2007; 29: 577–582

Peer-assisted learning in the acquisition ofclinical skills: a supplementary approach tomusculoskeletal system training

JOANNE BURKE1, SAEED FAYAZ2, KEITH GRAHAM1, ROBERT MATTHEW1 & MAX FIELD1

1University of Glasgow, Scotland, UK, 2University of Sunderland, UK

Abstract

Background: This study evaluates whether peer-assisted learning (PAL) can be used to improve students’ clinical examination

skills.

Methods: Four year 4 students trained in PAL techniques and musculoskeletal (MSS) examination used the Gait, Arms, Legs and

Spine (GALS) system in a five-week student selected module. These students then recruited and trained 28 second-year trainees.

Trainees were evaluated using pre/post confidence questionnaires (100 mm visual analogue scale), a course experience

questionnaire (five-point Likert scales) and end-of-year objective structured clinical examination (OSCE) scores.

Results: Baseline data from the experimental group were no different from a separate control group, but after training a

statistically significant difference in confidence levels was observed in all parts of GALS, <38 to >73 (p < 0.0001). Course experience

questionnaires demonstrated benefits in all parameters including communication skills and group work with all students

recommending PAL training. In end-of-year OSCE 93% of PAL-trained students passed the MSS examination station compared with

67% for those participating in the standard curriculum alone (p < 0.0001). Examination results for other clinical skill stations showed

no difference in performance between the two groups.

Conclusions: This study shows that PAL is a useful adjunct to MSS training, and could be incorporated into medical curricula to

enhance clinical skills.

Introduction

Higher education is increasingly using novel teaching

techniques to enhance student learning (Forster et al. 1995).

One approach is peer-assisted learning (PAL), which allows

senior students to assist their junior colleagues with teaching

and learning support and has been implemented in many

undergraduate and postgraduate programmes (Whitman 1988;

Topping & Ehly 1998). The recognized advantages of PAL are

that student trainers are often more familiar with their courses

than faculty staff, readily integrate new learning experiences

in context, and are deemed by the trainees to be more

approachable (Sheldon 1973). In addition, peer interaction is

also known to improve self-esteem and commitment to work,

and promote mutual concern amongst participants (Topping &

Ehly 1998).

The use of PAL in medical education has not been widely

reported in the literature despite several of the principles

underpinning PAL, such as gaining experience in teaching and

learning, being endorsed by the General Medical Council

(GMC 2003). Examples of where medical students are involved

directly in undergraduate training do include the acquisition

of theoretical knowledge using peer-led facilitation in

problem-based learning sessions (Sobral 1994; Steele et al.

2000; Kassab et al. 2005). In the practical clinical skills setting,

PAL has been used to assist training of physical examination,

basic life support and general clinical skills examination

(Haist et al. 1998; Perkins et al. 2002; Field et al. 2004).

This research provides quantitative and qualitative data

supporting PAL and in some reports participating in PAL has

been shown to improve examination performance, but this

has never been fully evaluated in the context of a single

clinical skill.

Previous reports have suggested that musculoskeletal

system (MSS) examination screening could be improved in

many UK medical schools (Kay et al. 2000) and assessment

of fifth-year medical students at the University of Glasgow

Practice points

. Peer assisted learning (PAL) increases undergraduate

exposure to clinical skills.

. PAL improves student trainee confidence and examina-

tion performance.

. Studies are required to compare PAL to training by

experts.

. Qualitative data are required for in depth analysis of

benefits of PAL for trainees.

. Qualitative and quantitative data are required to

investigate advantages of PAL for trainers.

Correspondence: Max Field, Education and Administration Division, University of Glasgow, Wolfson Medical School Building, University Avenue,

Glasgow G128QQ, Scotland, UK. Tel: 0141 330 8038; fax: 0141 330 2776; email: mf4a@clinmed.gla.ac.uk

ISSN 0142–159X print/ISSN 1466–187X online/07/060577–6 � 2007 Informa UK Ltd. 577DOI: 10.1080/01421590701469867

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showed that students’ confidence in their ability to take a

history and examine the MSS is lower when compared with the

other major body systems (Burke & Field 2007). This indicates

an inadequacy in training that could be improved by extra

tuition to help rectify this situation. The Gait, Arms, Legs, Spine

(GALS) MSS screen (Docherty et al. 1992), is a quick, easy to

perform and sensitive indicator of MSS problems (Plant et al.

1993). GALS has been endorsed by the British Society of

Rheumatology and is used as a basic standard training tool

for examination of the MSS for all medical students at the

University of Glasgow.

This study hypothesized that PAL could be used as an

adjunct to standard GALS training to improve students’ ability

to examine the MSS. Senior medical students chose a student-

selected module (SSM) to learn about PAL, small-group

teaching and the GALS technique to acquire the knowledge

and skills to train junior students in examination of the MSS

and the outcome of this extra training was evaluated.

Methods

Curriculum training for MSS

At the University of Glasgow, all medical students participate

in clinical skills training in the musculoskeletal system

examination beginning in year 1 when learning about the

range of joint movements. In year 2, students watch the GALS

examination (Docherty et al. 1992), and practice GALS on each

other guided by vocational studies tutors. These tutors are

either general practitioners, or hospital doctors, all with MBBS

(with or without MRCGP or MRCP). In year 3, students gain

further experience by examining patients with clinical

problems, which forms the basis for learning prior to exposure

to patients during hospital and general practitioner

attachments in years 4 and 5.

Training student trainers for PAL

The undergraduate medical curriculum includes

five-week-long Student Select Modules (SSMs) during which

students can study subjects of their own choice in more depth.

The Musculoskeletal System (MSS) PAL module was chosen by

two groups of year 4 students as one of these SSMs.

Each MSS PAL training module consisted of the following

timetable and was set in place on two separate occasions four

months apart.

. Week One : student trainers (n¼ 2) received training in

educational theory and produced a discussion paper on

PAL and small-group teaching, following a literature review.

. Week Two : under clinical supervision by an experienced

physiotherapist, trainers viewed the GALS video and

practised examination on one another to reinforce

this skill. Trainers then offered critical review of their

performance to each other while under supervision by the

physiotherapist. The student-trainers also began advertising

by email and posters and recruiting year 2 student

volunteers for MSS PAL training.

. Week Three : each student-trainer provided the first PAL

training session (for three hours) for year 2 colleagues

(n¼ 14). Before starting the training session, information

sheets were provided and written consent was obtained

from each participant to allow the use of their data in

this study.

. Week Four : each student-trainer provided the second

three-hour PAL training session.

. Week Five : a reflective dissertation discussing PAL and

detailing the year 2 student training was produced by the

trainers, and evaluated by the SSM supervisors.

Evaluation of PAL training

Before commencing PAL training, each student trainee

(n¼ 28) was given a questionnaire to evaluate his/her

confidence in his/her ability to take a history and examine

the MSS. Students were asked to indicate their level

of confidence in: MSS questions for history-taking, and

examination of the gait, upper limb, lower limb and spine

using a100 mm visual analogue scale (VAS) (Miller & Ferris

1993). In order to ascertain whether the students in this group

were comparable to the same year group an analysis of data

from students attending a foreign-language-based SSM was

assessed (n¼ 38).

Following the second MSS PAL training session, each

trainee was asked to fill out the VAS confidence questionnaire

again so that differences could be evaluated using appropriate

statistical tests. Students were also asked whether they would

recommend this PAL training module to others using yes/no

indicators. At the same time each trainee evaluated his/her

course experience using a questionnaire based on

one previously validated by Broomfield and Bligh (1998).

In order to evaluate the range of student trainee responses, as

well their views on trainers’ ability as educators, the data were

analysed by assigning each category an ordinal number

using a five-point Likert scale graded from 1 (strongly

disagree) to 5 (strongly agree).

All year 2 students (n¼ 246) undergo an OSCE at the end of

the second year, which for the two MSS PAL study groups

occurred one and five months after PAL training. This OSCE

contains clinical skills stations including one assessing

examination of the MSS, but students are not told the exact

examination content. In the MSS station students were

required to use the GALS screen to examine the gait and

lower limb. This allowed a comparison of the pass rates

obtained by student trainees who had partaken in PAL (n¼ 28)

and those who had undertaken standard curriculum training

without PAL (n¼ 218) using a chi-squared analysis.

All OSCE examiners undergo general training in

examination technique. The five OSCE examiners for the

MSS station (one for each hospital site where the examination

was held) received extra training using videos of students of

different standards. To maintain marker impartiality,

the examiners were unaware of which students had received

the additional MSS PAL training. Results in the MSS

examination were compared with those from other OSCE

clinical skills stations where extra training had not been given

(abdominal, cardio-respiratory and neurological stations).

J. Burke et al.

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This was designed to investigate whether any students

attaining high marks in the MSS station after training did so

because of the training effect and not due to a high

performance generally in all clinical skills.

Ethics

The University of Glasgow Faculty of Medicine Ethics

Committee provided ethics approval for the study.

Analysis

Statistical analyses were processed using the SPSS for

Windows� 11.5.0 statistics package, and the course evaluation

questionnaire data were analysed using a Microsoft�

Excel 2000 spreadsheet. For detailed analysis of the data

non-parametric tests were performed taking into account

whether the samples were related (Wilcoxon signed rank test)

or independent (Mann–Whitney U-test). When comparing

results for possible errors resulting from multiple comparisons,

the Bonferroni correction was applied (Perneger 1998).

Results

Demography

There were 246 students (female:male ratio¼ 65:35) in year 2

during this study. Since this PAL training SSM was set up twice,

a total of 28 (female : male ratio¼ 75 : 25) students (two groups

of 14) took the opportunity to receive additional MSS training

from their year 4 counterparts (two groups of 2). The data from

the two training groups were combined for the purpose of

analysis, as there were no statistically significant differences

in the pre-training or post-training confidence scores, course

evaluation data and OSCE results. Of the 38 control students

who attended the foreign-language-based SSM, 25 were

female, 10 male and three failed to identify their gender.

The ratios obtained are comparable to those of the year groups

at the University of Glasgow Medical School as a whole.

Confidence

Table 1 shows a comparison of confidence between students

at the start of the MSS PAL training session with that of a group

of control students undertaking an unrelated language-based

SSM. These data show that there is no significant difference in

confidence levels between the two groups of students in each

of the five parameters used in the GALS MSS examination.

However, analysis of pre- and post-training confidence

levels using VAS (see Table 1) showed an increase from 32 mm

to 73 mm for confidence in MSS history-taking when using the

100 mm VAS score (p < 0.0001). Similarly, the remaining

four parameters of GALS also increased from pre-training to

post-training, demonstrating a significant difference in all

categories (p < 0.0001 for each). There were no significant

differences between the confidence scores of female and male

students (data not shown).

Course evaluation questionnaires

The data from the course evaluation questionnaires are given

in Table 2, with the responses expressed as a percentage of

students who answered each question. All 28 students agreed

(or strongly agreed) that the PAL training module had

improved their MSS screening skills and enhanced their

confidence in their ability to screen the MSS.

When asked about their student-trainers, all the year 2

trainees agreed (or strongly agreed) that the trainers had made

the MSS training sessions interesting, provided helpful answers

to questions, offered good explanations, and perceived that

the trainers seemed familiar with the training course content.

The majority of the trainees (92%) agreed (or strongly agreed)

that the student-trainers gave helpful feedback throughout the

PAL training, and that the trainers motivated them to do their

best work.

The course evaluation questionnaire also included state-

ments relating to learning skills involved in working in small

groups (see Table 2). All of the year 2 student trainees agreed

(or strongly agreed) that the PAL training module had helped

their ability to learn. In total, 93% perceived that they could

now apply the learned principles from the PAL training to new

situations, 82% considered that PAL training had stimulated

Table 1. Results of student confidence in each of the five parameters of GALS screening for examination of the MSS in three groups ofsecond-year students.

Control group (n¼38)confidence Mean�SD

Pre-training (n¼ 28)confidence Mean�SD

Post-training (n¼ 28)confidence Mean�SD

History-taking 41�19 32�15 73� 13

Gait 49�24 34�19 85� 11

Arms 38�23 38�22 86� 12

Legs 39�21 38�23 86� 11

Spine 41�22 34�19 86� 11

All not significant All p < 0.0001

Notes: The control group (column 1, n¼38) evaluated confidence during a language-based SSM. The PAL group (columns 2 and 3, n¼ 28) assessed confidence

before and after completing the training module. Mean scores in millimetres on a 100 mm visual analogue scale.

Peer-assisted learning in the acquisition of clinical skills

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their enthusiasm for further learning, and 62% indicated that

they agreed (or strongly agreed) that the PAL training helped

them work as a team member.

All the year 2 student trainees indicated that they would

recommend the MSS PAL training module to other students.

OSCE data

In the end-of-year OSCE examinations all year 2 students

(n¼ 246) completed 11 OSCE stations. Four of the stations

assessed students’ clinical skills including the musculoskeletal,

abdominal, cardio-respiratory and neurological systems.

There were no statistical differences in the students’

performance among the five hospital examination sites

(data not shown).

The data for the PAL-trained (n¼ 28) and untrained

(n¼ 218) students for the MSS station are given in Table 3.

Of the trained students, 26 (93%) passed the MSS station,

whereas only 67% (146) of the untrained students attained a

pass. Using chi-squared analysis a significant association was

found between PAL training and a higher pass rate at the MSS

station (p < 0.005). Students were 1.5 times more likely to pass

with an odds ratio of 6.4.

By comparison, analysis of the students’ pass rates at the

abdominal system station for PAL-trained (96%) and untrained

(90%) students were not statistically different. Similarly

there were no statistical differences at the neurological and

cardio-respiratory clinical skills stations.

Discussion

To our knowledge this is the first time that peer-assisted

learning has been implemented and evaluated in an

undergraduate medical curriculum for musculoskeletal system

clinical skills training. By using PAL, year 4 students can

increase the year 2 students’ confidence in clinical examination

Table 2. Results of Year 2 students’ evaluation (n¼28) of the course experience questionnaire immediately following the musculoskeletalsystem PAL training session.a

Statement Strongly disagree Disagree Not sure Agree Strongly agree

As a trainee I

Improved MSS screening skills 0 0 0 21 79

Developed confidence to do MSS screening 0 0 0 25 75

The trainer:

Made MSS interesting 0 0 0 57 43

Gave helpful answers to questions 0 0 0 46 54

Provided good explanations 0 0 0 25 75

Was familiar with MSS contents 0 0 0 18 82

Provided helpful feedback 0 4 4 14 78

Motivated me to do my best work 0 0 0 57 43

Working in small groups:

Helped my learning 0 0 0 48 52

Helped me apply principles to new situations 0 0 7 57 36

Stimulated my enthusiasm for further learning 0 0 18 68 14

Helped me to work as a team member 0 0 38 38 24

aThese were scored on a five-point Likert scale, and are expressed as a percentage of the number of students answering each question.

Table 3. Results of OSCE from second-year students (n¼ 246) for the four clinical skills stations.a

MSS Abdominal Cardioresp Neurological

OSCE Station Pass (%) Fail (%) Pass (%) Fail (%) Pass (%) Fail (%) Pass (%) Fail (%)

PAL trained 26 (93) 2 (7) 27(96) 1 (4) 22(79) 6(21) 27(96) 1(4)

Untrained 146(67) 72(33) 198(90) 20(10) 185(85) 33(13) 196(89) 22(11)

Chi-square p < 0.005 n.s. n.s. n.s.

Notes: aStudents were divided into those that received PAL training (n¼ 28) and those that had undertaken the standard curriculum training alone (n¼218). Numbers

of students, percentages and p-values are shown; n.s.¼ not significant.

J. Burke et al.

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of the MSS and improve end-of-year OSCE performance.

This project extends previous observations (Field et al. 2004)

by using more robust, subjective and objective assessment

methods to confirm the benefits of PAL exclusively in the

context of a single clinical skill. This study therefore supports

the hypothesis that students can be successful trainers.

However, it remains to be elucidated whether extra intervention

using volunteers for PAL is comparable to training offered by an

expert teacher, but preliminary evidence shows that it is at least

equivalent (Graham et al. 2006).

Twenty-eight (11%) year 2 students volunteered for MSS PAL

training. This was undertaken as an adjunct over and above that

offered in the standard curriculum. Pre-training confidence

levels were found to be generally low across all five aspects of

the GALS examination, and were comparable with those from a

control group of students taking a language-based SSM, who

had also only undertaken the standard curriculum training. This

implies that our group of volunteers were not self-selecting

according to academic ability or a perceived weakness in this

subject and a need for extra tuition.

In each element of the GALS screen, post-training

confidence levels were significantly improved following PAL

training. In addition, data from the course experience

questionnaire showed that all 28 students agreed (or strongly

agreed) that the MSS PAL training had developed their

confidence to do MSS screening. Although these are subjective

data, they are strongly supported by the objective examination

results, which confirm that the PAL trained students were

1.5 times more likely to pass the GALS station in the OSCE

examination. This indicates that trained students are more

proficient at MSS examination after PAL training and it is

unlikely that the subjective improvement in confidence results

from the ‘Hawthorne Effect’, where participants respond more

favourably as a consequence of being monitored as part of

a research project (Campbell et al. 1995).

When comparing results from the OSCE clinical skills

stations other than the MSS (abdominal, cardio-respiratory and

neurological systems), there were no differences between the

PAL-trained and untrained students. This shows that the higher

pass rate at the GALS station (93% cf. 67%, p < 0.005) was

specific to the MSS, and not the result of trained students being

more adept at clinical skills examination across the board.

Interestingly, the two MSS PAL trainee groups undertook

training one and five months prior to the examinations but

no statistically significant differences were found in OSCE

performance between the groups (data not shown).

This demonstrates that time did not diminish the effect of

PAL when assessed using the OSCE. However, it would be

necessary to analyse the examination results for subsequent

academic years in order to fully evaluate the longer-term

effects of the PAL training.

The trainees also perceived that participating in PAL

enhanced their overall performance in a variety of parameters,

in particular their ability to work in small groups and apply

learning principles to new situations. It is more difficult to

assess these parameters objectively but these are transferable

skills that all physicians would find valuable, and in addition

are regarded as beneficial attributes for medical training by the

GMC (General Medical Council 2003). These data suggest

that there is considerable added value to PAL training, which

could be further investigated using qualitative data

derived from one-to-one discussions, focus groups or

reflective diaries.

This study did not directly address the responses of the four

trainers, because the small numbers limit detailed analysis.

However, PAL has been shown to have beneficial effects for

trainers in both subject learning and generic skills (Johnston

1996), and informal discussions with the trainers confirm that

this is likely to be the case in this study. In support, information

from the trainees’ course evaluation questionnaires showed

that trainers made the subject interesting and provided

an environment that was conducive to asking questions.

In addition, explanations provided by the trainers were

targeted to the correct level of expertise. These comments

suggest that PAL trainers effectively deliver the training and

fulfil the GMC theme of enhancing the students’ teaching

portfolio (General Medical Council 2003). Having proved

the benefit of PAL the next phase could be to integrate

this learning technique into the standard curriculum.

By incorporating PAL in this way, larger numbers of students

would be involved and data from this cohort could be

used to investigate a variety of different questions. These

could include whether PAL is as effective for trainees in

this setting, whether PAL makes the most efficient use of staff

time, and addressing whether PAL is of a similar value to

the trainers.

One strength of this study is that all four student trainers

were volunteers, a feature specifically designed for this SSM.

While this might introduce an element of self-selection,

in practice it should attract students who are interested,

enthusiastic and willing to assimilate new skills. Academic

ability and financial incentives have been used to recruit

students for PAL in other studies (Sobral 1994; Haist et al.

1998), but the aim of this project was not to use students as

unpaid teachers; rather it was to encourage mutual gain for

the benefit of trainers and trainees since this is the

optimal environment in which student learning prospers

(Wadoodi & Crosby 2002). Indeed, in an ideal situation, all

participants should be given the opportunity to build

confidence and self-esteem, reinforce experience of teamwork

and develop teaching skills as part of their development

portfolio, all of which are benefits of partaking in PAL and are

qualities endorsed by the GMC (GMC 2003).

Physicians are generally enthusiastic about teaching

medical students and junior staff, but contractual obligations

lead to pressures on time, and few clinicians have specific

training in education (Busari et al. 2002). This study confirms

that clinical skills training can be improved using PAL in

combination with the GALS technique thereby enhancing MSS

examination skills. This encourages attributes endorsed by the

GMC (Haist et al. 1998), and has the advantage of having the

students’ support. In addition, since the benefits of PAL

training have been shown to be transferable between subjects

(Topping 1996) it has the potential to be valuable for

all clinical skills. Our study and others have highlighted

the numerous benefits of PAL, which, following careful

consideration, could be a useful adjunct to medical student

training.

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Notes on contributors

JOANNE BURKE BSc (Hons), PhD, ILTM, PGDip, is a Senior University

Teacher in the Medical School at the University of Glasgow. She helps to

deliver, assess, evaluate and support undergraduate medical education.

Her interests in educational research include problem-based learning and

peer-assisted learning.

SAEED FAYEZ BScPT (Hons), MScPT, MSc, Sports Medicine, is a

Physiotherapist interested in musculoskeletal medicine and undergraduate

education. Until August 2005 he was working as Research Fellow in peer-

assisted learning at the University of Glasgow. He is now Senior Lecturer in

sports injury at the University of Sunderland.

KEITH GRAHAM BSc (Hons), MCSP, is a Chartered Physiotherapist with

an interest in musculoskeletal medicine and undergraduate education.

Up until December 2006 he was working as Research Assistant to support

research into peer-assisted learning in the undergraduate medical

curriculum at the University of Glasgow.

ROBERT MATTHEW MSc, PhD, Eur. Ing., C.Eng., MIEI, ILTM is a Professor

in the Learning and Teaching Centre at the University of Glasgow. His

interests include enhancing student learning experiences through devel-

oping student autonomy. He has worked in this area with medical and

paramedical professional as well as engineers.

MAX FIELD BSc, MD, FRCP is a Reader in Rheumatology and Medical

Education. He directs the final year curriculum at the University of Glasgow

Medical School. He has research interest in Medical Education in

Rheumatology and is Chair of the arc undergraduate education group.

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