New education method or tool
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Exploring the experience of medical students as peer teachers in clinical ultrasonography: why do they do it and how do they perform?

Benedicte Coiffier[1], Christopher See[2], Elaine Lee[1], Julie Chen[3], Keith Wan Hang Chiu[1], Pek Lan Khong[1]

Institution: 1. The University of Hong Kong, Department of Diagnostic Radiology, 2. The University of Hong Kong, The School of Biomedical Sciences, 3. The University of Hong Kong, Department of Family Medicine & Primary Care
Corresponding Author: Dr Elaine Lee ([email protected])
Categories: Teaching and Learning, Clinical Skills, Undergraduate/Graduate
Published Date: 21/10/2019

Abstract

Background

A pilot project aimed to understand the experience and performance of medical students as peer tutors (Student In Medical Education Program, SIME) in the undergraduate ultrasound module at the University of Hong Kong.

Methods

Four SIME tutors contributed to teaching of third year medical students (n=184) via a 3-hour hands-on session. Pre-module training was given to SIME tutors. Students were divided into small groups to practise abdominal ultrasound scanning on each other under the guidance of senior tutors (radiologists/sonographers) or SIME tutors.

Learning outcomes were assessed through pre- and post-module quizzes. Qualitative exploration was undertaken through thematic coding of dedicated observers’ notes from teaching sessions and the round table discussion conducted with SIME tutors to discuss the project effectiveness.

Results

Seventy-five percent (n=138) of the medical students submitted both pre- and post-module quizzes. The senior tutors’ and the SIME tutors’ groups scored similarly on the post-module quiz, 8.26 and 7.93 respectively.

Themes emerging from the qualitative analysis included SIME tutors motivations for teaching such as giving them insight to the limitations of their own knowledge. They valued the proximity of age to their students and understood the learning needs of the students. Some barriers to peer-teaching were also identified such as concerns over sufficiency of knowledge to teach, and logistic arrangements.

Discussion

SIME program was successfully introduced in the ultrasound module, improving SIME tutors’ self-confidence in teaching and better understanding of ultrasound without affecting the quality of teaching.

Keywords: Curriculum; learning; teaching; medical students; ultrasonography.

Introduction

Engaging medical students as peer-teachers can have benefits for both teachers and students at multiple levels (Bene and Bergus, 2014), (Rees et al., 2016), through creating a friendly learning environment leading to improved confidence in performing a clinically orientated skill or task. Peer-teachers offer education to students at their own cognitive level, without any pressure and thus enhancing their motivation and interest (Lockspeiser et al., 2008). The free flow discussion between the students and their peers improves communication skills (Rees et al., 2016), builds collaborative relationships with better understanding of the challenges for exam success.

As the practice of point-of-care ultrasound increases since the 1990s, integration of ultrasound teaching into the undergraduate medical curriculum is important to ensure its early exposure and safe use (Moore and Copel, 2011), (Bahner et al., 2014). A new ultrasound module was implemented in the undergraduate medical curriculum at the University of Hong Kong (HKU) resulting in improved awareness and better understanding of this bedside technique (Coiffier et al., 2019).

The aim of this study was to explore the experience of newly-trained peer-teachers in the ultrasound module, and to assess the educational benefits to themselves as well as the students they teach.

Methods

The pilot project involving medical students as peer-teachers through the Student In Medical Education (SIME) program was introduced in the ultrasound module at HKU in September 2018, aimed to improve the learning and teaching experience during a 3-hour hands-on session. This implementation of peer-teaching was adapted from the Association of Medical Education in Europe (AMEE) guidance document (Ross and Cameron, 2007). Participation in the SIME program was voluntary, but students must have previously joined the Special Study Module (SSM) from the Department of Diagnostic Radiology, in year 3. The 4-week SSM offered training in ultrasound acquisition techniques, Focused Assessment with Sonography with Trauma and upper abdominal ultrasound imaging. Pre-module training was organized for SIME tutors for more hands-on experience and teaching guidance. They shadowed the senior tutors (experienced radiologists or sonographers) during the first session for pedagogy training.

The undergraduate ultrasound module was run four times in the academic year for all third year medical students. A total of 184 students, 4 SIME tutors and 12 senior tutors participated in the project. During each session, the students were randomly divided into 4 small groups of 12-13 students, led by either a senior tutor or a SIME tutor supervised by a senior tutor.

The learning outcomes of the module were: (1) to understand the important considerations before and during scanning and (2) to recognize normal abdominal anatomy. Tutors received guidance notes prior the session and were instructed to follow a standardized approach starting with an explanation of the imaging planes and knobology, followed by demonstration of the use of ultrasound apparatus on a volunteer student, to provide hands-on tips and to explain how to recognize the different appearances of normal abdominal anatomy on ultrasound. Each student then practiced upper abdominal scanning on each other under the tutor’s supervision.

Learning outcomes were evaluated using a quiz, before and after the module. The pre-module quiz contained 5 questions on basic ultrasound to assess baseline knowledge on ultrasound. The post-module quiz consisted of the same 5 questions to assess knowledge improvement and 5 additional questions to evaluate the acquired ultrasound skills.

A research assistant not involved in teaching observed the different peer-teachers during the training session, took notes on their behaviors and collected feedbacks from the students after the session and through 8 questions sent by email. A round table discussion was conducted with project investigator and SIME tutors after the sessions to discuss the effectiveness and challenges of this pilot project. The notes taken by the observer and during the round table discussion were entered into qualitative analysis software (Nvivo 9) and thematic coding was undertaken to identify common themes relating to the motivations and experiences of the SIME tutors.

Results

Among the 221 students enrolled into the program, 83% of them participated in the ultrasound training sessions (n=184), leading to a 1:12 tutor to student ratio. 75% (n=138) submitted both pre- and post-module quizzes. The average grade for the pre-module quiz was 3.95 and 3.70  out of total score of 5 respectively for the senior tutor groups and SIME groups, showing a reasonable sound knowledge of ultrasound. The groups with senior tutors and those with SIME tutors both performed highly on the post-module quiz with mean grading of 8.25 and 7.93 (out of total score of 10), respectively (Table 1).

Table 1: Average score of the pre- and post-module quizzes for n=138 quizzes.

 

Pre-module quiz (total score 5)

Post-module quiz (total score 10)

 

Average Tutor’s groups

Average SIME’s groups

Average Tutor’s groups

Average SIME’s groups

Session 1

3.90

/

8.30

/

Session 2

3.88

4.25

9.00

8.70

Session 3

3.52

3.05

7.53

6.95

Session 4

4.59

3.80

8.18

8.13

Total Mean

3.95

3.70

8.26

7.93

Variance

1.44

1.31

1.59

2.94

P value

0.23

0.19

 

A two-sample t test assuming equal variances was performed to assess the P-Value of each group.

Four qualitative themes were identified: (1) Peer-tutors motivations to teach, (2) Positive teaching and learning behaviors, (3) Facilitators of peer-teaching, and (4) Barriers to peer teaching. SIME tutors reported positive experiences such as the opportunity to have interactive discussions with the students. Benefits to SIME tutors themselves were also identified in their motivation  for themselves, for example:

      “Teaching is also a great way for me to learn and revise.”

      “Questions raised by students often inspire me to think more and have new insights into the limitations in my understanding.”

They felt more confident in teaching after these sessions and improved their own ultrasound skills responding to the students’ questions. Analysis of observer notes showed that students in the groups with the SIME tutor were engaged and enthusiatic with more verbal participation. This triangulated with statements by SIME tutors that close age and empathy were facilitators of teaching. Barriers to peer teaching identified by SIME tutors include the feelings of insufficient knowledge and the request of more independence in teaching during the sessions, as they were supervised by senior tutors. SIME tutors reported the desire to teach without supervision and to develop additionnal sessions outside the module.  

Discussion

The study demonstrated that SIME tutors trained through a 4-week SSM and a pre-module training performed as well as senior tutors in helping students learn basic ultrasound knowledge and techniques. Our training is consistent with the effective approach highlighted by Celebi et al. who described three ways to train peer-tutors: course, internship or both (Celebi et al., 2019).

Our observational findings of increased interactivity between tutors and students and establishment of a friendly learning environment match the putative benefits of peer-teaching put forward by other authors (Ten Cate and Durning, 2007). The benefits to SIME tutors’ such as improved self-reported confidence in using ultrasound came without compromising on the teaching quality.

As a pilot study, this study has several limitations. First, only 4 SIME tutors were enrolled to teach in the ultrasound module. However, with these positive results, there will be scope to expand the project to enlist more volunteered SIME tutors for future sessions. Second, the post-module results were not based on a competency-based assessment. We are gradually introducing this evaluation (Kumar, Kugler and Jensen, 2019) into the module to better evaluate students’ performance.

Conclusion

In conclusion, the SIME program successfully trained peer-teachers who were equally effective teaching ultrasound as senior tutors, and demonstrated additional benefits such as improving self-confidence among the SIME tutors and increased interactivity amongst students.

Take Home Messages

  • Senior students as adjunct tutors through the Student In Medical Education (SIME) program.
  • Engaging peer-teaching in the ultrasound curriculum does not affect the quality of teaching.
  • SIME tutors reported positive experience in teaching.
  • SIME tutors felt more confident in teaching after this program and improved their own ultrasound skills.

Notes On Contributors

Prof Khong (ORCID 0000-0002-9280-6778) is the head of Department of Diagostic Radiology, HKU;

Dr Lee (ORCID 0000-0002-0627-5297) and Dr Chiu (ORCID 0000-0002-7930-1193) are Clinical Assistant Professors;

Ms Coiffier (ORCID 0000-0001-6577-5040Research Assistant in this Department;

Dr See (ORCID 0000-0002-4229-660X) is a Lecturer from the School of Biomedical Sciences, HKU;

Dr Chen (ORCID 0000-0002-7444-6182) is Associate Professor in the Department of Family Medicine and Primary Care, HKU.

Acknowledgements

The authors thank the team of radiologists, sonographers and observers involved in the hands-on sessions and the SIME volunteers who participated in the pilot program. The authors also thank Professor Ivan Hung, Assistant Dean in Clinical Curriculum & Assessment, and Professor Gilberto Leung, Associate Dean in Teaching & Learning, HKU, for their support.

Bibliography/References

Bahner, D. P., Goldman, E., Way, D., Royall, N. A., et al. (2014) 'The state of ultrasound education in U.S. medical schools: results of a national survey', Acad Med, 89(12), pp. 1681-6. https://doi.org/10.1097/ACM.0000000000000414

Bene, K. L. and Bergus, G. (2014) 'When learners become teachers: a review of peer teaching in medical student education', Fam Med, 46(10), pp. 783-7, https://www.ncbi.nlm.nih.gov/pubmed/25646829

Celebi, N., Griewatz, J., Malek, N. P., Hoffmann, T., et al. (2019) 'Outcomes of three different ways to train medical students as ultrasound tutors', BMC Med Educ, 19(1), p. 125. https://doi.org/10.1186/s12909-019-1556-4

Coiffier, B., Shen, P. C. H., Lee, E. Y. P., Kwong, T. S. P., et al. (2019) 'Introducing point-of-care ultrasound through structured multifaceted ultrasound module in the undergraduate medical curriculum at the University of Hong Kong', Ultrasound. https://doi.org/10.1177%2F1742271X19847224

Kumar, A., Kugler, J. and Jensen, T. (2019) 'Evaluation of Trainee Competency with Point-of-Care Ultrasonography (POCUS): a Conceptual Framework and Review of Existing Assessments', J Gen Intern Med. https://doi.org/10.1007/s11606-019-04945-4

Lockspeiser, T. M., O'Sullivan, P., Teherani, A. and Muller, J. (2008) 'Understanding the experience of being taught by peers: the value of social and cognitive congruence', Adv Health Sci Educ Theory Pract, 13(3), pp. 361-72. https://doi.org/10.1007/s10459-006-9049-8

Moore, C. L. and Copel, J. A. (2011) 'Point-of-care ultrasonography', N Engl J Med, 364(8), pp. 749-57. https://doi.org/10.1056/NEJMra0909487

Rees, E. L., Quinn, P. J., Davies, B. and Fotheringham, V. (2016) 'How does peer teaching compare to faculty teaching? A systematic review and meta-analysis (.)', Med Teach, 38(8), pp. 829-37. https://doi.org/10.3109/0142159X.2015.1112888

Ross, M. T. and Cameron, H. S. (2007) 'Peer assisted learning: a planning and implementation framework: AMEE Guide no. 30', Med Teach, 29(6), pp. 527-45. https://doi.org/10.1080/01421590701665886

Ten Cate, O. and Durning, S. (2007) 'Peer teaching in medical education: twelve reasons to move from theory to practice', Med Teach, 29(6), pp. 591-9. https://doi.org/10.1080/01421590701606799

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Ethics approval was sought and granted by the local Institutional Review Board. Name of committee approving the research: Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB). Reference number: UW 18-439.

External Funding

This article has not had any External Funding

Reviews

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Hui Meng Er - (05/11/2019) Panel Member Icon
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This is an important study that adds to the literature about the benefits of peer teaching and its effectiveness. More details on the background of the peer tutors should be given, e,g their academic year, the criteria for peer teachers, and how were they trained. Were there reliability data for the pre- and post-module quizzes? It is encouraging that the observer noted that “the groups with the SIME tutors were more engaged and enthusiastic with more verbal participation”. It would be useful for the readers to know how these were assessed given the subjectivity. Besides, there could also be personal bias as I presume the observer knew who the SIME tutors were. How was this addressed? More in-depth discussion on the barriers to peer teaching and lessons learned would benefit the readers.
Alexander Woywodt - (29/10/2019) Panel Member Icon
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This article caught my eye. Many Medical Schools and teaching hospitals consider ways to teach undergraduates basic ultrasound techniques. While the rationale of doing this is very convincing the implementation remains difficult. This study reports peer teaching of basic ultrasound by students who have been trained up themselves. I have some reservations about this article. I agree with the previous reviewer that the results are not very clearly presented. It would also help to report the actual quiz questions that were used to test the students. More detail would help understand what was done there, for example the length and topics of sessions, percentage of hands on time for learners and ultrasound equipment used. I am also not sure that from using a relatively basic quiz one could conclude that trained students are as good as teachers in basic ultrasound as seasoned sonographers or radiologists. I have chaired renal ultrasound courses for a number of years in the past and my experience has always been that particularly early on hands on teaching by an experienced sonographer is invaluable. I would like to see more detail to convince me otherwise.
Megan Anakin - (28/10/2019) Panel Member Icon
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Thank you for submitting this article about peer-teaching clinical ultrasonography. This article caught my interest because at my medical school, we are grappling with how to teach clinical ultrasonography efficiently and ethically across our undergraduate medical programme. The idea to train peers as teachers can be a solution to address the challenge of involving busy, and often limited numbers of clinicians in teaching clinical skills to medical students. The study summarised in this brief article had three aims and the methods described outline them sufficiently. At present, the results are incomplete because the results of the t-test are not reported and the qualitative results are not clearly introduced to the reader. The authors may wish to consider improving how the results are reported by organising the results with subheadings that align to the three aims. This will help the reader better understand the merit of this article and to interpret the significance of the results. Despite these limitations, this article addresses a topic that will be of interest to medical educators and other healthcare professionals.