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.     

The clinical reasoning process

Medical school teachers must have an accurate idea of the doctor's clinical reasoning process (CRP) in order to provide students with learning experiences and evaluations that will ensure their acquisition of an effective and efficient CRP. It is difficult to derive this understanding from much that has been written on the subject. It is important to recognize that clinical problems are ill-structured and that the doctor's reasoning is built around a temporal unfolding of information. A model for the CRP is described along with a critique of other models that have been suggested. The results of research that examines components of the process must be seen in relation to the overall process.     

Diagnostic error and clinical reasoning

Context There is a growing literature on diagnostic errors. The consensus of this literature is that most errors are cognitive and result from the application of one or more cognitive biases. Such biased reasoning is usually associated with ‘System 1’ (non‐analytic, pattern recognition) thinking. Methods We review this literature and bring in evidence from two other fields: research on clinical reasoning, and research in psychology on ‘dual‐process’ models of thinking. We then synthesise the evidence from these fields exploring possible causes of error and potential solutions. Results We identify that, in fact, there is very little evidence to associate diagnostic errors with System 1 (non‐analytical) reasoning. By contrast, studies of dual processing show that experts are as likely to commit errors when they are attempting to be systematic and analytical. We then examine the effectiveness of various approaches to reducing errors. We point out that educational strategies aimed at explaining cognitive biases are unlikely to succeed because of limited transfer. Conversely, there is an accumulation of evidence that interventions directed at specifically encouraging both analytical and non‐analytical reasoning have been shown to result in small, but consistent, improvements in accuracy. Conclusions Diagnostic errors are not simply a consequence of cognitive biases or over‐reliance on one kind of thinking. They result from multiple causes and are associated with both analytical and non‐analytical reasoning. Limited evidence suggests that strategies directed at encouraging both kinds of reasoning will lead to limited gains in accuracy. Medical Education 2010: 44 : 94–100     

Examining the effects of adapted peer tutoring on social and language skills of young English language learners

The purpose of this study was to examine the effects of adapted peer tutoring (APT) on social interactions and early language and literacy skills of pre-school-age children who were English language learners (ELLs). APT was the treatment for this study. Quasi-experimental group comparison design was applied. Two inclusive pre-school classrooms were randomly assigned as the experimental group and two other classrooms were assigned as the comparison group. A total of 75 children participated in this study. The ELLs from the experimental group demonstrated significant improvement than their peers from the comparison group in positive social interaction behaviour, receptive language, and print knowledge. The total effect indicated that children's social interaction behaviour moderately mediated the APT effectiveness on language acquisition.     

Integrated Case Learning: teaching clinical reasoning

Learning how to ‘think like doctors’ can be difficult for undergraduate medical students in their early clinical years. Our model of collaborative Integrated Case Learning (ICL) and simulated clinical reasoning aims to address these issues. Taking a socio-cultural perspective, this study investigates the reflective learning interactions and practices of clinical thinking that emerged in the ICL environment. We also explore how third year medical students perceived their ICL experiences in relation to the clinical situations encountered in the hospital setting. The context for the inquiry is a rural Clinical School in North West Victoria, Australia. We used a qualitative case study methodology following eight third-year medical students over an academic year. Individual and group interviews were conducted, together with observations and document/artefact analysis. Data was analysed using content and narrative methods. The ICL program was well received. Findings suggest that the group-based, simulated clinical reasoning process appears to help undergraduate medical students to rehearse, articulate and question their clinical decision-making pathways. We argue that the ICL process offers a professionally challenging, but supportive group learning ‘space’ for students to practise what it might mean to ‘think’, ‘talk’ and ‘perform’ like doctors in real settings. The ICL environment also appears to create a connective bridge between the ‘classroom’ and clinical practice.     

Using cultural-historical activity theory to study clinical reasoning in context

The aim of this paper is to describe sources of conflict and congruence in critical areas of practice with caregivers of persons with dementia, using cultural-historical activity theory as an analytic framework. Findings are drawn from an ethnographic study that described the context of occupational therapists' (OTs') clinical reasoning in a funded, home-based environmental skill-building program designed to help caregivers manage the daily care of a family member with dementia. Data were gathered through observation of intervention sessions, debriefing sessions, semi-structured interviews with therapists, and review of intervention documentation. Primary sources of conflict and congruence within the identified practice context included conflicts between therapists and caregivers concerning which environmental strategies were best for addressing problems in caregiving and expectations regarding OT and caregiver roles. Areas of congruence included the fit between intervention protocols used to guide treatment and the approaches therapists developed to help caregivers modify care receivers' living environments. The study revealed the complexity of OT practice and demonstrated that practice contexts can be systematically analyzed using cultural-historical activity theory to determine key factors influencing clinical reasoning. The approach also presents an alternative perspective on clinical reasoning that more directly integrates clients/caregivers and therapists as co-constructors of OT intervention.