Perspectives
Students as teachers Students who learn to teach effectively may facilitate other students’ learning and their own ew would challenge the assertion that senior doctors play a vital role in teaching and supervising peers, junior colleagues and students. Junior doctor teaching of medical students is also significant, and students estimate that up to one-third of their knowledge can be attributed to junior doctors.1 Effective teaching is a learned skill; teaching workshops develop and refi ne teaching skills, improve attitudes towards teaching and may introduce new teaching tools.2 Such “faculty” development, although more available these days, still remains optional for many, and particularly for junior doctors, learning such skills may compete with patient care responsibilities and specialty training.1 We believe Australian medical schools should strongly consider implementing a comprehensive, vertically integrated student teaching program employing peerassisted learning (PAL). PAL refers to “people from similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching”.3 Through PAL, students learn how to teach and give feedback, and under supervision are given the chance to practise and consolidate these skills. It has been used successfully to teach theoretical information, as well as procedural and clinical examination skills to medical students in small group settings.4,5 Although most evidence is based on predominantly extracurricular programs in American and European medical schools, an extracurricular program at the University of Western Australia (UWA) has recently been described with similar fi ndings.6 Recent publications offer detailed discussions of many issues related to the implementation of PAL.4,7 A number of practicalities deserve special consideration in the Australian context, and in this paper we offer recommendations on how these issues might be approached.
F
Should learning to teach be compulsory for all students? We are strongly in favour of compulsory teaching skills training. The ability to teach effectively from day one is an essential skill for junior doctors, both to improve the doctor–patient interaction (explaining medical information to patients) and because of their involvement in student teaching. In addition, the structure of a hospital medical or surgical team is in fact an example of PAL, where the difference in experience between teacher and student may be as small as 1 year.8 Completion of a comprehensive training course will not only equip students with the skills required to teach, but will also improve their personal learning effectiveness and communication skills.4,5 The latter is especially 164
MJA 199 (3) · 5 August 2013
Benjamin I Silbert MB BS(Hons), Student Grand Rounds Coordinator 20101
Stephanie J P Lam MB BS, Student Grand Rounds Coordinator 20111
Robert D Henderson MB BS, Student Grand Rounds Coordinator 20111
Fiona R Lake MD, FRACP, Head of School and Eric Saint Chair in Medicine2 1 Western Australian Medical Students’ Society, University of Western Australia, Perth, WA. 2 School of Medicine and Pharmacology, University of Western Australia, Perth, WA.
Benjamin.Silbert@ health.wa.gov.au
important, as evidence suggests that communication is a learned skill that requires specific training, rather than a skill developed purely through experience.9 Increasing awareness of the importance of communication skills training has seen it become a core component of medical curricula in recent years, and we consider teaching skills training to be an important but necessary extension to this.
Should all students be required to teach? Challenges associated with involving all students in teaching activities include capacity, and difficulties with engaging unenthusiastic students or those who are poor teachers or struggling students themselves. Commitment to teaching is an important characteristic of effective teachers, and students who are forced to participate in PAL are unlikely to demonstrate this.10 Ultimately, the ability to practise and develop effective teaching methods will confer the greatest gains to tutors and thus tutees. In addition, the experience of teaching increases students’ confidence, reduces anxiety and may increase the likelihood that they will participate in teaching as a junior doctor.4,5
doi: 10.5694/mja12.10970
At what stage of the curriculum should PAL be introduced? The specific stage at which it is appropriate for PAL to be introduced will differ depending on a number of factors, including the type of course (undergraduate or graduate entry), course duration, and the tutorial content (eg, theory or clinical skills). It seems logical that PAL should be introduced early in the medical curriculum in order to allow skills to develop and maximise benefits. PAL has successfully been implemented using tutors and tutees from all stages of the medical course, 5 including fi rst-year students for whom the ability of peer teachers to alleviate anxiety may be particularly valuable.8 PAL is a versatile teaching tool and has been applied to the teaching of theory, procedural skills, peer physical examination and the examination of hospital patients.4-6
How will tutors be trained? Adequate tutor training is an important element of any teaching program, and a number of papers offer recommendations about the content of training courses.4,7 Adult learning theory and the principles of effective teaching should be discussed with particular emphasis on the settings in which PAL tutorials will be conducted (eg, small group discussions, bedside tutorials, procedural skills training). Training on how to give constructive feedback and how to evaluate one’s own teaching is important, and an interactive workshop
Perspectives that provides students with the opportunity to practise teaching and receive feedback from their peers is highly desirable. PAL tutor training courses described in the literature are often delivered in short, focused sessions just before the fi rst scheduled tutorial.7 Ongoing periodic training throughout the medical course and continuing into postgraduate training is likely to consolidate and further develop skills.4 Ideally training would be delivered by PAL supervisors who have obtained higher degrees in education and have extensive teaching experience. Medical schools in Queensland and Western Australia are fortunate to have a comprehensive “how to teach” course readily available for training student tutors. Teaching on the Run (TOTR) is an internationally recognised training course that was developed in Perth, WA, specifically designed to improve the teaching skills of clinicians in a busy clinical setting. At UWA a modified TOTR course, co-facilitated by a senior clinician and a senior student, is delivered to student tutors. It focuses on the skills required to teach in a PAL context, including how to teach with patients, and has been shown to be well received.6
How should student tutors be assessed? The most appropriate methods of evaluation will differ between individual PAL programs depending on a number of factors, for example the content of tutorials and the availability of resources.7 Appraisal of tutor performance is likely to be most reliable if obtained from a combination of experienced faculty teachers, fellow student tutors and tutees. In addition, both qualitative and quantitative methods of feedback are important. The most valuable feedback for tutors may be informal (preferably anonymous) feedback from tutees after each tutorial, as they are the ones who can best comment on teaching effectiveness and have the most to gain from improving tutor performance. Feedback from fellow tutors and faculty teachers is an important supplement to that from tutees as it can be used to evaluate the tutor’s use of teaching principles and techniques. We suggest that tutorials should be observed periodically for this purpose, and that tutors should also be able to request formative evaluation and feedback from experienced teachers. Formal testing of tutee knowledge using quizzes before and after tutorials may also be useful as an objective measure of tutorial outcomes and will facilitate quality control. It is important to consider whether the teaching ability of students should be formally assessed if student tutors are to have a formal role within the medical curriculum. Although it is imperative to ensure that both their level of knowledge and standard of teaching are adequate, introducing formal assessment may risk adversely affecting student willingness to participate or attitudes towards teaching. For this reason, if formal assessment is to be performed we suggest that a pass or fail rating be used rather than a numerical score. One method
by which teaching skills could be formally assessed (if required) is through the inclusion of a “teaching station” in end-of-year examinations. For example, instead of instructing candidates to suture a wound they could be asked to teach a “student” how to do it.
Further potential challenges Challenges commonly faced when introducing PAL programs include fi nding adequate time (for tutor training and PAL tutorials) and inadequate resources (both human and fi nancial, for the development, monitoring and evaluation of PAL).7 This issue will be best addressed by educators if considered during the planning stage of implementation, ideally in the context of curriculum restructuring. The ability to teach effectively from day one is an essential skill for junior doctors
Conclusion: why now? Increasing awareness of the benefits associated with PAL and developing students’ teaching skills has seen a surge in the number of overseas medical schools providing tutor training programs linked to PAL opportunities. Despite this, Australian medical students are missing out: few of our medical schools provide teaching skills training for students (own unpublished data). A number of Australian medical schools have recently completed or are currently undergoing course restructuring, offering an excellent opportunity to formally implement a vertically integrated PAL and teaching skills program into medical curricula. Students will gain experience and confidence in teaching, improve their communication skills, and benefit from the ongoing process of revision and reinforcement of core medical knowledge. These skills may facilitate a more therapeutic doctor–patient relationship, and increase the student’s enthusiasm for future teaching in a postgraduate setting. Competing interests: No relevant disclosures. Provenance: Not commissioned; externally peer reviewed. 1 Bing-You RG, Sproul MS. Medical students’ perceptions of themselves and
residents as teachers. Med Teach 1992; 14: 133-138. 2 Ende J. Theory and practice of teaching medicine. Philadelphia: American
College of Physicians Press, 2010. 3 Topping KJ. The effectiveness of peer tutoring in further and higher
4 5 6 7
8
9 10
education: a typology and review of the literature. Higher Education 1996; 32: 321-345. Dandavino M, Snell L, Wiseman J. Why medical students should learn how to teach. Med Teach 2007; 29: 558-565. Ten Cate O, Durning S. Peer teaching in medical education: twelve reasons to move from theory to practice. Med Teach 2007; 29: 591-599. Silbert BI, Lake FR. Peer-assisted learning in teaching clinical examination to junior medical students. Med Teach 2012; 34: 392-397. Ross MT, Cameron HS. Peer assisted learning: a planning and implementation framework: AMEE guide no. 30. Med Teach 2007; 29: 527-545. Lockspeiser TM, O’Sullivan P, Teherani A, Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ Theory Pract 2008; 13: 361-372. Kurtz SM. Doctor-patient communication: principles and practices. Can J Neurol Sci 2002; 29 Suppl 2: S23-S29. Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008; 83: 452-466.
MJA 199 (3) · 5 August 2013
165
Students as teachers Students who learn to teach effectively may facilitate other students’ learning and their own ew would challenge the assertion that senior doctors play a vital role in teaching and supervising peers, junior colleagues and students. Junior doctor teaching of medical students is also significant, and students estimate that up to one-third of their knowledge can be attributed to junior doctors.1 Effective teaching is a learned skill; teaching workshops develop and refi ne teaching skills, improve attitudes towards teaching and may introduce new teaching tools.2 Such “faculty” development, although more available these days, still remains optional for many, and particularly for junior doctors, learning such skills may compete with patient care responsibilities and specialty training.1 We believe Australian medical schools should strongly consider implementing a comprehensive, vertically integrated student teaching program employing peerassisted learning (PAL). PAL refers to “people from similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching”.3 Through PAL, students learn how to teach and give feedback, and under supervision are given the chance to practise and consolidate these skills. It has been used successfully to teach theoretical information, as well as procedural and clinical examination skills to medical students in small group settings.4,5 Although most evidence is based on predominantly extracurricular programs in American and European medical schools, an extracurricular program at the University of Western Australia (UWA) has recently been described with similar fi ndings.6 Recent publications offer detailed discussions of many issues related to the implementation of PAL.4,7 A number of practicalities deserve special consideration in the Australian context, and in this paper we offer recommendations on how these issues might be approached.
F
Should learning to teach be compulsory for all students? We are strongly in favour of compulsory teaching skills training. The ability to teach effectively from day one is an essential skill for junior doctors, both to improve the doctor–patient interaction (explaining medical information to patients) and because of their involvement in student teaching. In addition, the structure of a hospital medical or surgical team is in fact an example of PAL, where the difference in experience between teacher and student may be as small as 1 year.8 Completion of a comprehensive training course will not only equip students with the skills required to teach, but will also improve their personal learning effectiveness and communication skills.4,5 The latter is especially 164
MJA 199 (3) · 5 August 2013
Benjamin I Silbert MB BS(Hons), Student Grand Rounds Coordinator 20101
Stephanie J P Lam MB BS, Student Grand Rounds Coordinator 20111
Robert D Henderson MB BS, Student Grand Rounds Coordinator 20111
Fiona R Lake MD, FRACP, Head of School and Eric Saint Chair in Medicine2 1 Western Australian Medical Students’ Society, University of Western Australia, Perth, WA. 2 School of Medicine and Pharmacology, University of Western Australia, Perth, WA.
Benjamin.Silbert@ health.wa.gov.au
important, as evidence suggests that communication is a learned skill that requires specific training, rather than a skill developed purely through experience.9 Increasing awareness of the importance of communication skills training has seen it become a core component of medical curricula in recent years, and we consider teaching skills training to be an important but necessary extension to this.
Should all students be required to teach? Challenges associated with involving all students in teaching activities include capacity, and difficulties with engaging unenthusiastic students or those who are poor teachers or struggling students themselves. Commitment to teaching is an important characteristic of effective teachers, and students who are forced to participate in PAL are unlikely to demonstrate this.10 Ultimately, the ability to practise and develop effective teaching methods will confer the greatest gains to tutors and thus tutees. In addition, the experience of teaching increases students’ confidence, reduces anxiety and may increase the likelihood that they will participate in teaching as a junior doctor.4,5
doi: 10.5694/mja12.10970
At what stage of the curriculum should PAL be introduced? The specific stage at which it is appropriate for PAL to be introduced will differ depending on a number of factors, including the type of course (undergraduate or graduate entry), course duration, and the tutorial content (eg, theory or clinical skills). It seems logical that PAL should be introduced early in the medical curriculum in order to allow skills to develop and maximise benefits. PAL has successfully been implemented using tutors and tutees from all stages of the medical course, 5 including fi rst-year students for whom the ability of peer teachers to alleviate anxiety may be particularly valuable.8 PAL is a versatile teaching tool and has been applied to the teaching of theory, procedural skills, peer physical examination and the examination of hospital patients.4-6
How will tutors be trained? Adequate tutor training is an important element of any teaching program, and a number of papers offer recommendations about the content of training courses.4,7 Adult learning theory and the principles of effective teaching should be discussed with particular emphasis on the settings in which PAL tutorials will be conducted (eg, small group discussions, bedside tutorials, procedural skills training). Training on how to give constructive feedback and how to evaluate one’s own teaching is important, and an interactive workshop
Perspectives that provides students with the opportunity to practise teaching and receive feedback from their peers is highly desirable. PAL tutor training courses described in the literature are often delivered in short, focused sessions just before the fi rst scheduled tutorial.7 Ongoing periodic training throughout the medical course and continuing into postgraduate training is likely to consolidate and further develop skills.4 Ideally training would be delivered by PAL supervisors who have obtained higher degrees in education and have extensive teaching experience. Medical schools in Queensland and Western Australia are fortunate to have a comprehensive “how to teach” course readily available for training student tutors. Teaching on the Run (TOTR) is an internationally recognised training course that was developed in Perth, WA, specifically designed to improve the teaching skills of clinicians in a busy clinical setting. At UWA a modified TOTR course, co-facilitated by a senior clinician and a senior student, is delivered to student tutors. It focuses on the skills required to teach in a PAL context, including how to teach with patients, and has been shown to be well received.6
How should student tutors be assessed? The most appropriate methods of evaluation will differ between individual PAL programs depending on a number of factors, for example the content of tutorials and the availability of resources.7 Appraisal of tutor performance is likely to be most reliable if obtained from a combination of experienced faculty teachers, fellow student tutors and tutees. In addition, both qualitative and quantitative methods of feedback are important. The most valuable feedback for tutors may be informal (preferably anonymous) feedback from tutees after each tutorial, as they are the ones who can best comment on teaching effectiveness and have the most to gain from improving tutor performance. Feedback from fellow tutors and faculty teachers is an important supplement to that from tutees as it can be used to evaluate the tutor’s use of teaching principles and techniques. We suggest that tutorials should be observed periodically for this purpose, and that tutors should also be able to request formative evaluation and feedback from experienced teachers. Formal testing of tutee knowledge using quizzes before and after tutorials may also be useful as an objective measure of tutorial outcomes and will facilitate quality control. It is important to consider whether the teaching ability of students should be formally assessed if student tutors are to have a formal role within the medical curriculum. Although it is imperative to ensure that both their level of knowledge and standard of teaching are adequate, introducing formal assessment may risk adversely affecting student willingness to participate or attitudes towards teaching. For this reason, if formal assessment is to be performed we suggest that a pass or fail rating be used rather than a numerical score. One method
by which teaching skills could be formally assessed (if required) is through the inclusion of a “teaching station” in end-of-year examinations. For example, instead of instructing candidates to suture a wound they could be asked to teach a “student” how to do it.
Further potential challenges Challenges commonly faced when introducing PAL programs include fi nding adequate time (for tutor training and PAL tutorials) and inadequate resources (both human and fi nancial, for the development, monitoring and evaluation of PAL).7 This issue will be best addressed by educators if considered during the planning stage of implementation, ideally in the context of curriculum restructuring. The ability to teach effectively from day one is an essential skill for junior doctors
Conclusion: why now? Increasing awareness of the benefits associated with PAL and developing students’ teaching skills has seen a surge in the number of overseas medical schools providing tutor training programs linked to PAL opportunities. Despite this, Australian medical students are missing out: few of our medical schools provide teaching skills training for students (own unpublished data). A number of Australian medical schools have recently completed or are currently undergoing course restructuring, offering an excellent opportunity to formally implement a vertically integrated PAL and teaching skills program into medical curricula. Students will gain experience and confidence in teaching, improve their communication skills, and benefit from the ongoing process of revision and reinforcement of core medical knowledge. These skills may facilitate a more therapeutic doctor–patient relationship, and increase the student’s enthusiasm for future teaching in a postgraduate setting. Competing interests: No relevant disclosures. Provenance: Not commissioned; externally peer reviewed. 1 Bing-You RG, Sproul MS. Medical students’ perceptions of themselves and
residents as teachers. Med Teach 1992; 14: 133-138. 2 Ende J. Theory and practice of teaching medicine. Philadelphia: American
College of Physicians Press, 2010. 3 Topping KJ. The effectiveness of peer tutoring in further and higher
4 5 6 7
8
9 10
education: a typology and review of the literature. Higher Education 1996; 32: 321-345. Dandavino M, Snell L, Wiseman J. Why medical students should learn how to teach. Med Teach 2007; 29: 558-565. Ten Cate O, Durning S. Peer teaching in medical education: twelve reasons to move from theory to practice. Med Teach 2007; 29: 591-599. Silbert BI, Lake FR. Peer-assisted learning in teaching clinical examination to junior medical students. Med Teach 2012; 34: 392-397. Ross MT, Cameron HS. Peer assisted learning: a planning and implementation framework: AMEE guide no. 30. Med Teach 2007; 29: 527-545. Lockspeiser TM, O’Sullivan P, Teherani A, Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ Theory Pract 2008; 13: 361-372. Kurtz SM. Doctor-patient communication: principles and practices. Can J Neurol Sci 2002; 29 Suppl 2: S23-S29. Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008; 83: 452-466.
MJA 199 (3) · 5 August 2013
165
![[Anesthesiologists teach teachers, teachers train students, students are lifesavers!].](/assets/img/hold.png)
