Peer Teaching and Computer-Assisted Learning: An EffectiveCombination for Surgical Skill Training?
Backcollaboto teacin thepose. Ctype ofadvantfacultyevaluaing in
Resucomplesuresthe aveproporknot wpeercomputer-assisted learning alone group (P 5 0.04).
Concassistebinatio 2000 Ac
Key Wing; su
1 To w
Journal of Surgical Research 92, 5355 (2000)doi:10.1006/jsre.2000.5844, available online at http://www.idealibrary.com onlusions. Collaborative learning in a computer-d learning environment is not an effective com-n for teaching surgical skills to novices.
ords: peer teaching; computer-assisted learn-rgical skill training.
Approval was obtained from the institutional review board at theMedical College of Georgia. Freshman medical students were en-rolled in the study and each was randomly assigned to either thecomputer-assisted learning alone (CALA) group or the computer-assisted peer teaching (CAPT) group. The subjects were not paid toparticipate in the study but were allowed to keep the knot tyingboard, manual, and rope when the session was complete. Bothgroups used a CAL program that has been described previously .The subjects were placed in groups of 8 to 10. Subjects in the CALAgroup interacted individually with a single computer in a speciallyhom correspondence should be addressed.
53 0022-4804/00 $35.00Copyright 2000 by Academic Press
All rights of reproduction in any form reserved.David A. Rogers, M.D.,*,1 Glenn Regehr, Ph.D., MaThomas R. Howdieshell, M.D.,* an
*Department of Surgery, Medical College of Georgia, Augusta, GUniversity of Toronto, Toronto, Ontario, Canada M5G 2C
University of Illinois at Chicago, Chic
Submitted for publication O
ground. The surgical literature suggests thatrative learning using peers may be a valid wayh surgical skills and there is a growing interestuse of computer-assisted learning for this pur-ombining this evolving technology with thisteaching would theoretically offer a number ofages including a reduction in the amount oftime devoted to this task. In this study, we
te the efficacy of a type of collaborative learn-a computer-assisted learning environment.rials and methods. We designed a prospective,ized study comparing novice learners who
llowed to work in pairs with those who workedndently in a specially equipped computer-d learning classroom. Both pretest and posttest
ents were performed by videotaping this skill.experts then evaluated the videotapes, in a
d fashion. Three different outcomes were as-.lts. Seventy-seven subjects were enrolled in andted the study. Comparison of the outcome mea-
demonstrated no between group difference inrage performance scores or posttest times. Thetion of subjects who correctly tied a squareas significantly lower in the computer-assistedteaching group when compared with the
InBarsupeby preduThisbegaassiOuradvaersturea dientiourcontskilltheextestansurgto exronmGelula, Ph.D., Karen A. Yeh, M.D.,*hitney Webb, M.D.*
gia 30912-4070; Center for Surgical Research,and Department of Medical Education,, Illinois 60612-7309
er 26, 1999
he discussion of a surgical skills curriculum,et al.  describe a transition from a faculty-
ised experience to one of self-directed learningrs. The stated motivation for this shift was tothe time commitment of the faculty surgeons.
as also one of our primary motivations when weto evaluate a potential role for computer-
d learning (CAL) in teaching surgical skills .perience with CAL suggested that there areages to this teaching environment. Many learn-mented that they enjoyed the self-directed na-
this type of session. Further, the learner can seeized representation of an expert performing themotion of the skill. Despite these advantages,earch suggested that external feedback from at expert was a major component of effectiveeaching. The report by Barnes et al.  raisessibility that peers might provide this important
al feedback but we were unable to find an in-where this idea had been tested for teachingl psychomotor skills. In this study, our goal wasine the impact of peer teaching in a CAL envi-
nt on the acquisition of a basic surgical skill.
equippepairs anning of tand fastwas vidboard ansion. Inwith onadvisedof the seposttestistered tthis survsession
The tperformwhethernot agrethe knoidentifiescale waThe facu5-point sscore, wrecorded
Data wanalyzedWindowposttestaveragetype ANtion ofbetweenproportiaverageindepenstatistic
Sevepletedgroupgenderboth grperformtively.(Tablegroup(F 5 3groupinterac
both groups improved to a similar extent on this out-come. The proportion of knots squared (Table 2) in-
se1)thof, Ppreese pbs
ione ae odif0.
54 JOURNAL OF SURGICAL RESEARCH: VOL. 92, NO. 1, JULY 2000d classroom. Subjects in the CAPT group were assigned tod each pair interacted with a single computer. At the begin-he session, the subject was instructed to tie his or her bestest pair of two-handed square knots and the performanceeotaped. The subject was then supplied with a knot-tyingd tying rope and participated in a 45-min educational ses-
the CALA group, the subjects were instructed not to interacte another. In the CAPT group, the pairs of subjects werethat they might interact only with their partner. At the endssion, the subject was given identical instructions and theperformance was videotaped. Finally, a survey was admin-o all subjects asking for their opinions about the session. Iney the subjects were asked to rate the overall quality of the
using a 5-point modified Likert scale.hree surgical faculty members reviewed each videotapedance independently in a blinded fashion. He or she recordedor not the knot was square, and, in cases where all three dide, the majority opinion was recorded. Further, the quality oft tying was evaluated using a rating scale that explicitlyd all of the actions necessary for optimal performance. Thes created by dividing the entire skill into eight distinct steps.lty member then evaluated each step of the skill using acale. The sum of these numbers was termed a performance
ith a maximum value of 32. Finally, the time for the task wasfor each successful performance.ere entered in the Paradox 8.0 database (Corel Corp.) andusing Quattro Pro 8.0 (Corel Corp.) and SPSS 9.0 for
s (SPSS, Inc). The interrater reliability of the pretest andperformance scores was evaluated using Cronbachs a. Theperformance scores were compared using a two-way mixed-OVA. The within-group comparison of the change in propor-knots squared was performed using McNemars P. The-group comparison of this outcome was compared using x2 ofons. Times for successful completion of the test and theglobal rating by the students were compared using the
dent samples Student t test. A P , 0.05 was consideredally significant.
nty-seven subjects were enrolled in and com-the study. Forty subjects were in the CAPT
and 37 were in the CALA group. Average age,distribution, and handedness were similar foroups. The reliability of the pretest and posttestance evaluation was 0.72 and 0.78, respec-
The ANOVA on the average performance scores1) evaluating the effect of the session and the
revealed a significant main effect of the session24.78, P , 0.001) but no significant effect of
(F 5 2.96, P 5 0.09) and no group 3 sessiontion (F 5 0.386, P 5 0.536) suggesting that
Group Pretest Posttest
CAPT 2.1 (1.7) 15.1 (6.2)CALA 2.9 (2.3) 16.9 (6.2)
es shown are the average performance scores, with standardns in parentheses.d significantly in both groups (McNemar P ,and comparison of the groups demonstrated
e CAPT group had a significantly lower propor-knots squared in the posttest evaluation (x2 55 0.04). No comparison of time was made in
test group because so few of the subjects couldsfully complete the task. Comparison of the av-osttest time demonstrated no significant differ-
etween the CALA and CAPT groups (15.8 vs, t 5 0.87, P 5 0.39). Thirty percent of thes in the CAPT group reported that interactingpeer was an important positive aspect of thisand no student mentioned that this was a neg-
spect of the session. The average global ratingf the session by subjects in the CAPT group wasferent from that of the CALA group (3.95 vs 4.08,83, P 5 0.40).
results do not support the concept that surgicaln be acquired using this type of collaborativeg in a CAL environment. In fact, we have dem-
ted that this type of feedback of novices cany produce worse outcomes when compared withce learner working independently. Our results
explained by examining the theories of psy-tor skill acquisition and the unique attributes ofrative learning.s been suggested that surgical psychomotor skillired in three phases . In the cognitive phase,rner grasps the concept of the skill. Once thesets are mastered, the learner then moves into thetive phase where the skill is practiced. Finally,rner moves to the autonomous phase where theperformed without cognitive input. During thetive phase, the learner compares his or her ownance with that of the expert. The difference
n these two performances is the error. Ther attains expertise when the error is minimized.structor plays an important role in both the
Group Pretest PosttestWithin-group
0.11 0.60 0.49*0.10 0.81 0.71*
-group difference 0.01 0.21**
h value shown is the proportion of the group that tied anot.
nificantly different by McNemar test.nificantly different by x2 of proportions.
cognitive and associative phases of motor skill acquisi-tion . During the cognitive stage, the instructor pro-vides the conceptual framework for the task. Duringthe associative phase, the instructor has two functions.First the instructor must assess the skill and contrastit with the expert performance . Second, the instruc-tor must communicate to the learner information aboutthe errors and prescribe steps to eliminate them .Our previous work demonstrated the importance offeedback from a content expert in obtaining the opti-mal acquisition of skill. The central question in thisstudy is: Can a peer fulfill this role in a collaborativeteaching environment?
Collaborative learning is an instructional methodthat minimizes the role of the teacher during the teach-ing session  and a potential role in medical educationhas bepeers ilaboraTherelearninthat sutype ofhave baspectmancemedicaassess10]. Fusess thhave btask. Bwork,producresultsWhileCAPTaspectproduccompa
tools must be thoroughly evaluated before they areadopted .
Traditionally, surgical training has used more ad-vanced learners to teach beginning learners . Theresults of our previous work  and this present studyindicate that the level of advancement of the teachermay be a critical element of skills instruction. If theteacher is more like a peer, then poor outcomes can beexpected.
1. Barnes, R. W., Lang, N. P., and Whiteside, M. F. Halstediantechnique revisited: Innovations in teaching surgical skills.Ann. Surg. 210: 118, 1989.
2. Rogers, D. A., Regehr, G., Yeh, K. A., and Howdieshell, T. R.Computer-assisted learning versus a lecture and feedback sem-ina175KasurActPedEdSchpleCromeBasKledenWopeeCalandformProRissurObSouJ. SRezvalNoHo
55ROGERS ET AL.: PEER TEACHING AND COMPUTER-ASSISTED LEARNINGen described . In this instance, two truly equalnstructing each other is a specific subset of col-tive learning called reciprocal peer teaching .is evidence that this type of learning is suited tog some but not all tasks . Our results suggestrgical skills training is not a task for which thislearning is well suited. The peer teachers may
een unable to sufficiently master the cognitives of the task to assess their partners perfor-. The limited information on peer assessment ofl psychomotor skill suggests that the ability toa performance is acquired with experience [9,rther, even if peer instructors were able to as-e error in their partners task, they may noteen able provide instructions for correcting theased on learners comments during our previouswe believed that working with a peer woulde a more enjoyable learning experience but our
do not provide evidence that this was true.a substantial number of the subjects in the
group noted that learning in pairs was a positiveof the session, this factor was not sufficient toe a higher overall rating of the session whenred with the CALA group.agree with others there will be a future forter-assisted learning in surgical skills trainingt believe that our results suggest that these
13.r for teaching a basic surgical technical skill. Am. J. Surg.: 508, 1998.
ufman, H. H., Wiegand, R. L., and Tunick, R. H. Teachinggeons to operate: Principles of psychomotor skills training.a Neurochir. 87: 1, 1987.die, B. K. What underlies the teaching of motor skills. Phys.
uc. 52: 119, 1995.midt, R. A. Motor Learning and Performance: From Princi-
s to Practice. Champaign, IL: Human Kinetics Book, 1991.ss, K. P., and Steadman, M. H. Classroom Research: Imple-
nting the Scholarship of Teaching. San Francisco: Josseys, 1996.ffner, J. H., and Dadian, T. Using collaborative learning intal education. J. Dent. Educ. 61: 66, 1997.od, D., and OMalley, C. Collaborative learning betweenrs. Educ. Psych. Pract. 11: 4, 1996.houn, J. G., Woolliscroft, J. O., Hockman, E. M., Wolf, F. M.,Davis, W. K. Evaluating medical student clinical skill per-ance: Relationships among self, peer and expert ratings.
c. Annu. Conf. Res. Med. Educ. 23: 205, 1984.ucci, D. A., Tortolani, A. J., and Ward, R. J. Ratings ofgical residents by self, supervisors and peers. Surg. Gynecol.stet. 169: 519, 1989.ba, W. W. Reinventing the academic medical center.urg. Res. 81: 113, 1999.nick, R. K. Virtual reality surgical simulators: Feasible but
id? J. Am. Coll. Surg. 189: 127, 1999.len, W. A. The Making of a Surgeon. New York: Randomuse, 1968.