MEDICAL EDUCATION

Reciprocal Peer Teaching:Students Teaching Students in the Gross Anatomy Laboratory

AARON J. KRYCH,1 CRYSTAL N. MARCH,1 ROSS E. BRYAN,1 BEN J. PEAKE,1

WOJCIECH PAWLINA,2 AND STEPHEN W. CARMICHAEL2*

1Mayo Clinic College of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota2Department of Anatomy, Mayo Clinic College of Medicine, Rochester, Minnesota

Three common instructional strategies used to teach gross anatomy are lecture, discoveryor inquiry-based learning, and cooperative learning. One form of cooperative learning,called reciprocal peer teaching (RPT), illustrates circumstances where students alternateroles as teacher and student. By assuming the responsibility of teaching their peers, stu-dents not only improve their understanding of course content, but also develop communi-cation skills, teamwork, leadership, confidence and respect for peers that are vital todeveloping professionalism early in their medical careers. Traditionally in our Anatomydepartment, students dissect the entire body using a standard dissection manual. More non-traditionally, however, we have increased cooperative learning in the dissection laboratoryby involving students in a series of supplementary RPT activities. During these exercises,10% of the class practiced their demonstration with course instructors until the studentsfelt prepared to demonstrate the exercise to their classmates. We designed one peerdemonstration emphasizing three to six teaching objectives for most of the 40 dissectionunits. This resulted in a compendium of peer demonstrations for implementation through-out the course. The multitude of diverse exercises permitted each student many opportu-nities to teach their peers. A debriefing questionnaire was administered at the end of thecourse demonstrating that 100% of students agreed the RPT experience increased theirunderstanding of the topics they taught and 97% agreed it increased their retention ofinformation they taught to their peers. In addition, 92% agreed that RPT improved theircommunication skills, which can be applied beyond anatomy to their careers as future phy-sicians. Clin. Anat. 18:296–301, 2005. ' 2005 Wiley-Liss, Inc.

Key words: medical education; professionalism; tutoring; cooperative learning

INTRODUCTION

Peer teaching has been used in classrooms for

many centuries. The Roman philosopher, Lucius

Annaeus Seneca (4BC–AD65), advocated cooperative

learning through such statements as, ‘‘Qui Docet

Discet,’’ or ‘‘Those who teach learn’’ (Johnson et al.,

1998). Although in existence for thousands of years,

peer teaching is an underutilized, yet highly valuable

resource for higher education.

Three common instructional strategies used to

teach Anatomy are lecture, discovery or inquiry-

based learning, and cooperative learning (Jensen,

1996). Research has shown that cooperative learning,

such as pairing senior and junior students, provides

psychological support and aids professional and per-

sonal development (Walker-Bartnick et al., 1984).

Allen and Boraks (1978) first proposed the term reci-

procal peer teaching (RPT) to illustrate circum-

stances where students alternate roles as teacher and

student (Allen and Boraks, 1978). They found that

*Correspondence to: Dr. Stephen W. Carmichael, Department of

Anatomy, Mayo Clinic, Stabile 9-38, Rochester, MN 55905.

E-mail: carmichael.stephen@mayo.edu

Received 27 March 2004; Revised 8 August 2004; Accepted 2

September 2004

Published online inWiley InterScience (www.interscience.wiley.com).

DOI 10.1002/ca.20090

VVC 2005 Wiley-Liss, Inc.

Clinical Anatomy 18:296–301 (2005)

elementary students who were involved with RPT

had significantly greater reading achievement as

compared to elementary students who were taught

by college students trained to diagnose reading diffi-

culties. Despite this convincing argument for RPT,

few quality studies of peer teaching by students of

the same educational level have followed (with the

notable exception of Hendelman and Boss, 1986).

The bulk of peer teaching remains traditional, with

junior students learning from their senior colleagues

(Topping, 1996). Such traditional tutorials have been

successfully utilized among medical students in the

United States for some time (Escovitz, 1990).

Despite the fact that RPT (junior students teaching

each other) has been shown to be more successful

than traditional teaching methods in some gross

anatomy laboratory settings (Nnodim, 1997), imple-

mentation of RPT is exceedingly rare.

We propose that RPT can have a similar, if not

greater, impact in medical education for the follow-

ing reasons. First, RPT is a form of active learning.

Second, RPT increases collaboration among same-

class peers. Third, implementation of RPT plays an

important role in teaching professionalism in early

medical education. It fosters development of profes-

sional skills such as communication and oral pre-

sentation, teamwork, decision making, leadership,

confidence, and respect for peers.

To this end, RPT was introduced to the labora-

tory portion of the Gross Anatomy course as a form

of cooperative learning for first-year medical students

at the Mayo Clinic College of Medicine in 2000 and

a compendium of RPT exercises was created subse-

quently.

The purpose of the current study was to examine

the acceptability of RPT in learning both anatomical

concepts and career-long communication skills and

provide Anatomy educators with a resource of RPT

exercises to use for cooperative instruction and to

supplement lecture and dissection sessions.

MATERIALS AND METHODS

Teaching Demonstration

Before dissection, students received an interactive

lecture covering the anatomy to be dissected in the

laboratory that day. In the gross anatomy lab, stu-

dents used a standard dissection manual (Sauerland

and Sauerland, 1999) as a guide for their daily dis-

sections. As a supplemental exercise, small groups of

students were selected to conduct a demonstration

for their classmates in the laboratory. Previous years’

trials have shown that having approximately 10% of

the class (four students or one dissection table)

demonstrate the exercise to their 40 other classmates

facilitates optimal teaching (total class, n ¼ 44). The

group of demonstrators practiced selected exercises

with faculty until the students were comfortable

with the three to six points to be presented, usually

illustrating anatomical structures and function on a

prosected cadaver, skeleton, or 3D plastic model.

The demonstrators circulated in pairs throughout the

laboratory until all dissection groups had been ade-

quately taught. In this way, each demonstrator

repeated the exercise three to four times. A faculty

member or teaching assistant was present during the

presentations to serve as a resource. Once the teach-

ing group completed the exercise, they resumed the

dissection assignment for the day.

Assessment

A 13-item debriefing survey was administered at

the end of the course that utilized a 5-point Likert

scale. Students were asked to select strongly agree,agree, unsure, disagree, or strongly disagree for a series

of statements regarding their attitudes toward their

RPT experience. In addition, several open-ended

questions requested feedback on the students’ per-

ceptions of the benefits and setbacks of their RPT

experiences.

RESULTS

We designed 33 RPT exercises that emphasized

the importance of visual aids in learning. An exam-

ple of one of the student-taught exercises is the

demonstration of the latissimus dorsi during the

Superficial Back dissection unit. Using one of the stu-

dent learners as a model, the peer teacher approxi-

mates the muscle and its attachment to the

intertubercular groove of the humerus by standing

behind the learner and grasping the medial aspect of

the student learner’s arm. By encouraging the lear-

ner to contract the latissimus dorsi, the teacher

demonstrates adduction of the arm around the ante-

rior-posterior axis, extension of the arm around the

transverse axis, and medial rotation of the arm

around the vertical axis. This exercise emphasizes

the importance of visual understanding, rather than

rote memorization. A complete compendium of the

exercises used in the dissection laboratory can be

found in the Appendix.

Of 44 students, 38 (86%) completed the debrief-

ing questionnaire. Figure 1 shows students’ percep-

297Reciprocal Peer Teaching

tions of peer teaching. In general, students had a

positive experience with RPT, affirming its accept-

ability within the anatomy course.

Overall, 100% of students agreed that RPT

increased their understanding of anatomy concepts

as teachers and 92% agreed that it increased their

understanding as learners. Ninety-seven percent of

students agreed that RPT increased long-term reten-

tion of their teaching topic. More specifically, when

students assumed the role of teacher, 82% stronglyagreed that RPT increased understanding and reten-

tion of anatomy topics. Sixty-eight percent felt that

their retention as learners was increased; 8% dis-

agreed, and the remaining 21% were unsure. Com-

pared to the teachers, less students as learners

strongly agreed to increased understanding and reten-

tion of information presented to them (18% and

13%, respectively). We demonstrate a significant

difference (P< 0.05, t-test: two-sample assuming

unequal variances) in Likert scale values between

the roles of teacher and student in both understand-

ing and retention of the material presented during

RPT sessions (Fig. 2). This suggests that assumption

of the teacher role helps students acquire and retain

more complete knowledge and comprehension of

course content.

The students’ perception of skills acquired during

RPT also demonstrates the merits of its implemen-

tation in the anatomy course. Eighty-nine percent of

students agreed that teaching their peers during dis-

section laboratory helped to develop their teaching

skills, 92% believed they acquired improved commu-

nication skills, and 84% believed RPT increased

integration of anatomic terms into their vocabulary.

These data indicate that students, from their per-

spective, have gained valuable interpersonal skills

applicable beyond the dissection laboratory into

other medical school courses and throughout their

careers as physicians. Forty-seven percent agreed

that skills obtained during RPT would translate into

an increased ability to communicate with future

patients; 45% were unsure of the benefits to future

patients. These figures are highly appropriate, given

that these are first-year students not yet exposed to

significant patient contact.

Student responses to open-ended questions asked

in the debriefing survey are summarized in Figure 1.

DISCUSSION

In this study we have proven the acceptability of

RPT, and provided fellow anatomy educators with a

concrete resource of RPT exercises to supplement

existing curricular activities and teaching methods.

Previous studies have used peer teaching to demon-

strate dissections or as a way to learn anatomy as an

alternative to personal dissection (Hendelman and

Boss, 1986; Nnodim, 1997; Yeager, 1996; Johnson,

2002). We believe there is no substitute for personal

cadaver dissection, as it is necessary to establish the

primacy of the patient, learn the basic language of

medicine (Aziz et al., 2002), and practice medicine

safely (Auer and McDonald, 2003). Rather, we pro-

pose that RPT be used to enhance dissection

through understanding, rather than memorization of

anatomy.

Our study indicates the many positive outcomes

of RPT, and we propose that RPT may be further

optimized in the following ways. For students feel-

ing anxious about finding an effective balance of

time between lecture, dissection, and RPT exercises,

or finding it challenging to learn, assimilate, and

teach new material all in the same day, RPT can be

improved by allowing students more time to prepare.

Hendelman and Boss (1986) devised a successful

system in which peer teachers received their assign-

ments 48–72 hr before lab session. Giving student

Fig. 1. Student responses to debriefing questionnaire.

298 Krych et al.

demonstrators more time for preparation improves

the efficiency of their presentation, the quality of

the information presented, and the confidence in

their demonstrations. Of note, we already made a

conscious effort to defer RPT exercises on dissection

days that were long, such as when visiting surgeons

did their own demonstrations or presented clinical

correlation cases.

Another notable recommendation made by the

students is preparing review sheets with the three to

six objectives for each RPT exercise. Although stan-

dardizing the material learned by each group is

important, we caution against compromising indivi-

dualization of the peer demonstrations. One of the

advantages of RPT is the freedom to respond to the

cognitive and affective needs of medical students,

thereby tailoring a more effective educational experi-

ence (Schaffer et al., 1990).

In addition to the value of RPT in anatomic edu-

cation, the experience of creatively teaching others

and working with others to present material is a

valuable skill for budding physicians to acquire. For

example, the pterygopalatine fossa was one of the

best received demonstrations. In this case, given that

an exercise was not planned for that day, students

took the initiative to develop their own teaching

activity. It has been advocated that medical educa-

tors be forward-thinking and implement systems to

help medical students acquire relevant teaching

skills (Jolly and Rees, 1998), which will prepare

them for teaching roles as residents and physicians

(Pasquale and Pugnaire, 2002). We show that RPT

can be implemented as a well-accepted supplement

to the anatomy course, and promotes early acquisi-

tion of teaching skills by medical students. A signifi-

cant majority of students agreed that their teaching

Fig. 2. Questionnaire results: percentage of perceived advan-

tage of RPT. The bars indicate the sum of strongly agree and agree

answers. The numbers to the right of the bars in teacher vs. learner

role represent the mean Likert score for each category. There is a

significant difference between these Likert values for comparing tea-

cher vs. learner role (P< 0.05, t-test: two-sample assuming unequal

variances).

299Reciprocal Peer Teaching

and communication skills were enhanced and they

felt better trained to communicate with patients.

Students learn oral presentation proficiency through

trial and error, and RPT provided the opportunity

for students to improve the effectiveness of their

oral presentations, which will become important dur-

ing their clinical years (Haber and Lingard, 2001). In

addition, students are also taught skills necessary for

professionalism such as teamwork, decision making,

and leadership. We submit that this may translate

into better doctor-patient interactions, as well as

encouraging more effective future physician educa-

tors. We prove that ‘‘Qui Docet Discet’’ is true in

the anatomy setting and highly recommend RPT for

integration into medical school curricula within and

beyond anatomy courses.

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