gms | German Medical Science

Today’s medical students are tomorrow’s medical teachers [1]. However, faculties‘ medical curricula do no prepare medical students for their later teaching responsibilities which are immediately required in most teaching hospitals. A possible solution could be the implementation of teaching classes where medical students learn to teach [2], [3]. In order to reach that goal medical faculties have to establish new teaching and learning methods [1]. Teaching more practically relevant skills is already required by the new medical approbation order [4], however its implementation is limited by personal resources and, e.g. in paedicatrics, special needs of little children and their parents. Especially teaching in paedicatrics requires a more extensive, patient and committed supervision of the medical students as it may be required for other disciplines [5], [6], [7]. Considering increasing shortage of resources and further responsibilities of lecturers and physicians, new innovative and cheaper solutions are needed [5]. A possible solution might be the implementation of a well-structured, practical workshop in general paediatric examination techniques by student peer teachers (SPT). Data from prospective studies is missing so far showing the effectiveness of such a peer-assisted learning concept. In the University Children’s Hospital of Essen SPT’s are trained for almost twenty years in a 14-days intensive course to teach medical students in the following year in basic paediatric examination techniques [8], [9]. Prof. Olbing has successfully established the peer-teacher training concept in Essen which has been evaluated in 1996 [10]. However, a standard quantitative evaluation of the affective and sensomotorical skills is missing since it was considered to be methodocially too extensive. Instead of that, simply a student questionnaire asking the medical students for their overall satisfaction has been performed. A quantitative analysis was indirectly carried out by reviewing the results of the paper-test in paediatrics [10]. The external evaluation revealed that SPT’s are considered stimulating and helpful. There are only few studies demonstrating that SPT’s are equally capable of mediating selected paediatric skills when compared to senior paediatric lecturers (SL, [11]). Therefore, a quantitative analysis of peer teaching in paediatrics is urgently required, not only because teaching the peers and its’ organization is time consuming and expensive. However, this expense is justified if such a study could demonstrate that SPT’s are equally qualified to mediate selected basic paediatric skills. In this respect SPT’s should not replace teaching responsibilities of SL’s but should make teaching easier for them because of their intermediate position in a hospital’s hierarchy.

The aim of this prospective study is the clarification of two questions:

1.

Is a SPT after a 14-days intensive course able to equally mediate selected paediatric skills like a SL?

2.

Do medical students consider the use of SPT stimulating and helpful?

The last question should be answered by using a questionnaire at the end of the paediatric teaching course.

This study is a randomized, two-armed comparison study with 123 medical students of the same semester performed in a pre-/post-design. Medical students (52 male, 71 female) were randomly assigned to arm A or B with 60 and 63 students per group. In addition, 23 students (9 male, 14 female) of the same semester were not randomized and served as control group. A pre-test was performed solely in this group to check for preexisting experiences in paediatric examinations. The unequal group sizes resulted from organizational needs and were accepted. A student peer teacher (SPT) was assigned to 63 students (group A) and a senior lecturer (SL) to 60 students (group B). In a one hour paediatric class students had to examine a newborn. No more than two students were instructed in either SPT or SL groups and no further examintations of newborns were performed. After 1-4 days students had to demonstrate the learned skills in a modified 10-minute OSCE.

Since standard examination sheets were not available a non-validated checklist was designed in our hospital by a paediatric expert committee. Same criteria for the control group and the examination groups were used. The demonstration was performed in front of an independent examiner who was not informed about the study goal. To avoid a bias, video recording of the OSCE was perfomed in 30 cases (15 students from each group) and evaluated by an external observer. Students gave their written consent that they were willing to participate in the study and video recording.

Peer teaching took place from February 9th to February 20^th at the University Children’s Hospital of Essen. At that time all tutors finished the 4^th or 5^th medical semester and all applied for a position in this program in summer 2008. Eleven students were selected. An elective period in paediatrics over one month and the successful participation of the paediatric course was assumed. Peer teaching followed a fixed time table and lasted 80 hours. During the curriculum examination of 10 children, demonstration of the examination results and short lectures on specific diseases as well as special teaching lessons of examination techniques were performed. A script was handed out to each tutor. Lectures were performed by seven senior physicians and one junior physician assisted the tutors with the examinations. Tutors performed the same OSCE at the end of the curriculum which was later on used in the study. All paediatric lecturers were experienced and did not perform the OSCE.

Out of summer semester 2009 and winter semester 2009/2010, 60 and 63 medical students respectively have been randomly assigned to a study group. At that time all students participated in the 14-day paediactric class. All participants had the chance to listen to the paediatric lectures in the two semesters before and all passed the final written exam. The study group size of 60 students each arm resulted from a statistical calculation. A pre-test was performed in the control group only on the first day of the paediatric class in order to compare the student’s knowledge before and following the intervention. We assumed that the preexisting knowledge was different among the groups because of prior elective periods in paediatrics. The control group underwent the same teaching classes as the study groups; however, the OSCE was not repeated again at the end of the intervention in this group. Unequal group sizes resulted from organizing reasons. The students have been informed about the study goals prior to the intervention. Nobody underwent the OSCE before.

This study has been approved by the ethical committee of the University of Duisburg Essen (No.09-3967). All participants gave their written consent for the OSCE after being informed that the results of the examination do not count for the final exam results. A written consent for video documentation was given separately by the participants.

It seemed to be important that students had to perform the OSCE under conditions close to reality. Therefore, the examination took place in a standard examination room of our clinic supported by two nurses. The nurses have been trained to act as a mother with mirgration background.

OSCE-raters were specialized paediatricians as well as junior paediatricians. The raters did not take part in the student’s teaching classes before and they did not know whether the student has been taught by a SPT or SL. Due to the heterogeneity among the groups and to avoid a subjectivity bias (rater knew the student before and gave him/her a better score) a video documentation of the examination was performed in 30 cases. Those videos were observed by an external paediatrician later on who was not involved in the medical education of the University and did not know the students.

A regular OSCE was not suitable to answer the study question since a parcours consisting of different exercises was not possible to perform for 146 single examinations. Therefore we designed a single parcours and tested several skills in one examination (Amendement 1 [Attach. 1]). In five exercises, several skills were tested:

• Exercise 1: address the parents; begin the examination = communication skills
• Exercise 2: measurement of head circumference/demonstrate palpation of the pulses = practical skills
• Exercise 3: demonstrate neurological examination = practical skills
• Exercise 4a: summarize results as medical report = communication skills, abstraction
• Exercise 4b: prepare checklist = communication skills, abstraction

Considering the multiplicity of items, an examination time of 10 minutes was allowed for the modified OSCE. The number of points that could be reached per item was not equally distributed. Out of 38 total points, a maximum of 6 points could be reached in exercise 2 and 16 points in exercise 3 (neurological examination of a newborn). The OSCE took place on the last day of the week of the four clinical examinations. Therefore, the distance between the SPT and SL mediated intervention and the examination was 4 days maximum (Monday – Friday) or 1 day minimum (Thursday - Friday). Same distances were not possible because of the multiplicity of exams. The exercises and the checklist could not be validated prior to the study in a larger cohort. However, parts of this OSCE have been used for the first paediatric OSCE in summer 2009 and a sharp separation could be achieved in 115 students.

To calculate the number of subjects needed one had to assume that a single question needs to be answered in this study: Is a SPT after a 14-days intensive course able to equally mediate selected paediatric skills like a SL (yes/no)? The assumed α-mistake is <0.05 (5%). To reach a sufficient statistical power (> 0.80, power d≥0.5) a group size of at least 60 students per arm has to be selected. This has been considered for the calculations. Data are presented as mean ± standard deviation (SD) and the „range“ has also be given for all results. Statistical analysis was performed using a two-sided t-test for independent groups using the statistical program GraphPad Prism version 4.0 (San Diego, CA, USA).

Although participation in this study did not account for the final exams and students had to spend extra time we received a positive feedback from most of the students and a less enthusiastic participation was rarely observed. Most students found the study useful and only one student declined participation. Three students did not agree into a video documentation during the OSCE. All 146 examinations could be finished. Examination of the tutors took place in February 2009 and their results are also given as comparison.

A maximum of 38 points could be reached in the OSCE. The 11 tutors reached a high average result of 30.4±22 points (see Figure 1 [Fig. 1]). The control group reached 14.9±4.1 points, SPT 21.7±4.1 points and the SL group reached 22.6±3.6 points (see Figure 1 [Fig. 1]). Tutors performed significantly better when compared to all other groups (p<0.001); SPT and SL achieved a significantly better result when compared to controls (p<0.001), however, no significant difference was observed between SPT and SL (p=0.203, see Figure 1 [Fig. 1]). The distribution of points reached by all 123 students in the OSCE is given in Figure 2 [Fig. 2].

The modified OSCE consisted of 5 different exercises examining different skills. The results of all exercises are presented in Figure 3 [Fig. 3]. Results reached by students in the SPT and SL teacher are also given separately for a better understanding (see Figure 4 [Fig. 4]). It is remarkable that many significant differences were observed among the groups (see Figure 4 [Fig. 4] and Table 1 [Tab. 1]), e.g. students in the SPT and SL groups always reached significantly better results in all exercises when compared to controls (see Table 1 [Tab. 1]). However, only few differences became obvious when SPT and SL groups were compared directly (see Table 1 [Tab. 1]). Especially exercise 3 where only practical skills were tested no differences were observed among SPT and SL (7.44±2.15 vs. 7.97±1.87, p=0.154). In this important exercise 12 of 16 points maximum were reached in both groups with a similar range. Only in exercise 4 where students were asked to summarize their examination results into a medical report, SL groups performed better than SPT groups (p=0.004). However, this difference seems to be significant but not relevant when considering the total amount of points reached in this exercise (3.7±0.94 vs. 2.95±1.76 out of 6 points maximum). Tutors performed significantly better in all single exercises when compared to controls, SPT and SL groups (see Figure 3 [Fig. 3]). This demonstrates that the 11 tutors after taking part in a 14-days intensive course were capable to perform as teachers.

In 30 OSCEs‘ video recording was performed. Those 10 minute video films were evaluated by an external paediatrician using the same checklist. A maximum of 1 point difference was observed in exercise 4 and 5 among two students and also a maximum of 1 point difference in exercise 3 within 6 students. We used the video documentation to exclude that scoring depended on sympathy for a single student.

In summer 2009 we asked 112 students after they have finished their paediatric training whether they found teaching classes performed by tutors helpful and stimulating („Did you find the use of student peer teachers helpful? yes - no“). In 86 cases (77%) students answered that they consider the work with a student peer teacher helpful, howerver, 23% did not see an advantage using this form of medical education. Few interviews revealed that some students do not believe in general that a student teacher should be involved in medical education classes.

In this quantitative teaching/learning study the peer-to-peer teaching concept of the University Children’s Hospital of Essen was evaluated using a paediatric neurological standard examination situation. Although some paediatric studies addressing peer teaching in paediatrics were performed over the past years only few publications evaluated the role of student peer teachers in clinical classes [8], [9], [10]. Most studies referred to problem-based learning [16], virtual patient cases [12], [13] or taking a medical history in paediatrics [14] but only few data referring to paediatric peer-teaching using practical skills exist [15]. The aim of this study was to provide this data using a time and personal intensive, but simple design. We have demonstrated in this randomized study using an OSCE of a newborn examination that mediation of selected skills can be equally achieved by SPT and SL. Therefore it is feasible to use student peer teachers for clinical paediatric courses if they are well educated and mediation is limited to selected basic skills. Furthermore, the majority of students consider the tutorial support as helpful. In this respect we clearly answered to our primary research question.

To our knowledge this is the first study investigating in parallel the mediation of basic paediatric skills by SPT and SL. This is one major advantage of this study. The results confirm our recent teaching strategy and are highly motivating for all participants to carry on and improve the concept. There are also advantages for the paediatric departments since motivated tutors are the pool for recruiting future paediatricians. A further strength is the control of OSCE results by a blinded external observer since a subjectivity bias could be avoided and similar results were reached. The use of ‘standardized mothers’ with migration background was a further special feature of this study. This is a regional peculiarity and important to know. Adequate communication with parents is undoubtedly one of the major challenges in paediatrics. Upon study conception we could not look back on previous experiences although the learning benefit of standardized patients is well documented in the literature [16], [12]. So far, only few studies described the effectiveness of ‘standardized parents’ [13]. Therefore, there is only empiric experience in the communication with parents with migration background and we tried to train our nurses realistic using our own experiences.

However, caution should be used when interpreting the results. The study goal was not to define the better teacher. Such a question could not be answered using this simple design. It is also not permissible to relieve senior lecturers from their tasks and replace them by cheaper peer-teachers. Clearly the peer-to-peer-teaching concept in a paediatric course could be confirmed quantitatively in a prospective, randomized study. The student tutor is able to mediate selected clinical teaching responsibilities and is therefore a useful addition based on its intermediate position in a hospitals’ hierarchy. A tutor does not replace a lecturer because he does not secure the interpretation in an entire context. Such study limitations have to be considered when peer-teaching programs are established. Especially the quality of mediating complex skills has to be guaranteed by a senior lecturer and not a student peer [17]. You can’t assume that every student peer is also a good teacher. However, the good OSCE results of our 11 tutors demonstrated that the necessary tools and the specific background were given.

The success of peer-supported classes in medical schools can subjectively be demonstrated in several studies [11], [18], [19], [20], [21]. But only few studies, mostly presented as meeting abstracts, investigated quantitatively the effectiveness of peer-teacher mediated skills in direct comparison with postgraduated lectureres, e.g. using an OSCE [17], [18]. At least there are no major paediatric studies known beside meeting reports. In general, several educational goals can be reached by the establishment of tutor-programs [20]:

1.

Today’s medical students take over prime teaching positions in their hospitals later on.

2.

By taking part in tutorial programs future physicians are trained in communicative skills that might be extremely useful in their future careers.

3.

A better understanding of teaching and learning might also stimulate a students‘learning behavior.

At short notice implementation of classes like ‚learn how to teach for students‘might be more laborious for medical faculties. On a long-term basis the improvement of the existing teach/learn-culture might be useful for a University’s reputation [20]. There are two explanations from teaching psychologists why tutor-based education is successful. Allen’s roll theory [22] assumes that teacher and scholar accept different stereotypic rolls with different expectations, responsibilities and hierarchic positions, which are separated from each other by psychological and physical barriers. In this model the congruent roll of the tutor with the students strengthens one motivation to learn („self-directed learning“) while the fear to fail seems to be the learning trigger when educated by an experienced teacher. A further theory by Schmidt [23] postulates the existence of a cognitive incongruence between faculty members and students and congruence between student peer teachers and students. Therefore it is easier for SPT‘s to include preexisting knowledge or existing lacks, especially the usage of language and thinking in one’s teaching classes [23]. This might explain why the acceptance of a student tutor is higher than assumed [23], [24].

The methodological study limitations are obvious. Most of them were known when the study was designed but were accepted for practicability reasons. One problem is that the modified OSCE consists of several items but only a single rater. The design of a complete OSCE parcours with various exercises and different raters would be more adequate but too time-and observer-consuming and therefore not practicable [25]. It was our goal to design only one OSCE parcours and to test various clinically relevant skills in a single examination. Furthermore, the OSCE was meant to take part soon after the intervention since only a single hour was used for it. This requires an examination every week and not one major OSCE parcours at the end of each semester. The use of an external observer could at least demonstrate that the use of only one rater did not negatively influence the results.

The exam did reveal poorer results than normally expected in an OSCE, at least when considering the test-centered level for passing an exam according to Ebel or Angoff [26], [27]. Only 60% of all participants would have passed with an arbitrary limit of 60%. Therefore one has to ask whether the chosen form of examination is a valid tool to discriminate between competent and incompetent students or whether the level was too high for an OSCE in general. Again, the discrimination level would have been better in a parcours consisting of 5-10 items. It is also obvious that the difficulty of the 5 items varied, e.g. exercise 1, 2 and 5 were equally handled by all participants whereas solution of exercise 3 reveals a much greater heterogeneity, leaving exercise 3 with the highest difficulty and separation power. To further reveal the validity of our exam we also included the tutors’ and controls’ results in the analysis. When looking at the tutors’ results one can see that all exercises where solvable after some training since this group reached 30.4?2.2 of 38 points. The control group reached significantly fewer points when compared to all other groups. Therefore, one can conclude that the chosen form of exam was adequate to answer the study question since all participants reached better results following the intervention when compared to controls showing that they all profited from teaching classes. However, the chosen exam is not an adequate measure to discriminate between competent and incompetent students, but that was out of a question.

A majority of 77% found tutor’s teaching classes stimulating and helpful. In order to avoid an evaluation tiredness we deliberately asked only a single question which had to be answered by ‘yes’ or ‘no’. This does not reveal the individuals‘ intrinsic motivation. An entire questionaire would have been necessary to assess the quality of tutors‘ teaching classes in comparison to SL. Therefore, a possible Hawthorne-effect („but some students had a real lecturer…“) that might have changed one’s behavior in the exam cannot entirely be excluded by our results [28]. However, the quality of medical training has previously been evaluated in detail and was not the focus of this study [10].

The results of this quantitative teaching study reveal that student peer teaching can be a useful addition to classical paediatric teaching classes. Student peer teachers are as effective as senior lectures when mediating selective skills. A two week intensive training seems to be adequate to prepare the peers for their future tasks.

This study has been supported by a generous grant of the dean of studies of the medical faculty of the University of Duisburg-Essen.

This work is dedicated to Prof. Hermann Olbing [†].

The authors declare that they have no competing interests.