Temporal and group-related trends in peer assessment amongst medical students

Peer assessment has been increasingly recommended as a way to evaluate the professional competencies of medical trainees. Prior studies have only assessed single groups measured at a single timepoint. Thus, neither the longitudinal stability of such ratings nor differences between groups using the same peer-assessment instrument have been reported previously. Participants were all members of 2 consecutive classes of medical students (n = 77 and n = 85) at the University of Rochester School of Medicine and Dentistry who completed Years 2 and 3 of medical school consecutively. All participants were evaluated by 6-12 classmates near the end of both Years 2 and 3. Main outcome measures were mean numerical ratings on peer-assessed scales of professional work habits (WH) and interpersonal attributes (IA). Both scales had high internal consistencies in both years (Cronbach's alpha 0.84-0.94). The IA and WH scales were moderately correlated with one another (r = 0.36 in Year 2, r = 0.28 in Year 3). Year 2 scores were predictive of Year 3 scores for both scales (WH: r = 0.64; IA; r = 0.62). Generalisability and decision analyses revealed that 1 class was consistently more discriminating with the WH scale, while the other was more discriminating with of the IA scale. Depending on the class, year and scale, the number of raters needed to achieve a reasonable reliability ranged between 7 and 28. Although Year 3 peer ratings were consistently higher than Year 2 peer ratings for both WH and IA, individual scores were highly correlated across the 2 years, despite the fact that different individuals were chosen as peer raters. Abilities appear to be stable between Years 2 and 3 of medical school. Groups may differ in their ability to discriminate different kinds of skills. Generalisability analysis can be used to discover these patterns within groups.     

Peer-assisted learning: a novel approach to clinical skills learning for medical students

OBJECTIVE: This study aimed to determine whether peer-assisted learning (PAL) can enhance clinical examination skills training. METHODS: Three student trainers studied small-group theory and clinical examination and provided PAL as extra tuition for 86 trainees. Trainees watched an examination video, were videotaped practising the examination and, after constructive feedback, repeated the examination. Responses to PAL were evaluated to attain an overview of trainee and trainer performance using visual analogue and Likert scale analyses. Year-group review was undertaken using questionnaires. RESULTS: Trainees evaluated all aspects of PAL highly, including their post-training confidence in examination skills (mean > 7.7 on a 10-cm scale), indicating that the PAL was effective. Written comments confirmed the students perceived the sessions as well structured and of high quality. Compared with trainees in the first groups, those from later groups gave all parameters similar or higher gradings. Those for interest (P = 0.03) and appropriateness (P = 0.01) were significantly higher, suggesting that trainers may improve their technique with time. Students with previous degrees gave similar or lower gradings than standard entry students, with answers about post-training confidence and recommendation to friends being statistically lower (P < 0.006). Six months later, year-group analysis showed that 90% of trainees rated PAL highly, and 86% wished to become trainers. Of the trainers' year group, 79% perceived that PAL training could improve examination skills. CONCLUSIONS: In the context of clinical skills training, PAL was highly evaluated across many parameters, including confidence after training. Student interest and enthusiasm supports suggestions that PAL could be a useful adjunct to clinical skills training.     

The need for teaching in medical audit: a survey in one medical school

Summary: Summary. A questionnaire survey was carried out among senior clinical teachers at Newcastle upon Tyne Medical School, UK about their current practice and attitudes toward the teaching of medical audit in the undergraduate curriculum. A response rate of 88% was achieved. Less than a fifth of respondents provided such teaching, but the majority were in favour of seeing the topic introduced. A variety of teaching methods were used, and feedback from students was generally favourable. A number of concerns were expressed, including the problem of curriculum overload, the timing of the teaching, and the need to ensure that the learning was experiential with a minimum of theoretical teaching. Those who were in favour of introducing such teaching, or who were unsure, were also concerned about pressures on curricular time, but some felt in addition that the topic was more appropriately a postgraduate one. A short attitude scale demonstrated a skew towards favourable attitudes among the whole group. The implications of the survey for teaching about audit and quality are discussed.     

Analysis of verbal interactions in tutorial groups: a process study

INTRODUCTION: Collaborative learning, including problem-based learning (PBL), is a powerful learning method. Group interaction plays a crucial role in stimulating student learning. However, few studies on learning processes in medical education have examined group interactions. Most studies on collaboration within PBL used self-reported data rather than observational data. We investigated the following types of interactions in PBL tutorial groups: learning-oriented interactions (exploratory questioning, cumulative reasoning and handling conflicts about knowledge); procedural interactions, and irrelevant/off-task interactions. AIM: The central question concerned how much time is spent on the different types of interaction during group sessions and how the types of interaction are distributed over the meeting. METHOD: Four tutorial group sessions in Year 2 of the PBL undergraduate curriculum of Maastricht Medical School were videotaped and analysed. The sessions concerned the reporting phase of the PBL process. We analysed the interactions using a coding scheme distinguishing several verbal interaction types, such as questions, arguments and evaluations. RESULTS: Learning-orientated interactions accounted for 80% of the interactions, with cumulative reasoning, exploratory questioning and handling conflicts about knowledge accounting for about 63%, 10% and 7% of the interactions, respectively. Exploratory questioning often preceded cumulative reasoning. Both types occurred throughout the meeting. Handling conflicts mainly occurred after the first 20 minutes. CONCLUSIONS: Task involvement in the tutorial groups was high. All types of learning-orientated interactions were observed. Relatively little time was spent on exploratory questions and handling conflicts about knowledge. Problem-based learning training should pay special attention to stimulating discussion about contradictory information.     

Consultant attitudes to undertaking undergraduate teaching duties: perspectives from hospitals serving a large medical school

OBJECTIVE: To explore attitudes among National Health Service consultants responsible for delivering basic clinical teaching to medical students. DESIGN: Postal questionnaire. SUBJECTS AND SETTING: A total of 308 acute hospital trust consultants working in 4 'new' and 4 'established' teaching hospitals in the West Midlands metropolitan area, and involved in the delivery of clinical teaching to Year 3 medical students at the University of Birmingham Medical School during 2002-03. MAIN OUTCOME MEASURE(S): The questionnaire explored contractual requirements, actual teaching commitments and perceptions of medical students' knowledge and attitudes. Responses from doctors and surgeons and from respondents working in established and new teaching hospitals were compared. RESULTS: A total of 249 responses were received (response rate 80.8%). Although many consultants enjoy teaching students, their enjoyment and their ability to deliver high standards of teaching are compromised by time and resource constraints. For many the situation is aggravated by the perceived inappropriate organisation of the clinical teaching curriculum and the inadequate preparation of students for clinical practice. Linking these themes is the overarching perception among teachers that neither service nor educational establishments afford teaching the levels of recognition and reward associated with clinical work or research. CONCLUSION: To overcome barriers to teaching requires more reciprocal links between hospital staff and medical schools, opportunities for consultants to understand and to comment on curricular and timetable developments, and, perhaps most importantly, recognition (in contractual, financial, managerial and personal terms) of the importance of undergraduate teaching in the competing triad of service, research and education.     

Health care ethics teaching for medical students

This paper describes an innovatory teaching programme in health care ethics for medical undergraduates. The general aims and objectives are outlined and the 1990 course is discussed specifically. The course has several unusual features, including the use of performers and the presentation of ethically based decisionmaking implements, which are highlighted. The course is evaluated. The 1990 results are encouraging.     

Learning human anatomy: student preferences of methods in a Nigerian medical school

The present study evaluates the usefulness, as perceived by students, of the various methods by which anatomical information is presented during the preclinical part of the medical course. Assessments of these learning methods were elicited from a cohort of medical students at the University of Benin by a questionnaire based on their selection of questions to attempt in Anatomy Paper 2 (Essays) of the First Professional examination (= 2nd MB). An algorithm was provided to enable the quantification of the preferences expressed and hence the derivation of a utility index for each learning method. The results showed that reading/private study, formal lectures, informal discussions with peers and practical work were the learning methods from which the students had benefited, in descending order of usefulness. These findings are discussed in the context of the teaching and learning of human anatomy in the particular circumstances studied.     

Audit: teaching medical students in general practice

Summary. Audit is being seen as an increasingly important topic for medical students. Many departments of general practice in the UK now incorporate audit as part of their course work. It remains controversial as to whether this is perceived to be worthwhile by the students. Following an introductory seminar final-year medical students at the University of Glasgow were asked to perform a case-note review of 10 randomly chosen diabetic patients for a number of process and outcome measures during their practice attachments. Feedback was given in their final teaching session. 128/153 (84%) students completed an evaluation of the course on their knowledge and attitudes to audit. Unsurprisingly, 39% found the data collection boring or very boring; however, 60% found the feedback session very interesting or interesting. Both the data collection and the feedback were considered relevant by the majority of students (57% and 70% respectively). Students' self-reported knowledge also dramatically increased (P < 0.0001 ).     

Students' views of reflective learning techniques: an efficacy study at a UK medical school

OBJECTIVE: To describe the effects of a voluntary intervention using reflective learning techniques on students' learning. DESIGN: An interventional study with reflective learning techniques offered to medical students. SETTING: Year 3 of undergraduate medicine at Cardiff University where the curriculum is integrated with early clinical contact. PARTICIPANTS: All 232 Year 3 students were invited to participate. A total of 65 attended an introductory lecture. After the lecture 35 students agreed to take part; 15 of these subsequently dropped out (some before attending tutorial groups, others after taking part for some weeks). INTERVENTIONS: Participants kept learning journals for 2 terms and attended fortnightly, facilitated tutorial groups where they discussed their reflective journal entries. Main outcome measures were qualitative interviews and examination results. RESULTS: Interviews were carried out with 19 full participants, 4 initial participants and 7 non-participants. Participants perceived that they gained a greater ability to identify learning objectives and to integrate learning. The tutorial groups encouraged students to compare progress with their peers. Some students did not take part because they thought that the large factual content of the curriculum would make reflective learning less useful. There were no differences between the groups in examination results. CONCLUSIONS: Students among the small, self-selected group of participants were better able to identify what they needed to learn although there was no improvement in examination results. Students appear unlikely to take up voluntary reflective learning if they do not think it relates to the curriculum and assessments. Student culture exerts a potent effect on willingness to attend extra tutorial groups.     

Health education poster: a teaching model for clinical medical students

Summary. The teaching of health education or health promotion to medical students is often difficult because they have little experience on which to base their learning. They have limited clinical knowledge and in particular their awareness of the value of and the opportunities for health promotion in general practice is limited. The problem-oriented teaching method described here attempts to make the subject interesting and relevant by asking students, while in their practice attachments, to identify areas of need for health promotion or health education and then to prepare a poster, with supportive background and research, to satisfy that need for display in their given practice.     

Anatomical dissection as a teaching method in medical school: a review of the evidence

CONTEXT: Discussions about dissection as a teaching method in gross anatomy are characterised by a lack of objective evidence. METHODS: A search for such evidence in the literature produced 14 relevant papers. These were reviewed for objective data on the effect of cadaver dissection on cognitive learning outcomes. RESULTS: All reviewed studies compared groups of students exposed to different teaching approaches, including active dissection, learning on prosected material, or a combination with computerised teaching aids. Study and course designs varied substantially and student groups compared were not always homogeneous. In all studies, compared learning experiences differed in more than 1 variable, and assessment of anatomical knowledge was not standardised. DISCUSSION: It is difficult to interpret and generalise from the results of the reviewed studies. Considering the bias that must be assumed for teachers who develop new course designs and compare these with traditional ones, the review shows a slight advantage for traditional dissection over prosection. CONCLUSIONS: More sophisticated research designs may be necessary to solve the general problem of the small measurable impact of educational interventions and to come to scientifically sound conclusions about the best way to teach gross anatomy. Such research will have to include sufficient sample sizes, the use of validated assessment instruments, and a discussion of the educational significance of measured differences. More educational research in anatomy is necessary to counterbalance emotional arguments about dissection with scientific evidence. Anatomical knowledge is too important to future doctors to leave its teaching to the educational fashion of the day.     

Short-term outcomes and long-term impact of a programme in medical education for medical students

Objectives  There is growing appreciation of the value of early preparation of future medical educators. Staff development programmes, conferences and workshops pertaining to the training of educators may be crucial to the pursuit of a school's larger educational mission to educate students, doctors and scholars and to provide comprehensive knowledge, research, patient care and service. This study examined the efficacy of a 1-week educational intervention aimed at preparing medical students to become effective doctor educators by building skills early in their careers. The study asked whether participation in a 5-day teacher training programme led to increased knowledge of instructional methods, more favourable attitudes towards teaching, and the integration of structured instructional design methods in a student-developed teaching project.
Methods  A mixed methods research design was employed with quantitative data captured through pre- and post-test inventories, qualitative components captured through written comments, and a 2-year post-intervention survey. Quantitative analyses included pre-/post-intervention repeated measures with calculated effect sizes. Qualitative analysis was conducted using constant comparative methods.
Results  Subjects demonstrated improved content knowledge and more positive attitudes towards motivation, teaching confidence, teacher roles, varied pedagogy, and use of assessment, instructional planning, and evaluation. Subjects were able to incorporate the programme's teaching theory and methods into their teaching projects and assessment of peers' and others' teaching in their own institutions 2 years post-training.
Conclusions  This study demonstrates that a well-designed programme for teacher preparation can be pedagogically effective for training medical students to become better educators and that this learning can be incorporated into long-term practice.     

Effects of rater selection on peer assessment among medical students

CONTEXT: Although peer-assessment appears promising as a method to assess interpersonal skills among medical students, results may be biased by method of peer selection, particularly if different kinds of classmates are assigned systematically by different methods. It is also unclear whether students with lower interpersonal skills may be more negative towards their classmates than students with higher levels of interpersonal skills and, if so, how much bias this may introduce into the results of peer assessment. It is also unclear whether low-rated students are more likely to ask to rate one another. DESIGN, SETTING, AND PARTICIPANTS: Participants were 296 medical students from the classes of 2004, 2005 and 2006 at the University of Rochester School of Medicine and Dentistry. All participants were evaluated by between 6 and 12 classmates near the end of both their second and third years. In some classes peer-raters were assigned from class lists, while in other classes students were asked to recommend classmates to rate and be rated by. MAIN OUTCOME MEASURES: Mean numerical ratings of interpersonal-attributes scores received from peers, compared with mean scores simultaneously assigned to peers. We also examined students' selection of peer-raters, as well as scores received by their peer-raters. RESULTS: For all 3 classes in both second and third years, students in the lowest quartile of received scores were significantly more likely to simultaneously assign lower scores to their peers. Among third-year students, such low-scoring students were significantly more likely to ask to rate and be rated by other low-scoring students. Among third-year students, low-rated students were more likely to rate and be rated by other low-rated students, irrespective of how rater assignments are made. Most students who were originally in the lowest quartile of received scores remained so after removing the scores assigned by low-rated raters. Among pre-clinical second-year students, however, low-rated students were no more likely than high-rated students to be rated by other low-rated students. CONCLUSION: Students with low levels of peer-assessed interpersonal attributes are more negative in their judgements of classmates. Third-year medical students with low levels of interpersonal attributes are more likely to be rated by other students with low levels of interpersonal attributes, irrespective of method of rater assignment. This effect was not seen in the second year of medical school. Biases in selection of raters among third-year students, however, do not appear to affect the results of peer assessment. Thus, medical schools that choose to institute peer assessment can select the method of peer-rater assignment based on practicality and logistical considerations. Students' affiliations with one another in the third year appear to be related to peer-assessed interpersonal attributes.     

Medical ethics contributes to clinical management: teaching medical students to engage patients as moral agents

Objectives  In order to teach medical students to engage more fully with patients, we offer ethics education as a tool to assist in the management of patient health issues.
Methods  We propose that many dilemmas in clinical medicine would benefit by having the doctor embark on an iterative reasoning process with the patient. Such a process acknowledges and engages the patient as a moral agent. We recommend employing Kant's ethic of respect and a more inclusive definition of patient autonomy drawn from philosophy and clinical medicine, rather than simply presenting dichotomous choices to patients, which represents a common, but often suboptimal, means of approaching both medical and moral concerns.
Discussion  We describe how more nuanced teaching about the ethics of the doctor–patient relationship might fit into the medical curriculum and offer practical suggestions for implementing a more respectful, morally engaged relationship with patients that should assist them to achieve meaningful health goals.     

Approaches to learning in a problem-based medical programme: a developmental study

In this study we investigate how the introductory phase of the problem-based medical programme in Maastricht affects the study methods of students. On the first day of the academic year, 142 men and women medical students completed the Short Inventory of Study Approaches and again at the end of the introductory period. The study indicates that these study methods are fostered by training in problem-based learning given during the introductory period.     

Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients

Objectives  Peer-assisted learning (PAL) has been reported to have educational benefits in cross-year, small-group teaching in other contexts. Accordingly, we explored whether senior medical students are effective tutors for their junior peers in clinical skills education, and how the participants in the learning triad (tutors, learners and simulated patients [SPs]) perceive the learning environment created in PAL.
Methods  Year 2 students were randomly allocated to one of two groups for skills training. Group 1 ( n  = 64) were tutored by volunteer Year 6 students, and Group 2 ( n  = 67) by paid doctors. The results of both groups in a clinical skills examination were compared using an independent samples t -test. Qualitative data, obtained from Year 2 students ( n  = 125) by written questionnaire and Year 6 students ( n  = 11) and SPs ( n  = 3) by focus group interviews, were analysed for themes.
Results  Students receiving PAL did at least as well in the clinical skills examination as students with qualified tutors (difference in mean total score: 0.7 marks out of 112; 95% confidence interval − 3.8 to 2.4). The PAL environment was perceived as 'comfortable' and fostered the development of confidence in all participants. Peer tutors created a more active learning environment than doctor tutors for both learners and SPs and reported personal benefits from teaching.
Conclusions  With appropriate support, volunteer Year 6 student tutors are as effective as graduate doctors for small-group structured tutorials in clinical skills. Educational relationships were forged between all participants in the learning triad.     

Cross-year peer tutoring experience in a medical school: conditions and outcomes for student tutors

AIMS: To examine the features of cross-year peer tutoring and to explore their relationships to learners' characteristics and educational outcomes from the student-tutor perspective. METHOD: The records of 447 final year medical students were examined to provide data on the starting terms, frequency and course targets of peer tutoring activity of student tutors. The relationships of these features with their learners' characteristics, academic achievements and selective clerkship pathways were analysed. SETTING: The medical education programme at the University of Brasilia, Brazil. RESULTS: Analysis showed that about 96% of all graduates had acted as student tutors at some time during the programme, with great variation in starting terms, numbers and types of courses tutored. The average number of tutored courses per tutor was four. Frequency and variety of tutored courses were significantly related to achievement, learning style and gender. Higher achievers acted as student tutors for many terms and explored different subjects, and there is evidence that the experience expanded their academic expertise. Specific tutoring in a clinical course also related to strength of early career preference. Furthermore, there was a significant correlation between the number of terms of tutoring undertaken in a clinical course and the proportion of students choosing selective clerkship training in the same area by the end of programme. CONCLUSIONS: The findings suggest that acting as a peer tutor can be an appealing and constructive educational opportunity to further students' academic development. Enhanced expertise seems to relate to the accumulation and breadth of tutoring experience. Moreover, clinical tutoring may help students in making decisions regarding choice of career.     

Comparison of computer-assisted learning with tutorial teaching in a group of first-year dental students

Two identical groups of first-year dental students were instructed in the pathology of dental caries and periodontitis using computer-assisted learning (CAL) or tutorial teaching (TT). A cross-over arrangement, in which the first group was taught about dental caries by CAL and periodontitis by TT and the second group in the reverse order, allowed comparison of the two methods. The comparison included a knowledge test and completion of a questionnaire. CAL and TT were equally effective as far as acquisition of knowledge was concerned. Students felt pressurized with CAL and had problems with note-taking. They liked a teacher to be present. Nevertheless, CAL was an acceptable method of instruction and was more economical, in terms of staff involvement, than TT.     

A comparison of computer-assisted instruction and small-group teaching of cardiac auscultation to medical students

Cardiac auscultation is suffering from declining interest, caused by competing diagnostic technology and inadequate training of doctors. Computer-assisted instruction (CAI) supporting graphics and digitized sound could be ideally suited for teaching and sharpening this skill. To evaluate this premise we randomized 35 third-year medical students to 3 hours of seminar teaching plus the use of audiotapes (group 1), the self-use of a MacIntosh-based CAI (group 2), or both (group 3). All students took a pre- and post-test consisting of eight pre-recorded cardiac events and were also assessed for computer anxiety. Although there were no significant differences between pre- and post-tests for each group and among groups, group 1 had a 4.5% deterioration in its diagnostic score compared to the 7.2% and 3.2% improvements of groups 2 and 3 respectively. Group 2 used the CAI significantly more than group 3. We conclude that CAI is at least as effective as seminars in teaching cardiac auscultation to third-year medical students.     

Attitudes of medical students to old people: a cross-national comparative study

Medical students' attitudes to the elderly were compared at the start and finish of a 5-week clinical attachment in health care of the elderly at the Christchurch School of Medicine. The study investigated students in their first clinical year (fourth year of their medical course) over five terms using a questionnaire employing a Rosencranz-McNevin semantic differential scale to measure general attitudes to old age and a Likert scale to measure attitudes to medical care. A question was also asked about career preferences. There was significant improvement in attitudes measured by both scales (Rosencranz-McNevin P less than 0.001, Likert P less than 0.001). Students also showed an increase in interest in health care of the elderly as a career choice. When compared with two cohorts of students from Nottingham Medical School, attitudes were significantly better in the Christchurch group at the commencement of the run. Students at both schools showed an improvement in knowledge but this was more marked for Christchurch students.