gms | German Medical Science

Concepts of peer-assisted learning (PAL) and student tutorials are taking on an increasingly essential role in many areas of medical education, such as anatomy, problem-oriented learning, acquiring practical clinical skills and interdisciplinary competence [1], [2], [3], [4]. Current studies show that peer tutors are just as able to impart certain knowledge and clinical skills as university instructors [1], [5], [6], [7], [8], [9], [10], [11], [12], [13]. In light of tight resources, student tutors present a major opportunity. So that PAL concepts can function at a high level and the necessary foundations for the best possible training of the students can be created, professional training and mentoring of the tutors is important.

In the case of previously established concepts, the training of medical tutors usually takes place directly through the responsible departments and focuses primarily on subject-specific content. Pedagogical skills, which are crucial for teaching academic courses, are only covered to a minimal extent by many training programs. Increasingly, there are individual attempts to establish structured teacher training at a central, university-wide level, such as at the Center for Higher Education at the University of Duisburg-Essen [14], the University of Cologne [15], Ulm University [http://www.uni-ulm.de/misc/uulm-pro-mint-med/massnahmen-des-projekts/methodisch-didaktische-weiterbildung-von-tutoren-und-mentoren.html] and by the central Student Advisory Service at the Ruhr-Universität Bochum [http://www.ruhr-uni-bochum.de/tutprogramm/SchulungenderZAT.html], the Instructor Service Center at the Universität zu Lübeck [http://www.uni-luebeck.de/universitaet/dozierenden-service-center/angebote-nach-zielgruppe/fuer-studierende.html] and the Department for Key Competencies and Higher Education at Heidelberg University [16]. However, didactic training that is both interdisciplinary and specifically focused on medical students only exists at the universities in Tübingen and Heidelberg. The program in Tübingen encompasses didactic training lasting one and a half days at the Baden-Württemberg Competence Centre for University Teaching in Medicine [http://www.medidaktik.de/]. In Heidelberg, a two and a half-day basic course in Medical Teaching and Leading Groups is offered within the scope of the mentor-tutor program [7], [17] [http://www.medizinische-fakultaet-hd.uni-heidelberg.de/Startseite.110378.0.html]. What has been missing for peer tutors in medicine is structured training in teaching medicine in the form of a curriculum, such as those which have already been in place for years for instructors and post-docs [17], [18], [19], [20]. To fill this gap, a curriculum for didactic training of student tutors analogous to the teacher training for university instructors has been developed and culminates in the University of Heidelberg Teaching Certificate for Tutors (Didaktischen Zertifikat der Universität Heidelberg für TutorInnen).

For many years, student tutorials have been integrated into the medical school at Heidelberg University, primarily in anatomy, conducting interviews, problem-oriented learning, macroscopic anatomical preparation and sonography. A basic course in medical teaching for tutors already existed as of 2007. The goal of this present project was to integrate these existing concepts into a structured, longitudinal curriculum that not only promoted the students’ medical skills, but also their competencies in teaching.

The curriculum was developed based on the Kern cycle [21]. First, a focus group made up of four student tutors, four teaching coordinators from the subjects listed above, and two responsible representatives from the university level was convened in the summer of 2009 to conduct a specific needs assessment. The selection of the program’s four modules and the definition of the individual tasks and requirements of the student tutors took place concurrently. The basic course in medical teaching that has existed since 2007 and has proven its value was assumed as Module I in the new curricular concept (see Results). During the 2009-10 winter semester, the curricular design was undertaken in coordination with the Department for Key Competencies and Higher Education at the Heidelberg University based on audio recordings of the focus group and their analysis and closely oriented toward the structure of the Baden-Württemberg Certificate in Academic Teaching, as well as recommendations for post-graduate medical teaching curricula [16], [17], [18] [http://www.medizinische-fakultaet-hd.uni-heidelberg.de/Startseite.110378.0.html].

Modules I through III are evaluated using standardized questionnaires (quantitative evaluation), whereby within the scope of this paper only the evaluations of Module I (basic course in medical teaching) are presented, since Modules II and III are evaluated directly by the particular university departments where the tutorials take place. In addition, as part of Module IV, individual conferences with the program graduates were conducted. These covered a systematic assessment of the individual components of the portfolio focusing on the written reflections, as well as semi-structured interviews (N=18, à 12±3 minutes) consisting of six main questions about motivation, benefits, and students’ experience of the program’s requirements to evaluate the overall concept (see Appendix 1 [Attach. 1]). The latter is the focus and qualitative component of the evaluations presented here.

The training program has a modular structure and covers (minimum) requirements totaling 200 curricular units spread out over four modules (see Figure 1 [Fig. 1]).

Module I: Basic course “Medical Teaching and Leading Groups” (20 curricular units)

Forming the basis of the training is a two and a half-day basic course consisting of the sub-modules Medical Teaching & Moderation, Communication & Presentations, and Groups & Leadership. In rotating small groups of a maximum of eight participants per group, the tutors learn “teaching tools” through theory input and interactive exercises, meaning the various pedagogical methods (e.g. theory input, sociometry in action, practical exercises, reflection, role playing, simulated doctor-patient interaction, video analysis, feedback) and social forms (individual work, partner work, small group work, full group sessions), along with possibilities for their use. The focus is on assuming the role of instructor as quickly as possible and acquiring confidence in moderating and leading groups. For example, in the role of instructor the students guide their peers through parts of the physical examination, with help from Peyton’s four-step approach [22] for acquiring practical clinical skills.

Module II: Topic-specific Preparation (60 curricular units)

This part of the training is done according to the tutorial topic (e. g. intercultural communication with patients with bronchitis) by the responsible departments (e.g. General Practice, Internal Medicine and Psychosomatic Medicine). In particular, subject-specific content is imparted to the prospective tutors that will then be communicated by these tutors to their peers during tutorials. For instance, the sonography tutors undergo four days of preparation regarding the medical knowledge needed to conduct the course, including didactic aspects.

Module III: Conduction of Tutorials (84 curricular units)

This component encompasses the teaching of topic-specific lesson plans and represents the actual, individual teaching, including preparation and post-processing of the tutorial, as well as the creation of teaching materials in coordination with the teaching coordinators.

Module IV: Evaluation of the Learning Process (36 curricular units)

This final module covers the evaluation of the learning process during and upon completion of the training and is meant to ensure the sustainability of the acquired skills. This includes supervisions, peer observations and a portfolio that is compiled over the course of the training program.

Each tutor participates in supervision activities that amount to eight curricular units, during which challenging situations in tutorials and how to handle tutees are discussed as a group and practice is gathered in assuming leadership. Furthermore, the tutors are responsible for observing two tutorial sessions held by fellow students (8 units). The tutors receive concrete criteria for observing tutorials in order to give their fellow tutors targeted feedback afterwards and to document areas for improvement. By the end of the training, the tutors will have created a portfolio that is made up of three parts: in the basic portfolio there are four private reflections, one on each area of university teacher competency [23], and a final reflection that covers the entire teaching experience within the context of the individual’s development. For the personal portfolio three pieces of the student’s own materials may be freely chosen. The qualification portfolio contains all formal documentation of the training sessions and teaching experience (Modules I to III). Successful participation in the training program outlined above is officially recognized with the granting of the University of Heidelberg Teaching Certificate for Tutors (Didaktischen Zertifikats der Universität Heidelberg für TutorInnen). This certificate is awarded during an official ceremony by the Medical School in cooperation with Heidelberg University (Department for Key Competencies and Higher Education).

The financial, human, and organizational resources involved in realizing the curriculum developed here were ensured through student fees, allowing the program to be implemented in summer 2010. Due to its close coordination with the curriculum for the Baden-Württemberg Certificate in Academic Teaching, the tutor training certificate can be counted toward the Baden-Württemberg Certificate in Academic Teaching with 40 curricular units for that program’s Module II on professional teaching (total of 60 curricular units).

Currently, 27 tutors (12 male, 15 female) of a mean age of 24.6 years (MW; SD= 1.5), have completed the training program as part of their medical studies; 56 tutor trainees are presently enrolled, with registration numbers showing a steady increase: 11 registered in the first cohort, 12 in the second, 15 in the third, 21 in the fourth and 24 in the fifth (winter semester 2010-11 through winter semester 2012-13). All program graduates have taught various tutorials over the course of their training, in particular on the subjects of anatomy, conducting interviews, problem-oriented learning, macroscopic anatomical preparation, sonography, and even histology. On average, the graduates fulfill distinctly more than the required minimum for the teaching units (MW=359 units, SD=.89 or 200 units), which primarily results from many years of extensive experience in leading tutorials (Module III). In addition, a total of 495 tutors have been trained in the basic course in medical teaching, which was integrated into this training program as Module I and was evaluated with the academic grade of 1.7 (MW; SW=0.6; 28 courses during 2007-2013).

The qualitative evaluation of the interviews (N=18) consisting of six questions investigated how the graduates assess the project after the fact (see Appendix 1 [Attach. 1]).

Significant incentives for participating in the training program include the opportunity for tutors to acquire early teaching qualifications and attain the certificate upon completion, particularly if a university career is being considered as an option. The program graduates describe great joy and confirmation through teaching and the productive exchange with other tutors. They feel a need to develop beyond their chosen field, meaning in terms of teaching skills, communication and personally, and to prepare for future clinical work. Subjectively compared with non-participants, they profit not only in terms of their own studies, for instance in giving presentations, engaging in group work, selecting and processing information, but also in terms of their own scientific projects and in their interactions with hospital physicians and patients. When faced with new situations they feel more confident and action-oriented and notice (in themselves) a greater ability to self-reflect, brought about by the “new” knowledge concerning communication processes and group dynamics. Overall, they feel themselves to be more competent not only as teachers, but also as learners, something that they find positive both in terms of fulfilling future professional and personal demands placed on a good doctor and for their work as tutors. Moreover, they see a “competitive advantage” in having completed the training program, not just as a result of its applicability to the Baden-Württemberg Certificate in Academic Teaching. The written reflections prove to be the greatest challenge, while at the same time they are found to be very worthwhile because they allow perspective on a student’s own developmental progress and bring the different component skills together in an illuminating context. The training program certificate as such increases the perceived professional nature of the training (see also “competitive advantage”) and is experienced as a worthy recognition of achievement through its formal award for completion of an educational program that is beneficial in many aspects.

As the training program was being designed and implemented, the following aspects emerged as being of particular importance and which could be relevant when establishing comparable programs:

• A central coordination point has proven itself valuable for planning, realization and administration, as well as for assuming the supervision of tutors and evaluating the form and content of the individual requirements. To accomplish all this, a half-time position (50% minimum) filled by an academically qualified person is recommended.
• A training program with structured content increases the independence of tutors and the possibility of their designing tutorials which, as a result, are not bound by a prescribed time schedule.
• The evaluation of the learning process, e.g. through the use of portfolios and appropriate feedback from the supervisors on pedagogical and personal skills is a pre-requisite for enabling the acquired knowledge and skills to become sustainably effective.
• The granting of the training program certificate, which brings with it recognition for future professional activities, creates an effective incentive system. As a result of participating in the program, students have already been able to gather (positive) experience in the area of university teaching during their own studies, giving participants the chance to actively explore the possibility of a university teaching career.
• To maintain the commitment of tutors at a high level and to supervise the training process, regular group meetings are recommended, such as are possible for instance within the scope of supervisions. Particularly toward the end of the training, individual conferences could possibly be meaningful.
• When introducing structured, university-wide or medical school-wide training programs, one focus should be on networking the individual departments in order to optimally use the existing school resources and provide relief at the subject levels.
• To avoid possible resistance, it is important to include all responsible people from the start in the curricular development process. Centralization of tutor training may take the weight off the shoulders of individual departments, but it does mean a diminishment in the autonomy of decentralized structures.

The curriculum developed to train peer tutors in medical education consists of four modular components with a combined total of 200 curricular units: the basic course in medical education, the subject-specific preparation for the tutorials, the individual teaching activities, and the evaluation of the learning process through supervision, peer observation, and portfolios. The training counts toward the post-graduate university teacher training in Baden-Württemberg and complies with the principles and quality standards for medical teacher training as defined in the consensus paper of the national network for teaching in medicine, MedizinDidaktikNetz [24].

In the following, the results and aims of the training program presented here are discussed on three levels:

• on the level of the tutors (a),
• on that of the students as tutorial participants (b),
• and that of the faculty (c).

Since its introduction, 27 tutors have successfully completed this program; 56 other tutors are currently undergoing training. Although this number does not appear large, the number of registrations from cohort to cohort have developed positively and reflect the aim in designing the program of appealing to especially motivated tutors (in medical education).

The program graduate interviews indicate a high level of program acceptance and a long-term benefit for students’ own training. The certificate granted by the university is perceived by program graduates as an initial official recognition of their long-term commitment to teaching and they also value the training program as a possibility, during their studies, to formally acquire pedagogical skills for future teaching positions. In this, the program fulfills the objective of imparting didactic competencies to the students during their medical studies [25]. As a result of self-reliant teaching, the tutors profit in terms of learning through teaching by expanding their professional and personal skills in their studies and occupation [26]. The requirements fulfilled to obtain the certificate are counted after successful completion of medical school and upon assuming teaching activities toward the Baden-Württemberg Certificate in Academic Teaching, which tutors describe as an effective incentive and which anchors the training program hierarchically. As a limitation, it must be mentioned that for organizational reasons only 18 of the 27 program graduates took part in the interview, so that a selection bias cannot be ruled out.

Supporting the positive assessment of the program is the analysis of the quantitative evaluation of the basic course in medical teaching, which has been in existence since 2007 and has served as Module I since the start of the training program and which a total of 495 students have attended and evaluated. However, the quantitative data only permit qualified conclusions to be drawn since the analysis does not differentiate between program participants and non-participants. Despite this, the quantitative data provide a supplementary impression regarding the acceptance and also the size of possible target groups for training programs in medical teaching (a).

In a subjective comparison with non-participants, program graduates perceive themselves to be more competent, not just in the role of teacher, meaning as communicators of knowledge and role models, but also as contact persons. In turn, this benefits the tutees in these student-led tutorials and creates the basis for effective learning. In respect to this, however, the expansion of the standardized evaluations, e.g. in the form of an (objective) comparison of the evaluation of tutorials that are led by participants of the training program versus non-participants, is desirable to allow for authoritative conclusions (b).

Alongside the direct implications for students and tutors, the program contributes to faculty development. The student-led sessions serve the instructors as bolstering support in teaching and allow the students in-depth exposure to the subject matter in small groups. The instructors/coordinators responsible for the tutorials in the medical school were included early on in the process of developing the training program, something we deem conducive to the acceptance and subsequent implementation of the curriculum. Within the scope of the graduate interviews, it was also indicated that a loyalty to the medical school is fostered through participation in the training program and inclusion of the tutors in teaching. A standardized analysis of these factors in follow-up studies, e.g. in the form of a survey of the instructors or a follow-up on the program graduates has not yet been undertaken (c).

The implementation of structured training programs in teaching for student teachers contributes significantly to quality assurance and professionalism in medical teaching. Through uniform training, a school-wide pool of qualified tutors is created, who can then be deployed in various areas and this, in turn, can relieve the burden placed on the individual departments. Considering the limited resources, professional and centralized peer-teaching programs represent a major opportunity, since they enable intensive teaching and learning with minimal use of resources. The establishment, evaluation and development of comparable programs at other universities are desirable and should be made easier as a result of this paper.

The authors declare that they have no competing interests.