Teaching clinicalexamination using peer-assisted learning amongstgraduate-entry studentsJon M. Dickson, Macmillan Palliative Care Unit, Northern General Hospital, Sheffield, UKRichard Harrington, Department of Primary Health Care, Medical Sciences Division, TheUniversity of Oxford, UKMichael J. Carter, Department of Tropical Medicine, Centre for Clinical Vaccinology andTropical Medicine, University of Oxford, UK

SUMMARYBackground: We ran a peer-assisted learning programme forteaching clinical examinationamongst graduate-entry medicalstudents. We had three objec-tives: (1) to provide a forum forusing peer-assisted learning todeliver the medical schools’ clin-ical examination curriculum usingthe techniques of deliberatepractice; (2) to obtain feedbackon the programme using thenominal group technique; (3) touse the feedback to provide ameans of improving the pro-gramme in subsequent years.

Methods: The syllabus was basedon the medical school’s firstyear curriculum for clinicalexamination, and was drawn-upby one of the faculty members.The peer tutors were given alarge degree of autonomy to runthe programme as they thoughtbest. At the end of the pro-gramme we used the nominalgroup technique to generatefeedback.Results: Final-year graduate-en-try students are capable of or-ganising a high-quality peer-assisted learning programme toteach clinical examination based

on the medical school’s curricu-lum.Discussion: The nominal grouptechnique provided an excellentmethod of generating structuredfeedback from the peer tutees,which required minimal resourcesand only a few hours of inputfrom a neutral facilitator. Thefeedback session generated 14specific suggestions for improv-ing the programme in futureyears. These suggestions will bepassed on to the peer tutors fornext year, and in this way thefeedback cycle is engrained inthe programme.

Final-yeargraduate-entry

students arecapable of

organising ahigh-quality

peer-assistedlearning

programme

Clinicalskills

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INTRODUCTION

Peer-assisted learning

[Peer-assisted learning] ispeople from similar socialgroupings who are not pro-fessional teachers helpingeach other to learn andlearn themselves byteaching.1

Peer-assisted learning (PAL)is used widely to teach medicalstudents, and there is evidencethat it is popular amongst tutorsand tutees.2,3 Specific advanta-ges of PAL are empathy amongststudents who are at similarstages in their education,4 pro-viding role models,5 and provid-ing diverse teaching methodsand extra teaching capacity.6

Teaching, training and apprais-ing are requirements set out inGood Medical Practice, and PALprogrammes provide opportuni-ties for medical students tolearn and to demonstrate theseskills. Graduate-entry studentsbring a wide range of experi-ences and skills from their pre-vious degrees or careers, andmay be especially suited to thistype of learning.7

Despite the potential advan-tages of PAL and its widespreaduse in UK medical schools, thereare relatively few full-lengthpapers describing its use andthere are none specifically lookingat graduate-entry students.3 Thislack of data makes it difficult tolearn from the experiences ofother groups, and may impairprogress towards an evidence-based approach to PAL. Studentshave very limited training inteaching methods, and a rela-tively small medical knowledge-base, so it is important to haverobust processes for assuring thequality of teaching. PAL pro-grammes should include a processof feedback and reflective learn-ing so that concerns amongsttutees are properly taken intoaccount.

‘Deliberate practice’Clinical teaching is delivered bybusy doctors, some of whom mayhave little formal training inteaching methods.3 It is oftengiven within the workplace, andlearning opportunities may bead hoc and fleeting. Much ofmedical training is ‘on the job’, sosome of these problems areunavoidable, but research hasrepeatedly shown that a struc-tured approach to learning, or‘deliberate practice’, leads to fas-ter and better acquisition ofclinical skills than unstructuredlearning.8–10 Box 1 lists the keyelements of deliberate practice.

Nominal group techniqueThe nominal group technique(NGT) is increasingly used in theassessment of educational coursesin medicine and elsewhere.11 Theprocess begins by using openquestions for initial qualitativefeedback before incorporatingthese responses into a quantita-tive framework. The NGT providesmany advantages over standardstructured feedback forms, suchas allowing individual autonomywhilst working towards groupconsensus, providing a means ofincorporating unexpected pointsof view, which may transpire to bewidely held, requiring only amodest time commitment from

the facilitator, and allowingstructured feedback to occursimultaneously with exchangeand development of ideasamongst group members. Allthese attributes make it especiallysuitable for innovative courseswhere feedback is likely to bediverse and unexpected.

ObjectivesWe ran a small pilot of cross-yearPAL in clinical examination onthe graduate-entry medicalcourse at our medical school.12

We then introduced a formalprogramme across the whole yearwith three specific objectives,which are listed in Box 2. Wereport our results and experi-ences here.

METHODS

OrganisationThe programme was run by one ofthe final year tutors (JMD), wholiaised with the deputy director ofthe graduate-entry course (RH).RH drew up the syllabus, whichwas based on the first-year cur-riculum for clinical examination.This ensured that the learningobjectives were congruent withthose of the medical school. Allother aspects of the teachingprogramme, such as the schedul-ing of the tutorials, the content

Box 1. The key elements of deliberate practice

• Supervision and detailed feedback

• Well-defined tasks aimed at improving specific aspects of performance

• Ample opportunities to improve performance gradually by repetition of tasks

This is not feasible all of the time, but it should be an aspiration of all goodclinical educators.

Box 2. The objectives of the programme

• Provide a forum for using peer-assisted learning to deliver the medicalschools’ clinical examination curriculum using the techniques of ‘deliberatepractice’

• Obtain feedback on the programme using the nominal group technique

• Use the feedback to provide a means of improving the programme in sub-sequent years

Peer-assistedlearning is usedwidely to teachmedicalstudents, andthere isevidence that itis popularamongst tutorsand tutees

� Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 8–12 9

of the tutorials and the method ofteaching, were deliberately keptindependent of the medicalschool so that the participantsfelt that they had ownership ofthe programme.

All 30 final-year students werecontacted with a request to vol-unteer as peer tutors, and 10agreed to take part. All 25 first-year students were then con-tacted with an outline of theplanned teaching programme, andall 25 students volunteered totake part.

TeachingPAL tutorials began straightafter the tutors had completedtheir medical finals in January,and they continued for13 weeks. The cohort of 25tutees was split into five groupsof five, and each group wasallocated two tutors. Each grouphad one tutor for the first halfof the programme and anothertutor for the second half of theprogramme. The tutors wereasked to aim for weekly tutori-als, which lasted 1–2 hours andwhich were on a topic agreed bythe group in advance. Figure 1illustrates a typical tutorial. Theonly other instructions given tothe tutors by JMD was that theyshould aim to meet the objec-tives of the first-year curriculumin a flexible manner, using thetechniques of deliberatepractice.

Feedback using the nominalgroup techniqueSeven (28%) of the tuteesattended the data-gatheringmeeting with a neutral facilitator,where the process was explained.The task consisted of respondingto three questions.

1. ‘What did you learn fromthe peer teaching sessions?’– Content

2. ‘What was good about theway the sessions were run?’– Process

3. ‘What would make thesessions better?’ – Change

The participants spent15 minutes independently writingdown their responses, which werethen read out to the group in a‘round-robin’ fashion andrecorded verbatim on a flip chart.There then followed anaudio-taped group discussion toclarify and extend these initialresponses. These were thencollated into related groups orthemes, and similar items weremerged. Finally, a consensus wasachieved on what exact wordingwould be used for each item.The students then ranked eachitem in terms of importance tothem, without discussion withother group members. Adefinitive ranked list was drawn-up based on the sums of thesevotes.

RESULTS

Organisational skillsThe quality and effectiveness ofthe programme was assessedsubjectively by a faculty member(RH). The entire programme wasdevised and implemented by thegraduate-entry students, whoshowed excellent organisationalskills. They ran the programmeindependently, occasionallytaking advice from facultymembers, and their methodsepitomised the techniques ofdeliberate practice.

Nominal group techniqueresultsThe students expressed a veryhigh degree of satisfaction withthe programme, and providedabundant positive and construc-tive feedback. The detailed resultsof the feedback are available inappendix S1 online.

End-of-year examinationresultsOne hundred per cent of thetutees passed their clinicalexaminations. This compares withan average of 96 per cent over theprevious 5 years.

DISCUSSION

Did we meet our objectives?

Objective 1These results show that final-yeargraduate-entry students are capa-ble of organising a PAL programmeto teach clinical examinationbased on the medical school’scurriculum. The autonomy theyhad from the medical schoolempowered them to produce theirown programme that was innova-tive, flexible and context specific.The essence of PAL is that the peertutors have an insight into thelearning needs of the peer tutees,which medical school staff mayhave lost.13–15 As such it is essen-tial to allow the tutors the scope todeliver the programme that they

Figure 1. An explanation of normal breath sounds during a tutorial.

The entireprogramme was

devised andimplemented by

the under-graduatestudents

10 � Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 8–12

think is best. This juxtaposition ofclear curriculum outcomes andautonomy of the peer tutees wasintegral to the success of theprogramme.

The faculty members judgedthe programme to be a success, andthe exam results suggest that itcontributed to a successful cohortof students. However this is not asufficient measure of the quality ofthe teaching given by the peertutors. Where PAL programmes aregiven in addition to the traditionalfaculty teaching there is a ten-dency to use satisfaction amongstthe students as a proxy for quality.But, it is important to remainfocused on the quality of the actualteaching and the students’ out-comes. Future studies shouldincorporate objective measuresinto their study designs.

Objective 2The nominal group techniqueprovided an excellent method ofgenerating structured feedbackfrom the peer tutees that requiredminimal resources and only a fewhours of input from a neutralfacilitator. The feedback includedthe strengths of the programme aswell as practical suggestions forimprovement. The nature of thistype of programme is that tuteeswill have very diverse points ofview, and as such a structuredfeedback form is often unsuitable.The nominal group technique

gives the flexibility to encompassunexpected issues, which mayhave been neglected in tradi-tional structured feedback forms.

Only 28 per cent of the tuteestook part in the feedback session.This may have introduced biasinto the sample. Future yearsshould aim for higher return ratesto ensure that the sample isrepresentative of the wholegroup.

Objective 3The feedback session generated14 specific suggestions forimproving the programme infuture years. Most of these wereunexpected and would not havebeen included in structured feed-back forms written by the tutorsor programme directors. Further-more, the ranking allows each ofthe suggestions to be prioritisedfor action based on the breadthand depth of feeling within thegroup on the importance of eachissue. These suggestions will bepassed on to the peer tutors fornext year, and in this way thefeedback cycle will be engrainedin the programme.

CONCLUSIONS

This paper describes a successfulPAL format for teaching clinicalexamination to first-yeargraduate-entry students using

deliberate practice. It incorpo-rates peer-tutee feedback usingthe nominal group technique,which can be integrated withinthe programme to ensure anannual cycle of feedback, reflec-tion and change. It was very wellreceived by the peer tutees, andhad minimal resource implica-tions. Our experience and theresults reported here support theidea that PAL is a cost-effectivemeans of delivering high-qualityteaching in clinical examinationamongst graduate-entry medicalstudents. Such programmes givestudents valuable experience ofteaching, as well as the chance toobserve the process of giving andreceiving feedback.

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SUPPORTINGINFORMATION

Additional supporting informa-tion may be found in the online

version of this article available athttp://onlinelibrary.wiley.com/doi/10.1111/j.1743-498X.2010.00417.x/suppinfo.

Appendix S1. Results of thenominal group technique feed-back session.

Please note: Wiley-Blackwellare not responsible for thecontent or functionality of anysupporting materials supplied bythe authors. Any queries (otherthan missing material) should bedirected to the correspondingauthor for the article.

Corresponding author’s contact details: Jon M. Dickson, 237 Springvale Road, Sheffield, S10 1LG, UK. E-mail: jon.dickson@thejce.com

Funding: We did not receive any funding for this study.

Conflict of interest: There are no conflicts of interest.

Ethical approval: The regional ethics committee (University of Oxford, Central University Research Ethics Committee) considered this

study to be an audit of ongoing assessment, and formal ethical approval was deemed unnecessary. The work was carried out in

accordance with the Declaration of Helsinki, there was no potential harm to any of the subjects, the anonymity of the participants is

guaranteed and the informed consent of all participants was obtained.

12 � Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 8–12