Medical Science Educator © IAMSE 2011 Volume 21(4) 316

MEDICAL SCIENCE EDUCATOR The Journal of the International Association of Medical Science Educators Med Sci Educ 2011; 21(4): 316-319

SHORT COMMUNICATION

Evaluating the Utility of Peer-Assisted Learning in Pediatrics

Pradip D. Patel, Dan B. Kischnick, Scott G. Bickel, Craig H. Ziegler& Karen Hughes Miller University of Louisville School of Medicine, Louisville, KY, USA

Abstract Peer-assisted learning (PAL) is the signature teaching/learning strategy for training young physicians. This study reports on a PAL program held during the third-year pediatric clerkship. Respondents felt PAL was useful. A senior elective incorporating PAL is now an official course. PAL is an effective adjunct to traditional teaching methods.

Introduction Peer assisted learning (PAL) is a process by which students at a similar level of training, who are not trained educators, aid each other in learning. The suggested benefits of such systems derive from learning environments with few social or hierarchical barriers to engagement where material is delivered by a teacher who still views it through the lens of a student.1,2 Social and cognitive congruence between teacher and student allow for open exchanges between instructors and learners, and learners feel less inhibited about asking questions, engaging in discussion, and challenging the discussion leader.1,2 This fosters a more active learning approach and allows students to take ownership of delivered material.

PAL is the signature pedagogy of training young physicians.1 It has been used to positive effect to teach students clinical exam skills, technical skills, during problem-based learning sessions,8,9 and in the gross anatomy laboratory. 3-7,10-12 The majority of reported applications of PAL have taken place in the pre-clinical years.1 However, there is growing evidence that PAL can be equally effective during the clinical years of training.4,9,13

The purpose of this study was to design and evaluate a PAL program for third-year students

during their pediatric clerkship that would assist them in preparing for their National Board of Medical Examiners “shelf” exam. Four tutors were selected from rising fourth year medical students interested in pediatric medicine. These tutors, with the aid of the clerkship director, identified several topics of interest that were not covered by the existing curriculum. Tutors then compiled a set of exam style questions on these topics in three computer-based presentations. All 149 students rotating through Pediatrics were given the opportunity to attend any or all of the PAL session offered during their block. Attendance was voluntary and students were not required to prepare for the discussion topics.

Three 1-hour long group sessions, consisting of approximately 15 questions, were offered by the PAL team. Attendees were separated into teams of 3-4 students with peer tutors as proctors, reading each question and providing time limits for response. Students discussed questions in teams and provided a consensus answer via an audience response system. After each question the peer tutors would discuss all answer choices and answer any additional questions. Although each question covered only one topic of interest directly, related topics of interest were covered during post-question discussions. No faculty members were present during any of the PAL sessions to maximize participant comfort and anonymity in attendance. Corresponding author: Pradip D. Patel, MD Professor of

Pediatrics, Associate Vice Chair for Pediatric Medical Education, University of Louisville Pediatrics-Broadway 230 East Broadway Louisville, KY 40202, USA Tel: +1-502629-8901 Fax: +1-502852-8866 Email: pradip.patel@louisville.edu

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Prior to beginning the rotation, each student was asked to fill out a 5-point Likert-scale survey on the PAL project. The five point Likert-scale was anchored with “Strongly Disagree” and “Strongly Agree”. The survey contained questions regarding demographic information, level of anxiety, expectations of personal performance, study preferences, feelings about PAL, and attendance expectations for tutoring sessions. Students were provided with a similar survey during their rotation debriefing. One hundred and forty two (out of a total of 149) students responded to the pre survey and 116 responded to the post survey. Neither pre- nor post-surveys contained any identifying information and all responses were anonymous. All students were informed that the data from these surveys would be used for evaluation of the PAL sessions and for possible publication, and students were provided the right to refuse participation.

All data were analyzed using SPSS (SPSS, 2010) version 19.0. Data comparing the pre-survey with the post-survey was analyzed using the Mann-Whitney U statistics due to the nonnormality of the data. All p-values were two-tailed. Statistical significance was set by convention at p<0.05. This study was deemed exempt by the University of Louisville IRB (10.0669).

Several responses reached statistical significance. Detailed responses to the Likert questions are provided in Table 1. Notably, both the perception of the usefulness of group study (p=0.001), as well as, the usefulness of the PAL program (p=0.01) show statistically significant increases. These results indicate that students found value in the program.

Students indicated at the start of their Pediatrics rotation that they planned, on average, to attend 2.6 out of three voluntary sessions. Seventy-five percent estimated they would attend all three. Self-reported PAL attendance indicated that students tended to utilize fewer PAL sessions (M = 1.96, SD=1.12) than they initially planned (M=2.6, SD=0.74), p<0.001. Sixty-eight percent reported attending at least two sessions.

When asked about from whom or where advice was sought, students were significantly less likely to seek advice from internet message boards (p<0.001) and fellow students (p = 0.04), and more likely to seek advice from ‘no one’ (p<0.001). While there was not a statistically significant increase in those seeking advice from upperclassmen, this can be explained by the pre-score already being 97%. By comparison, the statistically significant decrease in those seeking advice from message boards also seems to confirm

the value of face-to-face tutoring. We speculate that a temporal response may have been responsible for the increase in students seeking advice from “no one.” If the question on the post-survey was interpreted by students as strictly applying to the pediatric exam, then there might no longer be sufficient time to seek out advice from other sources.

Students were also polled on their interest in pediatrics as a career. While pediatric interest improved from 36% to 44%, there was no overall significant change (p = 0.85) between pre- and post-surveys.

Paradoxically, students reported a significant decrease in their shelf score expectations from the pre-survey (administered eight weeks prior to the exam) compared to post-survey, which was administered just days before the exam (p<0.001) Likewise, anxiety levels showed a significant increase (p<0.001) between the two surveys. We anticipated that exposure to shelf-style questions, coverage of high-yield information, and modeling successful approaches to questions would lead to reduced test anxiety and higher expectations. In retrospect, the results appear related to the timing of the surveys. Regardless of the positive effects of the PAL sessions, students may have had elevated test anxiety and perhaps more realistic (or even pessimistic) score expectations after having realized the breadth of content to be covered on the swiftly approaching shelf exam.

We speculated that after the PAL sessions, a higher number of students would have a method for shelf style questions and a plan for shelf preparation. While both categories showed increases, neither reached statistical significance. A surprisingly large proportion were unsure about or denied having a method for study (pre, 44%, post, 35%) or method for answering shelf questions on both pre- and post-surveys (pre, 36%; post, 28%). These numbers may be the result of definitional incongruence between survey authors and survey takers. Though, in writing the survey question the authors considered any set goal for study to fit the definition of a “method”, such a definition was not explicit in the questionnaire.

When considered together, increases in agreement scores pre- and post- session for: (1) discussing questions in a group setting, (2) seeing cross-peer tutoring as useful, and (3) the high favorability for upperclassmen as sources of advice and for group study make a strong argument for the continuing and increasing use of programs of this nature.

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Disagree Neutral Agree Mean SD p-value

Q1 Pediatrics Interest Pre 21.1% 43.0% 35.9% 3.28 1.09

0.845 Post 30.2% 25.9% 44.0% 3.21 1.34

Q2 I expect to do well on the

pediatric shelf exam

Pre 0.0% 10.6% 89.4% 4.11 0.55 p<0.001

Post 5.2% 29.3% 65.5% 3.72 0.73

Q4 I am anxious about the shelf

exam

Pre 22.5% 31.7% 45.8% 3.29 0.93 p<0.001

Post 10.3% 19.0% 70.7% 3.72 0.87

Q5a I seek Advice from Faculty Pre 28.2% 22.5% 49.3% 3.18 1.03

0.342Post 26.7% 33.6% 39.7% 3.09 0.90

Q5b I seek Advice from

Upperclassmen

Pre 0.7% 2.8% 96.5% 4.51 0.59 0.732

Post 0.9% 0.9% 98.3% 4.50 0.57

Q5c I seek Advice from Fellow

Students

Pre 28.9% 7.7% 63.4% 3.49 1.45 0.039

Post 31.9% 12.1% 56.0% 3.25 1.21

Q5d I seek Advice from I-message

boards

Pre 37.3% 15.5% 47.2% 3.15 1.29 P<0.001

Post 54.3% 23.3% 22.4% 2.44 1.16

Q5e I seek Advice from no one Pre 62.0% 15.5% 22.5% 2.26 1.21

p<0.001Post 31.0% 10.3% 58.6% 3.25 1.44

Q6 Have Plan for Study Pre 18.3% 25.4% 56.3% 3.44 0.96

0.147Post 13.8% 20.7% 65.5% 3.62 0.85

Q7 Have method for shelf

questions

Pre 12.0% 23.9% 64.1% 3.59 0.82 0.152

Post 6.9% 20.7% 72.4% 3.74 0.71

Q8 Group setting Useful Pre 9.2% 27.5% 63.4% 3.63 0.82

p=0.001Post 6.0% 16.4% 77.6% 3.95 0.80

Q9 PALP Useful Pre 0.7% 29.1% 70.2% 3.91 0.73

0.010 Post 0.9% 11.2% 87.9% 4.14 0.63

Table 1: Summary of Responses to Likert Scale Questions. One hundred and forty two (out of a total of 149) students responded to the pre survey and 116 responded to the post survey. Responses may not add up to 100% due to rounding.

Additional anecdotal evidence is provided by the large number of students who volunteered to continue the pediatric PAL sessions for the Class of 2012. Currently, the PAL program is entering its third year with similar ratings of usefulness and high attendance. One past participant along with her clerkship director used the pediatric PAL course as a model for the implementation of a sister course in the Obstetrics and Gynecology clerkship. After discussions with the Associate Dean for Medical Education, senior students facilitating the PAL sessions will receive elective credit beginning with

the 2011-12 academic year via a Medical Students as Teachers elective. Furthermore, the Senior Associate Dean for Student Affairs has stated that PAL programs should be developed in all third-year clerkships based on the pediatric PAL course.

This study suggests that PAL can be an effective adjunct to traditional teaching methods in the clerkship years. Additional long-term studies of PAL programs during the clerkship years could provide insight into the utility of these instructional opportunities.

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Notes on Contributors PRADIP D. PATEL, MD is Professor of Pediatrics and Associate Vice Chair for Pediatric Medical Education at the University of Louisville Pediatrics-Broadway, Louisville, KY, USA. DAN B. KISCHNICK, MD, is a Pediatric House Staff Officer at University of Louisville School of Medicine, Louisville, KY, USA. SCOTT G. BICKEL, MD, is a Pediatric House Staff Officer at University of Louisville School of Medicine, Louisville, KY, USA. CRAIG H. ZIEGLER, MA, is a statistician at University of Louisville School of Medicine, Louisville, KY, USA. KAREN HUGHES MILLER, PhD, is the Director for Graduate Medical Education Research at University of Louisville School of Medicine, Louisville, KY, USA.

Keywords Peer assisted learning, near peer education, tutoring in clerkships

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