

The evaluation of the self-assessment part was based on a descriptive comparison of the stated frequency of positive self-assessment by students.

The mean values (MV) and standard deviations (SD) of the evaluations are shown in Figure 1 [Fig. 1]. For the question “How do you rate the practical relevance of the block placement?” the average was 3.29 (SD 1.239) for the 08 summer semester and 1.93 (SD 0.686) for the 08/09 winter semester. The practical relevance of the conventional BWP in paediatrics was judged as “good” or “very good” by 32.4% of students in the 08 summer semester; for the new model, this rate was 82.4% (p <0.001). For the question “How do you rate the BWP in paediatrics compared to the placements in other clinical subjects?” the MV for the 08 summer semester was 2.87 (SD 1.119) and 1.81 (SD 0.866) for the 08/09 winter semester. In comparison to other clinical block work placements the BWP in paediatrics was rated “good” or “very good” considerably more often (83.5%) in the 08/09 winter semester than in the 08 summer semester (36.8%) (p<0,001). For the question “How do you rate the BWP in terms of your confidence in dealing with children?” the MV were 3.34 (SD 1.341) in the 08 summer semester and 2.27 (SD 0.762) in the 08/09 winter semester. The evaluation of the BWP in relation to the confidence of the students in dealing with children also showed a significant increase of good and very good ratings of 64.7% in the new concept compared to 31.6% in the conventional BWP (p <0.001).

The opinions of student supervision by ward and senior physicians also showed significant differences between the two concepts. For the question “How was the support from ward physician in the BWP?” with 3.16 (SD 1.093) the mean value for the 08 summer semester was significantly worse than for the 08/09 winter semester (MV 2.64, SD 1.066). In the conventional BWP only 32.4% of students rated the supervision by the assistant doctors as “good” or “very good” while in the 08/09 winter semester 47% of students (p <0.05) rated it as such. This effect was even more clearly visible in the assessment supervision by the senior physicians. For the question “How was the supervision by the senior physicians?” the 08 summer semester ratings (MV 3.89, SD .979) were significantly worse than for the 08/09 winter semester (MV 2.94, SD 1.17). Through student tutoring, the frequency of good and very good ratings for the supervision by the senior physicians rose from 36.1% in the conventional course for the 08 summer semester to 70.9% in the BWP with student tutors from the 08/09 winter semester (p <0.001).

The question “How was the supervision by the tutors?” could only be asked after the introduction of the new concept in the 08/09 winter semester as no tutors were used in the conventional BWP of the 08 summer semester. The evaluation mean was 1.77 (SD 1.068). 52, 4% of students rated the tutor support as very good, 31% as good and 8.33% as satisfactory. The grades “sufficient” and “bad” were not awarded.

The results of the self-assessment questionnaire are shown in Figure 2 [Fig. 2] and 3 [Fig. 3]. A significantly greater frequency of positive self-evaluation of the students was apparent for the medical skills “Writing a discharge summary” and “documenting findings” at the end of the tutor-based BWP compared to the conventional BWP in paediatrics. The increase in positive self-assessments of the skill “Establishing a paediatric anamneses” from about 80% to 90% was, in the comparison between the 08 summer semester and 08/09 winter semester courses, relatively low because this topic is taught in detail both in the conventional BWP and the BWP with the student tutoring (see Figure 2 [Fig. 2]). Students judged the practical skills they acquired in paediatric examination techniques and diagnostic or therapeutic measures significantly higher in the newly designed student tutoring BWP (see Figure 3 [Fig. 3]) than the BWP purely led by doctors. For throat inspection and otoscopy examination techniques, there was an increase in positive self-evaluation from about 40% to about 80% and for the therapeutic measure “inhalation technique in bronchopulmonary obstruction” from about 10% to about 90% through the teaching of practical skills by student tutors.

The conventional BWP in paediatrics at the University of Cologne was also rated as good by the students. This is presumably in part due to the attractiveness of the specialisation. Discussions with students and personal observations showed, however, that a purely medically-led BWP leads to good factual knowledge but too little practical skills. The main reason for this is the lack of time of the medical personnel. Since the practical skills were in the learning target catalogue for paediatrics in Cologne [22], these also had to be taught in the new BWP design. For this, a peer-teaching model was implemented and evaluated in this study. Studies by Graham et al [7] for the subject of rheumatology showed that practical examination techniques can be taught by trained students just as well as by doctors.

The practical relevance, quality of supervision as well as the self-assessment of the students’ confidence in dealing with children was judged to be significantly better in the BWP with student tutors than the conventional BWP (see Figure 1 [Fig. 1]). This is almost certainly primarily caused by the change in the teaching method for the BWP. Compared with the BWPs of other clinical subjects, the BWP in paediatrics performed significantly better after the introduction of the peer-teaching model (see Figure 1 [Fig. 1]). Self-assessment of students also substantially improved in terms of mastery of the practical learning content of the BWP (see Figure 2 [Fig. 2] and 3 [Fig. 3]). It is likely that the positive influence of active and protected learning environment amongst peers or people of the same status is an important reason for the positive assessment of peer teaching. This model supported the self-confidence of students and promoted the understanding of learning content taught [3], [5], [10].

This positive impact of peer teaching on the self-assessment of clinical competencies was also found by some other studies [7], [30]. Other working groups [11] on the other hand could not prove a positive effect of peer teaching on the self-assessment of students’ clinical competencies. The impact of peer teaching on exam results is evaluated differently in the literature [1], [8].

Self-assessment questionnaires as a measure of the success of a course is viewed critically in the literature [17]. An external assessment of the students, for example using a standardised clinical examination by the senior physicians of the children’s hospital would have been a good way to objectify the questionnaire data. This study could not conduct a final examination at the end of the BWPs due to curricular requirements. Practical skills in paediatrics are only tested at the end of the semester after the BWP as part of a compound OSCE which tests clinical core subjects in three paediatric OSCE stations. It was not possible for this study to wait for these exam results. Moreover, the “power” to find a difference in only three stations is low and after such a long period before examinations, external influences such as contamination and maturation of students cannot be excluded. As a result of the direct contact in the afternoon part of the BWP, the teaching physicians, however, gained the impression that using the tutor model, practical learning content could be taught significantly better and with more lasting effect than was previously possible. To objectify these findings, more studies would be needed in the future, for example using different testing methods such as a mini-CEX [15]. In a study by Heckmann et al [8], in neurology no differences in the OSCE exam results of students taught in the conventional model and those from peer- assisted skills training during the BWP could be found. Another result of this study was the fact that the quality of the supervision by the ward physicians was judged to be better when using student tutors than in the conventional BWP. This seems paradoxical, since student tutors took on a certain amount of the teaching. But it was this shift of certain repetitive content to student tutors which led to the positive effect of doctors having more time for their routine work. Thus they were better motivated to get involved in student teaching. Overall, a complete shift of teaching from physicians to students tutors did not occur, which had been feared by some students. It can be assumed that the better use of medical staff resources and skills had a positive effect on the motivation and the engagement of doctors and thus the quality of teaching. Further studies are needed to investigate the reasons for this motivation increase amongst assistant physicians in their teaching duties. It appeared that an essential prerequisite for a successful tutoring was the availability of physicians during the course for additional questions that the teaching of complex clinical content was carried out only by physicians [30]. This was the case in the present concept. At the level of senior physicians too, student tutoring seemed to lead to better motivation and engagement in teaching. This effect, however, was not as clear as at the level of the assistant physicians.

The tutors themselves benefited considerably from their teaching. We were able to detect this positive effect during the weekly feedback sessions. Structured feedback affects the quality of the tutors positively [13]. The teaching activities requires them [2] to deal intensively with the material and master it. They can thus reach a much deeper level of understanding and knowledge of the subject. We could also observe an increase of their practical experience in the taught subjects. Wong et al [31] and Ocel et al [16] demonstrated that “peer teachers”, after intensive preparatory training, achieve better exam results (USMLE1, USMLE2, GPA) than those without teaching experience during their undergraduate studies. This shows that peer teaching does not “exploit” student tutors but that it has a measurable positive influence on their academic achievements. Personality development and attitude to their own learning also changed positively through teaching. These benefits of peer teaching have been long known in other disciplines [2], [4], [6], [26] and are confirmed by psychological research [14].

An essential prerequisite for successful student tutoring is thorough tutor training before they start teaching (see Table 1 [Tab. 1]). The importance of adequate training and supervision for the success of student tutoring is stressed by Weyrich et al [30]. In addition, good organisation within the hospital was also necessary. The physicians responsible for the course had to be continuously reachable, needed the necessary leadership and decision-making authority within the department and had to be able to delegate tasks [29]. In this way this model relieves the doctors but does not free them from teaching.

A weakness in the chosen methodological approach is the fact that it is a feasibility study with a historical control group design. This was justified through the great success of the pilot project and its popularity among students. The modified course was seen as the only clinical BWP with very good practical teaching quality. Not least of all due to the positive response by the physicians at the children’s hospital it would have been virtually impossible to stream students into the conventional course without protest. This led to the decision to forego a randomised research design and to introduce regular student tutoring at the start of the 08/09 winter semester already. The best available control group consisted of students in the second half of the 08 summer semester when the BWP was still conventionally managed by medical staff only.

It is possible that the evaluation results were also influenced by the bias of a Hawthorne effect [18]. The clinical part of undergraduate medical studies continues to suffer from a lack of teaching with concrete practical, even after the introduction of the pilot program. This gap, long criticised by students, was addressed in the children’s hospital by the introduction of student tutoring the 08/09 winter semester, while it persists in most other clinical subjects. This discrepancy in the quality of practical clinical teaching may have influenced the students to positively evaluate the block work placement. Other confounding factors could be the motivation of doctors and students during the construction phase of tutoring, the improvement of the communicative climate within the hospital through the introduction of tutoring and the general popularity of the subject of paediatrics.

The intensive training of practical learning content in paediatrics in a positive learning environment through the use of student tutors improved the evaluation results of the block work placement in paediatrics by the students and the self-assessment of their acquired practical clinical skills. An essential prerequisite for successfully conducting this innovative teaching approach was professional training of the student tutors and continuous supervision by the doctors of the clinic. The concept of a BWP with student tutoring under medical supervision can be recommended as a successful model for other clinical disciplines. The present results give rise to further questions. One goal of future research should be answering the question of how the tutors themselves benefit from their work for their studies. Similarly, the impact of the use of student tutors in clinical teaching on motivation and engagement of doctors in teaching and communication amongst employees on the wards stations and within the clinic should to be examined.

We would like to thank Dr Hans Martin Bosse, Children’s Hospital, Rupprecht-Karls University of Heidelberg for his support in designing a learning target catalogue for paediatrics. We would like to thank Dr Andreas Busch, University Children’s Hospital Tübingen for his support in introducing student tutoring at our clinic. We would like to thank Prof Stefan Herzig for his advice and willingness to help in the design and implementation of the present study. We would like to thank the staff of the Dean of Studies’ Office of the Medical Faculty of the University of Cologne and Tamara Kern, an undergraduate student, for her assistance with the data analysis for the study.

The authors declare that they have no competing interests.