DESCRIPTIVE ARTICLE

Use of an Audience Response System During Peer TeachingAmong Physical Therapy Students in Human Gross Anatomy:Perceptions of Peer Teachers and Students

Kevin R. Wait, Beth A. Cloud, Lindsey A. Forster, Tiffany M. Jones, Jessica J. Nokleby,Cortney R. Wolfe, James W. Youdas*

Program in Physical Therapy, Mayo School of Health Sciences, Mayo Clinic, Rochester, Minnesota

An audience response system (ARS) has become popular among educators in medicineand the health professions because of the system’s ability to engage listeners during a lec-ture presentation. No one has described the usefulness of ARS technology during plannednonlecture peer teaching sessions in gross anatomy instruction for health professionals.The unique feature of each peer teaching session was a nongraded 12–15 item ARS quizassembled by six second-year doctor of physical therapy (DPT) students and purposelyplaced at the beginning of the review session for those first-year DPT students in attend-ance. This study used a ten-item questionnaire and a five-point Likert scale in addition tothree open ended questions to survey perceptions of both first-year and second-year DPTstudents about the usefulness of ARS technology implemented during weekly interactivepeer teaching sessions during a semester course in Anatomy for Physical Therapists. First-year students overwhelmingly acknowledged the ARS system permitted each student toself-assess his/her preparedness for a quiz or examination and compare his/her perform-ance with that of classmates. Peer teachers recognized an ARS quiz provided them anopportunity to: (1) estimate first-year students’ level of understanding of anatomical con-cepts; and (2) effectively prepare first-year students for their weekly quizzes and futureexaminations. On the basis of the mutual benefits derived by both students/tutees andteachers/tutors, physical therapist educators may wish to consider using ARS technologyto enhance teaching methods for a class in gross human anatomy. Anat Sci Educ 2:286–293,

2009. © 2009 American Association of Anatomists.

Key words: audience response system (ARS); peer teaching; gross anatomy; formativefeedback; physical therapy students

INTRODUCTION

An audience response system (ARS) has become popularamong educators in medicine and the health professionsbecause of the system’s ability to engage listeners during apresentation (Copeland et al., 2000; Nasmith and Steinert,2001; Schackow et al., 2004; Streeter and Rybicki, 2006;Alexander et al., 2009). The educator can periodically display

a question using a multiple-choice or true–false answer for-mat and each member of the audience can respond anony-mously using an ARS keypad (Latessa and Mouw, 2005).Audience responses are immediately tallied and shown on thescreen in real-time providing formative feedback to thelearner regarding how well he/she understood the material.Furthermore, summative feedback regarding the class per-formance is also available to the teacher (Premkumar andCoupal, 2008).

ARS keypad technology has been used with positive feed-back among medical students (Nayak and Erinjeri, 2008;Alexander et al., 2009), medical residents (Homme et al.,2004; Schackow et al., 2004; Torbeck, 2007), physicians dur-ing continuing medical education programs (Copeland et al.,2000; Miller et al., 2003; Eggert et al., 2004; Streeter andRybicki, 2006), and nurses (Stein et al., 2006; DeBourgh,2007). Proponents of the ARS contend that the technology:

*Correspondence to: James W. Youdas, PT, MS, Program in PhysicalTherapy, 1105A Siebens Building, Mayo Clinic, Rochester, MN 55905,USA. E-mail: youdas.james@mayo.edu

Received 17 June 2009; Revised 11 August 2009; Accepted 24August 2009.

Published online 17 September 2009 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/ase.107© 2009 American Association of Anatomists

Anat Sci Educ 2:286–293 (2009) NOVEMBER/DECEMBER 2009 Anatomical Sciences Education

(1) enhances student attention and learning during a lecture;(2) motivates reluctant students to interact since responsesare anonymous; and (3) permits the presenter to rapidlyassess the audience’s knowledge, attitudes, or opinions(Collins, 2008). According to the literature, the primarysetting for use of the interactive ARS system has been aclassroom during a didactic presentation. Presently there is ashortage of information on the perceived benefits of ARStechnology during a semester course in gross anatomy whensecond-year students tutor first-year students outside thevenue of a formal didactic lecture.

Several reports have described the benefits of peer teachingduring a course in gross anatomy in the dental (Bruecker andMacPherson, 2004), medical (Yeager, 1981; Peppler et al.,1985; Yeager and Young, 1992; Nnodim, 1997; Johnson,2002, Krych et al., 2005), and physical therapy literature(Lake, 1999; Youdas et al., 2007, 2008). Nearly all the den-tal, medical, and physical therapy students surveyed perceivedpeer teaching sessions to be most helpful for learning impor-tant anatomical concepts and relationships. Peer teaching suc-cess is predicated on the belief that peer teachers (tutors) andstudents (tutees) connect more effectively than in a traditionalsetting of teachers and students (Allen and Boraks, 1978).Although perceived benefits of peer teaching have beenclearly documented for students/tutees, only a few reportshave examined the benefits of peer teaching from the view-point of the teachers/tutors. Third-year medical students atthe Mayo Clinic (Ocel et al., 2003) were surveyed about theapparent benefits of acting as teaching assistants (TAs) duringa first-year course in gross and developmental anatomy.Nearly all (97%) TAs perceived one-on-one teaching experi-ences with first-year medical students enhanced the tutors’ability to communicate with patients. More recently, four sec-ond-year doctor of physical therapy (DPT) students at theMayo Clinic (Youdas et al., 2008) served as peer teachers toa group of 28 first-year DPT students during a semestercourse in gross anatomy. Second-year DPT peer teachers pro-vided written reflections about the benefits and challenges ofacting as a peer teacher. The peer teachers acquired clinicallydesirable teaching, academic, organizational, and time man-agement skills from the experience. Presently there are noreports in the literature describing the perceived benefits ofARS technology from the viewpoint of both students/tuteesand teachers/tutors during a semester course in gross anatomythat included weekly planned peer-teaching sessions.

Our purpose in this study was two-fold: (1) to survey per-ceptions of first-year DPT students about the usefulness ofARS technology implemented during weekly interactive peerteaching sessions during a semester course in Anatomy forPhysical Therapists and (2) to describe the benefits and chal-lenges of using ARS technology during the nonlecture interac-tive sessions as perceived by second-year DPT students whoserved as peer teachers/tutors. We believe this is the onlyreport in the literature describing the effect of ARS technol-ogy during planned nonlecture peer teaching sessions in grossanatomy instruction for health professionals.

MATERIALS AND METHODS

Gross human anatomy is a foundational course in theacademic curriculum of all physical therapy (PT) programsbecause of the need for physical therapists to understand nor-mal and abnormal human motion (Mattingly and Barnes,

1994). At Mayo School of Health Sciences, Anatomy forPhysical Therapists was a six-credit semester class that meton Monday, Wednesday, and Friday for three consecutivehours per day during the 16-week fall semester of 2008. Thefirst hour consisted of a didactic lecture where the instructorhighlighted the gross anatomy and salient relationships of thestructures to be dissected during the subsequent two-hour labo-ratory session. The 28 first-year DPT students were divided intoseven groups of four students and each group assigned a desig-nated dissection table for the duration of the semester (Ellis,2001). Daily dissection instructions were provided by the in-structor and the first-year DPT students were also encouragedto consult an atlas (Netter, 2003). Typically three core PT fac-ulty members were available to answer students’ questions andassist with daily dissections. There were ten announced quizzesand four written and laboratory practical examinations overthe duration of the 16-week semester course. Generally, quizzeswere given on Fridays whereas the written and laboratoryexaminations were scheduled on a monthly basis.

Peer teaching was integrated into Anatomy for PhysicalTherapists to augment the learning of anatomical conceptsand relationships by first-year DPT students (Youdas, 2008).During the spring semester of 2008, six soon-to-be second-year DPT students approached the course coordinator andvolunteered to serve as peer teachers during the fall semesterof 2008. Each volunteer had demonstrated admirable scholar-ship and dissection skills during the fall semester of 2007when they were enrolled in Anatomy for Physical Therapists.Each peer teacher earned a course grade of at least an A-(90%) in Anatomy for Physical Therapists which confirmedexcellent cognitive skills in addition to psychomotor skillsnecessary for completing clear anatomical dissections. Fur-thermore, the course coordinator determined that each peerteacher, during his/her first-year in the Mayo DPT Program,had exhibited the requisite interpersonal and communicationskills (Jette and Portney, 2003) necessary to engage first-yearDPT students in peer teaching sessions. On completion of the16-week course each second-year DPT student tutor wasremunerated for his/her time by the Mayo Clinic PhysicalTherapy Alumni Association.

Before the 2008 fall semester began, the course coordina-tor and peer teachers met and identified dates and times forthe 13 peer teaching sessions. Attendance by first-year DPTstudents at the peer teaching sessions was voluntary and all28 first-year DPT students simultaneously attended the sameoptional review session. To accommodate the academicschedules of both first-year and second-year DPT students,the peer teachers and course coordinator scheduled weekly90-minute review sessions in the late afternoon on Thursdaybetween 3:30 and 5:00 PM. For the first-year DPT studentsthis teaching session was the final chance to ask questionsbefore the next morning’s graded quiz. Subject matter foreach peer teaching session centered on weekly course objec-tives found in the course syllabus for Anatomy for PhysicalTherapists. Having taken the course in gross anatomy theprevious fall semester, each peer teacher declared that he/shewas familiar with the peer teaching resource materials whichincluded: (1) articulated skeletons; (2) cadaveric tissuerecently dissected by first-year DPT students (Ellis, 2001); (3)anatomical atlases; (4) prosected joints; and (5) course text-books (Drake et al., 2005; Jenkins, 2002).

The unique feature of each peer teaching session was anongraded 12–15 question quiz strategically placed at the be-ginning of the review session and taken by those first-year

Anatomical Sciences Education NOVEMBER/DECEMBER 2009 287

students in attendance. Peer teachers constructed the quizusing ARS technology (Robertson, 2000) and instructionalobjectives located in the course syllabus. The inspiration forusing ARS technology as a form of peer teaching was attrib-uted to the second-year students’ limited exposure to ARSkeypad technology during year one when instructors primar-

ily used the system for polling purposes. Each peer teacherprepared two to three questions (Table 1) using a multiplechoice or true/false format one day prior to the review ses-sion. Questions were factual in nature and focused upon keyanatomical relationships covered during the most recent lec-ture and laboratory sessions. The ARS questions were writtenin the same format as the items that appeared on the nextmorning’s graded quiz. The responsibility for editing ARSquiz items submitted from each tutor was rotated on aweekly basis among the six second-year peer teachers. Onepeer tutor (K.R.W.) was responsible for formatting the ques-tions using the TurningPoint software (Turning Technologies,Youngstown, OH). During the 30-minute ARS quiz, eachpeer teacher individually provided clarification and furtherinstruction for his/her authored questions when indicated bythe response results or prompted by questions from the first-year DPT students.

On completion of the non-graded ARS quiz, first-year stu-dents received a packet assembled by the peer teachers(Youdas et al., 2008). Peer teachers did not lecture duringthis second phase of the review session, because first-yearstudents assembled in small groups of two to four students.The learning packet contained an assortment of study ques-tions prepared from class notes, textbook descriptions, or atutor’s own successful study tactic developed when he/shewas a first-year DPT student. Furthermore, concurrent with

Table 1.

Sample Question and Student Response

Which of the following muscles is not supplied by therecurrent branch of the median nerve?

Choice: Studentresponse:

1. Opponens pollicis 88%

2. Adductor pollicis

(correct answer)

69%

3. Abductor pollicis brevis 23%

4. Flexor pollicis brevis (superficial

head)

0%

Table 2.

Questions Included in the Questionnaire on the Audience Response System During Peer-Teaching and the Students’ Responses

Question

Response (percentage)

N Mean SD1 2 3 4 5

1. Using ‘‘clickers’’ during review sessions and immediately seeing the

distribution of responses and correct answers gave me confidence toverbally answer questions during small group sessions.

0 4 0 68 28 25 4.2 0.7

2. ‘‘Clicker’’ questions were clearly written. 0 4 24 56 16 25 3.8 0.8

3. Seeing the distribution of responses and correct answers during areview session allowed me to gauge my level of mastery of

lecture material.

0 0 0 60 40 25 4.4 0.5

4. Seeing the distribution of responses and correct answers during a

review session allowed me to gauge my level of mastery oflaboratory material.

1 12 16 64 8 25 3.7 0.8

5. I believe I was better prepared for the weekly anatomy quiz when

I attended a review session with ‘‘clickers’’.

4 4 24 28 40 25 4.0 1.0

6. Using ‘‘clickers’’ during the peer teaching session gave me immediate

feedback about my understanding of a concept.

0 0 0 64 36 25 4.4 0.5

7. Review session ‘‘clicker’’ questions helped me identifymisconceptions with my understanding of gross anatomy.

0 0 12 60 28 25 4.2 0.6

8. Responding to questions during peer teaching sessions using

‘‘clickers’’ facilitated interaction between students and peer teachers.

0 4 12 48 36 25 4.2 0.8

9. Responding to questions during peer teaching sessions using‘‘clickers’’ was an effective use of my time.

0 0 8 48 44 25 4.5 0.6

10. I would recommend using ‘‘clickers’’ in future anatomy peer teaching

sessions.

0 0 8 28 64 25 4.6 0.7

Rating scale: 1 5 strongly disagree; 2 5 disagree; 3 5 neither agree nor disagree; 4 5 agree; 5 5 strongly agree.‘‘Clicker’’ 5 Audience Response System (ARS) Keypad.

288 Wait et al.

Anatomy for Physical Therapists, second-year students wereenrolled in Musculoskeletal course, which necessitated theyreview anatomy to understand the rationale underlying proce-dures of orthopedic physical assessment. This reviewprompted second-year students to incorporate important ana-tomical relationships into the review session for the first-yearstudents. Review sheets promoted talking points for first-yearstudents by stimulating thought-provoking discussion of ana-tomical topics. The six peer teachers scattered among studentgroups and offered attention to individual students or groupsby answering questions, providing study tips or reemphasiz-ing key concepts. Tutors made note of first-year students whohad questions regarding specific items they had incorrectlyanswered on the ARS quiz. These students were subsequentlysought out for further individual instruction.

Perceived benefits about the usefulness of ARS technologyimplemented during 13 weekly interactive quizzes wereobtained via a structured questionnaire (Table 2) issued to allfirst-year students who attended the final peer review sessionof Anatomy for Physical Therapists during the fall semesterof 2008. Completion of the questionnaire was voluntary andanonymous. Twenty-five students (89%) completed the ques-tionnaire. In addition to ten survey items, the questionnairealso contained three open-ended questions that provided anoccasion for the first-year students to make narrativecomments about selected features of the ARS technology(Table 3). Furthermore, on completion of the course each of

the six second-year DPT students (100%) completed a ten-item questionnaire (Table 4) and responded to three open-ended questions (Table 5) that assessed the benefits and chal-lenges of using ARS technology during a nonlecture interac-tive session. This study was approved by the Mayo ClinicInstitutional Review Board.

RESULTS

Perceptions of Students/Tutees

A clear majority of first-year DPT students (question 1, 96%,by combining students who responded with ‘‘agree’’ and‘‘strongly agree’’) indicated the immediacy of feedbackprovided by the ARS technology enhanced their confidence toactively participate in subsequent small group discussionsduring the review session. A clear majority (72%) of respond-ents indicated ARS formatted questions were clearly written(question 2) and allowed them to gauge their mastery of lab-oratory/ dissection material (question 4), whereas 100%(question 3) of first-year DPT students perceived the ARSfeedback helped them estimate their personal level of masteryof lecture material. Sixty-eight percent of students (question5) believed they were better prepared for a weekly anatomyquiz when they participated in the ARS portion of the reviewsession than when they picked up a study packet and

Table 3.

Student Narrative Responses to Open-Ended Questions on Survey Instrument

Questions and comments Responses Percentage Students’ comments

1. What was the most usefulfeature about using ‘‘clickers’’

during the gross anatomy peer

teaching session?

� Immediate feedback� Stimulated class

discussion

� Answer questions

anonymously� Promoted quick thinking

6816

8

8

� ‘‘Immediately seeing the correct responsewas useful. Seeing how well I understood

the material compared to my classmates,

gave me insight into my preparedness for

an exam.� ‘‘We could ask clarification questions if

we did not understand the correct

answer.

2. What was the least usefulaspect of the ‘‘clickers’’ during

the peer teaching session?

� Sessions sometimesbecame too informal

with unnecessary chatter

by classmates

� Vaguely wordedquestions

� Need to actually see the

structures discussed byvisiting the gross

anatomy lab

56

32

12

� ‘‘Unnecessary classroom chatter wasfrustrating and impeded my learning.’’

� ‘‘Some questions were difficult to

understand and poorly/incorrectly written.’’

3. Would you recommend

continued use of ‘‘clickers’’ forgross anatomy?

Yes

No

96

4

� ‘‘I recommend the continued use of

clickers because they are a way to fosterdirect interaction between students and

peer teachers.’’

� ‘‘Clicker format is a rapid way to gauge

the information you know and theinformation you need to work on.’’

� ‘‘Peer teachers were very important, but

I am not sure about the effectiveness ofthe clickers.’’

Anatomical Sciences Education NOVEMBER/DECEMBER 2009 289

departed from the peer review session. Respondents unani-mously agreed (100%) the immediate feedback (question 6)provided by ARS technology helped them identify misconcep-tions (88%) about their understanding of an anatomical con-cept (question 7). A majority of first-year students (84%,question 8) acknowledged peer teaching sessions using ARStechnology facilitated interaction between students and sec-ond-year peer teachers/tutors. Ninety-two percent (question9) perceived sessions with the ARS to be an effective use oftheir study time, and a vast majority (92%) of first-year stu-dents recommended ARS ‘‘clickers’’ be used in subsequentanatomy peer teaching sessions (question 10).

The survey also included space for personalized comments(Table 3). First-year DPT students cited four main features ofthe ARS that contributed to their learning. One student wrote‘‘. . . seeing how well I understood the material compared tomy classmates gave me insight into my preparedness for anexam,’’ while another stated, ‘‘. . . we could ask clarificationquestions if we did not understand the correct answer.’’ Nega-tive opinions were also elicited. More than 50% of first-yearstudents thought unnecessary classroom chatter developed asstudents were responding to a particular question. Becausesome students responded more quickly than others, theslower responders alleged that ‘‘. . . classroom chatter wasfrustrating and impeded my learning.’’ Additionally 32% ofthe respondents with negative comments believed ‘‘. . . some

questions were difficult to understand and poorly/incorrectlywritten.’’ Lastly, 96% of first-year students’ recommendedcontinued use of the ARS since ‘‘. . . clickers fostered directinteraction between students and peer teachers.’’

Perceptions of Teachers/Tutors

On completion of Anatomy for Physical Therapists all sixsecond-year peer teachers (100%) completed the Question-naire (Table 4) regarding the ARS. One-hundred percent oftutors (by combining those who responded with ‘‘agree’’ and‘‘strongly agree’’) perceived the following benefits from theclicker formatted sessions: (1) allowed tutors rapid assess-ment of first-year students’ understanding of weekly peerteaching topics (question 1); (2) enhanced organization of thepeer teaching sessions (question 4); (3) promoted attendanceat the peer teaching sessions (question 5); (4) encouraged dis-cussion and stimulated interaction amongst the first-year DPTstudents and second-year peer teachers (questions 6 and 7);and (5) provided tutors insight into anatomical relationshipsthat needed additional discussion and clarification (question8). Over half of the tutors (67%) thought the first-year stu-dent response to clicker questions was helpful when preparingfuture peer teaching sessions (question 2), whereas 50% oftutors found it challenging to write questions of appropriatedifficulty using the ARS format (question 3). Finally, tutors

Table 4.

Questions Included in the Questionnaire on the Audience Response System During Peer-Teaching and the Teachers’ Responses

Question

Response (%)

N Mean SD1 2 3 4 5

1. Seeing students’ responses to ‘‘clicker’’ questions during the review

session helped me gauge their understanding of weekly peer teaching

topics.

0 0 0 50 50 6 4.5 0.6

2. Seeing students’ responses to ‘‘clicker’’ questions gave me insight into

how I might prepare for future peer teaching presentations.

0 0 33 50 17 6 3.8 0.8

3. I found it challenging to write questions of appropriate difficulty usingthe ‘‘clicker’’ format.

0 50 0 33 17 6 3.2 1.3

4. Preparing peer teaching review sessions that included ARS technology

was an effective way to organize the session.

0 0 0 17 83 6 4.8 0.4

5. I believe students were more likely to attend peer teaching review

sessions because of the ‘‘clicker’’ format

0 0 0 0 100 6 5.0 0

6. ‘‘Clicker’’ questions provoked discussion about anatomical concepts

that enhanced the peer review session.

0 0 0 67 33 6 4.3 0.5

7. ‘‘Clicker’’ questions during peer teaching sessions stimulated interaction

between students/tutees and teachers/tutors.

0 0 0 50 50 6 4.5 0.6

8. Seeing students’ responses provided insight on which topics requiredadditional discussion before peer teaching sessions could continue.

0 0 0 17 83 6 4.8 0.4

9. Writing questions using ‘‘clicker’’ format helped me review the material

in greater depth before the peer teaching session

0 0 17 33 50 6 4.3 0.8

10. I would recommend using ARS technology in future anatomy peer

teaching sessions.

0 0 0 0 100 6 5.0 0

Rating scale: 1 5 strongly disagree; 2 5 disagree; 3 5 neither agree nor disagree; 4 5 agree; 5 5 strongly agree.‘‘Clicker’’ 5 Audience Response System (ARS) keypad.

290 Wait et al.

unanimously (100%) supported using ARS technology infuture anatomy peer teaching sessions (question 10).

The survey for tutors also contained 3 open-ended ques-tions (Table 5). From their perspective the most useful fea-tures of the ARS peer teaching sessions were: (1) the abilityto identify topical areas that merited additional attention and(2) the opportunity for first-year students to answer questionsin an anonymous fashion. One tutor wrote, ‘‘. . . we couldassess the topics that needed to be reviewed in greater depth.’’On the other hand, second-year students perceived the writ-ing of conceptual questions in appropriate format to be leastuseful aspect of the clicker sessions. A tutor commented, ‘‘. . .clickers did stimulate questions and conversations about thematerial, nevertheless it is somewhat impersonal and apassive method of teaching.’’ Finally, the tutors unanimouslyrecommended the continued use of the ARS format in futureanatomy peer teaching sessions. One tutor commented ‘‘. . . itis a great way to engage students and allow them and thetutor to test their knowledge from week-to-week.’’

DISCUSSION

Perceptions of Students/Tutees

The nongraded quiz using ARS technology was the distinc-tive feature of this model of peer teaching during a semestercourse in gross anatomy for first-year doctoral students in

physical therapy. Unlike previous reports (Copeland et al.,2000; Miller et al., 2003; Nayak and Erinjeri, 2008) whichused an ARS to engage learners during a lecture, this studyutilized the ARS quiz at the onset of a 90-minute peerteaching session to provide a student with immediate forma-tive feedback regarding his/her mastery of key anatomicalrelationships emphasized during the most recent classroomlectures and laboratory sessions. These self-assessment fea-tures permitted each student to measure his/her preparednessfor an examination and compare his/her performance tothat of classmates (Collins, 2008; Premkumar and Coupal,2008). When a large number of students (usually greaterthan 20% of attendees) failed to answer an item correctlythe peer tutor in charge of administering the ARS quiz inter-rupted the presentation and discussion ensued until consen-sus was reached about the correct answer. Discussing incor-rect answer choices, or distracters, was helpful to most first-year students, because the second-year peer teacher couldexpand on the anatomical information and broaden thescope of the question (Stein et al., 2006). Furthermore, byidentifying misconceptions or specific gaps in comprehensionof critical anatomical concepts from the quiz, first-year DPTstudents could devise a strategy to augment their knowl-edge-gap during the second phase of the peer review session(Nayak and Erinjeri, 2008). Throughout second phase stu-dents gathered in small groups to complete and discussreview sheets found within the packets created by peertutors (Youdas et al., 2008).

Table 5.

Second Year Physical Peer Teachers’ Responses to Open-Ended Questions on Survey Instrument

Questions and comments Responses Percentage Teachers’ comments

1. What was the most usefulfeature about using ‘‘clickers’’

during the gross anatomy peer

teaching session?

� Identifying topics thatneeded additional

attention

� Allowed students to

answer questionsanonymously

83.3

16.7

� ‘‘It encouraged students to: (1)attend the sessions; (2)

anonymously gauge one’s

knowledge relative to classmates;

and (3) provided immediatefeedback.’’

� ‘‘We could assess the topics that

needed to be reviewed in greater

depth.’’

2. What was the least useful

aspect of the ‘‘clickers’’ during

the peer teaching session?

� Difficult to write

conceptual questions

with long answers

� Not interactive enough� All aspects were useful

50

33.316.7

� ‘‘Clickers did stimulate questions

and conversations about the

material, nevertheless it is also

somewhat impersonal and apassive method of teaching.’’

� ‘‘I don’t know of anything that was

not useful.’’

3. Would you recommend

continued use of ‘‘clickers’’ for

gross anatomy?

Yes 100 � ‘‘I would endorse the continued use

of clickers as they seemed to draw

students to peer teaching sessions

and sparked questions. However, Ibelieve other teaching methods

should be incorporated as well.’’

� ‘‘It is a great way to engage

students and allow them and thetutor to test their knowledge from

week-to-week.’’

Anatomical Sciences Education NOVEMBER/DECEMBER 2009 291

Although numerous reports have confirmed the ability ofan ARS to engage learners in classes where lecture is the pri-mary instructional method (Copeland et al., 2000, Milleret al., 2003,Uhari et al., 2003, Freeman and Dobbie, 2005,Collins, 2008, DeBourgh, 2008, Nayak and Erinjeri, 2008),the present study avoided lecture. Moreover, the majority offirst-year DPT students perceived the anatomy peer teachingsessions to be appealing because the ARS quiz made effectiveuse of their time and promoted verbal interaction betweenthemselves and second-year peer teachers (Youdas, et al.,2008). Although frequent users of ARS technology (Prem-kumar and Coupal, 2008) recommend one question every 20minutes during a lecture when the system serves as an activelearning strategy, they also suggest any number of questionsmay be used when the goal is formative student assessment dur-ing student review. This assertion was supported by percep-tions of the first-year DPT students in the present study.

According to first-year DPT student reports, one limitationof the ARS quiz format was the tendency for unnecessaryconversation to occur among some students who were rapidresponders to a question while they waited for less speedyclassmates to send their response to the classroom computer.Typically, the duration of an answering interval for a givenquestion lasted between 30 to 60 seconds or until responsesfrom all first-year students were logged. Fifty-six percent ofstudents perceived pointless chatter during the quiz to be dis-tracting and potentially impeded their learning. Such behaviordisplayed by future physical therapists is not professional anddemonstrates a lack of mutual respect for colleagues (Jette andPortney, 2003). In the future, first-year DPT students should beinformed of this undesirable professional behavior so that itdoes not repeat itself during the ARS portion of the anatomypeer teaching session. Another way to ameliorate unnecessaryconversation among attendees is for peer teachers to keep quizquestions short and easy to read with a maximum responseinterval of 15–20 seconds. This would discourage first-yearstudents from spending excessive time agonizing over an an-swer (Collins, 2008) thus creating lulls whereby classmates feltobliged to chat. Furthermore, in the future ground rules willbe established for the ARS sessions so that no talking will bepermitted during the answering interval.

Perceptions of Teachers/Tutors

The six second-year students initially volunteered to serve asanatomy peer teachers because they anticipated personalgrowth opportunities in such critical behaviors as (1) profes-sionalism, (2) communication management, (3) working rela-tionships, and (4) interpersonal skills (Jette and Portney,2003). These four behaviors are highly valued by clinicalinstructors of physical therapy when second-year studentsbegin terminal clinical rotations (Wolff-Burke, 2005).Although a previous report (Youdas et al., 2008) describedhow peer teaching in gross anatomy offered second-year DPTstudents a means to acquire critical clinical behaviors, thepresent study sought to describe the benefits and challengesof using ARS technology during the nonlecture interactivesessions as perceived by peer teachers/tutors.

Before the start of the course, Anatomy for PhysicalTherapists, peer teachers collectively opted to include theARS non-graded quiz as a principle component of the weeklypeer teaching review session. This decision was based on alearner’s perspective since all tutors were exposed to the ARSsystem during their first year in the program. In contrast to

other investigators who used the ARS quiz to engage studentsand reveal their knowledge level during the course of a lec-ture or a briefing session (Copeland et al., 2000; Miller et al.,2003; Uhari et al., 2003; Freeman and Dobbie, 2005; Collins,2008; DeBourgh, 2008; Nayak and Erinjeri, 2008; Alexanderet al., 2009), the second-year peer teachers did not lecturebecause they believed such a format would have been redun-dant and not likely to engage the audience. The 12–15-itemnongraded quiz was strategically inserted at the beginning ofeach peer teaching session to estimate first-year students’ levelof understanding of anatomical concepts covered in the thirdweek lectures and laboratory dissection periods (Copelandet al., 2000; Miller et al., 2003; Uhari et al., 2003; Freemanand Dobbie, 2005; Collins, 2008; DeBourgh, 2008; Nayakand Erinjeri, 2008; Alexander et al., 2009). Although first-year students gained confidence in their comprehension of an-atomical relationships as the peer teaching sessions pro-gressed, the second-year students similarly gained confidencein their personal preparation for subsequent peer teachingsessions (Nayak and Erinjeri, 2008). Writing questions forthe weekly ARS quiz prompted second-year students toreview the learning material in greater depth in anticipationof thought-provoking questions voiced by the first-year stu-dents (Youdas et al., 2008). One limitation of this model ofteaching was the peer teachers’ perceived lack of proficiencyin writing challenging test items. During the first cycle of thisform of peer teaching, the anatomy course teaching facultydid not review potential test items or assist the peer teachersin the proper question writing format. In the future, the anat-omy teaching faculty will implement a short tutorial for thesecond-year peer teachers on suggested techniques for writingeffective multiple choice test items.

After the weekly review session second-year peer tutorsreported they developed a strategy to prepare for future meet-ings. Using self-reflective thinking, a professional behaviorvalued highly by physical therapist clinical educators (Wolff-Burke, 2005) and embodied by expert clinicians in physicaltherapy (Resnik and Jensen, 2003), a peer teacher wouldrecall quiz items that elicited thought-provoking questionsbetween tutors and students versus those items that generatedconfusion. This strategy guided the peer teachers as theyrefined and improved their approach to the ARS componentof the anatomy peer teaching session.

CONCLUSION

A nongraded 12–15 item quiz using ARS technology was thesalient feature of a weekly peer teaching review sessionconducted by six second-year DPT students for 28 first-yearDPT students in a semester course in gross anatomy. Both stu-dents and peer teachers were surveyed about their perceptionsof the usefulness of the ARS system. First-year students over-whelmingly acknowledged the ARS system permitted each stu-dent to self-assess his/her preparedness for an examination andcompare his/her performance to that of classmates. Addition-ally, the ARS technology promoted student attendance atweekly review sessions. Peer teachers recognized an ARS quizprovided an opportunity to (1) estimate first-year students’level of understanding of anatomical concepts; (2) gain confi-dence in personal preparation for subsequent peer teaching ses-sions; and (3) acquire indispensable teaching skills for subse-quent use in the physical therapy clinical setting. On the basisof the mutual benefits derived by both students/tutees and

292 Wait et al.

teachers/tutors, physical therapist educators may wish to con-sider using ARS technology to enhance teaching methods for aclass in gross human anatomy.

NOTES ON CONTRIBUTORS

KEVIN R. WAIT, B.S., is currently a doctoral student in theProgram in Physical Therapy at Mayo School of Health Sci-ences, Mayo Clinic, Rochester, Minnesota. He served as apeer teacher in the Anatomy for Physical Therapists Coursefor the first-year Doctor of Physical Therapy students.

BETH A. CLOUD, B.A., is currently a doctoral student inthe Program in Physical Therapy at Mayo School of HealthSciences, Mayo Clinic, Rochester, Minnesota. She served as apeer teacher in the Anatomy for Physical Therapists Coursefor the first-year Doctor of Physical Therapy students.

LINDSEY A. FORSTER, B.S., is currently a doctoral stu-dent in the Program in Physical Therapy at Mayo School ofHealth Sciences, Mayo Clinic, Rochester, Minnesota. Sheserved as a peer teacher in the Anatomy for Physical TherapistsCourse for the first-year Doctor of Physical Therapy students.

TIFFANY M. JONES, B.A., is currently a doctoral studentin the Program in Physical Therapy at Mayo School of HealthSciences, Mayo Clinic, Rochester, Minnesota. She served as apeer teacher in the Anatomy for Physical Therapists Course forthe first-year Doctor of Physical Therapy students.

JESSICA J. NOKLEBY, B.A., is currently a doctoral stu-dent in the Program in Physical Therapy at Mayo School ofHealth Sciences, Mayo Clinic, Rochester, Minnesota. Sheserved as a peer teacher in the Anatomy for Physical Thera-pists Course for the first-year Doctor of Physical Therapy stu-dents.

CORTNEY R. WOLFE, B.S., is currently a doctoral stu-dent in the Program in Physical Therapy at Mayo School ofHealth Sciences, Mayo Clinic, Rochester, Minnesota. Sheserved as a peer teacher in the Anatomy for Physical Thera-pists Course for the first-year Doctor of Physical Therapy stu-dents.

JAMES W. YOUDAS, P.T., M.S., is an associate professorin the Program in Physical Therapy at Mayo School ofHealth Sciences, Mayo Clinic, Rochester, Minnesota. He isthe coordinator and instructor in the Anatomy for PhysicalTherapists Course for the first-year Doctor of Physical Ther-apy students.

LITERATURE CITEDAlexander CJ, Crescini WM, Juskewitch JE, Lachman N, Pawlina W. 2009.Assessing the integration of audience response system technology in teaching ofanatomical sciences. Anat Sci Educ 2:160–166.

Allen AR, Boraks N. 1978. Peer tutoring: Putting it to the test. Read Teach32:274–278.

Bruecker JK, MacPherson BR. 2004. Benefits from peer teaching in the dentalgross anatomy laboratory. Eur J Dent Educ 8:72–77.

Collins J. 2008. Audience response systems: Technology to engage learners.J Am Coll Radiol 5:993–1000.

Copeland HL, Longworth DL, Hewson MG, Stoller JK. 2000. Successfullecturing: A prospective study to validate attributes of the effective medical lec-ture. J Gen Intern Med 15:366–371.

DeBourgh GA. 2008. Use of classroom ‘‘clickers’’ to promote acquisition ofadvanced reasoning skills. Nurse Educ Pract 8:76–87.

Drake RL, Vogl W, Mitchell AWM. 2005. Gray’s Anatomy for Students. 1stEd. Philadelphia, PA: Elsevier. 1058 p.

Eggert CH, West CP, Thomas KG. Impact of an audience response system.Med Edu 38:576.

Ellis H. 2001. Teaching in the dissecting room. Clin Anat 14:149–151.

Homme J, Asay G, Morgenstern B. 2004. Utilization of an audience responsesystem. Med Edu 38:575.

Jenkins DB. 2002. Hollinshead’s Functional Anatomy of the Limbs and Back.8th Ed. Philadelphia, PA: WB Saunders. 400 p.

Jette DU, Portney LG. 2003. Construct validation of a model for professionalbehavior in physical therapist students. Phys Ther 5:432–443.

Johnson JH. 2002. Importance of dissection in learning anatomy: Personal dis-section versus peer teaching. Clin Anat 15:38–44.

Krych AJ, March CN, Bryan RE, Peake BJ, Pawlina W, Carmichael SW. 2005.Reciprocal peer teaching: Students teaching students in the gross anatomy labo-ratory. Clin Anat 18:296–301.

Lake DA. 1999. Enhancement of student performance in a gross anatomycourse with the use of peer tutoring. J Phys Ther Educ 13:34–38.

Latessa R, Mouw D. 2005. Use of an audience response system to augmentinteractive learning. Fam Med 37:12–14.

Mattingly GE, Barnes CE. 1994. Teaching human anatomy in physical therapyeducation in the United States: A survey. Phys Ther 74:720–727.

Miller RG, Ashar BH, Getz KJ. 2003. Evaluation of an audience response sys-tem for the continuing education of health professionals. J Contin Educ HealthProf 23:109–115.

Nasmith L, Steinert Y. 2001. The evaluation of a workshop to promote inter-active learning. Teach Learn Med 13:43–48.

Nayak L, Erinjeri JP. 2008. Audience response systems in medical student edu-cation benefit learners and presenters. Acad Radiol 15:383–389.

Netter FH. 2003. Atlas of Human Anatomy. 3rd Ed. Teterboro, NJ: IconLearning Systems. 604 p.

Nnodim JO. 1997. A controlled trial of peer-teaching in practical gross anat-omy. Clin Anat 10:112–117.

Ocel JJ, Palmer BA, Wittich CM, Carmichael SW, Pawlina W. 2003. Outcomesof the gross and developmental anatomy teaching assistant experience. ClinAnat 16:526–530.

Peppler RD, Kwasigrock TE, Houghland MW. 1985. Evaluation of simultaneousteaching of extremities in gross anatomy program. J Med Educ 60:635–639.

Premkumar K, Coupal C. 2008. Rules of engagement-12 tips for successful useof ‘‘clickers’’ in the classroom. Med Teach 30:146–149.

Resnick L, Jensen GM. 2003. Using clinical outcomes to explore the theory ofexpert practice in physical therapy. Phys Ther 83:1090–1106.

Robertson LJ. 2000. Twelve tips for using a computerized interactive audienceresponse system. Med Teach 22:237–239.

Schakow TE, Chavez M, Loya L, Friedman M. 2004. Audience response sys-tem: Effect on learning in family medicine residents. Fam Med 36:496–504.

Stein PS, Challman SD, Brueckner JK. 2006. Using audience response technol-ogy for pretest reviews in an undergraduate nursing program. J Nurs Educ45:469–473.

Streeter JL, Rybicki FJ. 2006. Education techniques for lifelong learning. Anovel standard-compliant audience response system for medical education.Radiographics 26:1243–1249.

Torbeck L. 2007. Enhancing programme evaluation using the audienceresponse system. Med Educ 41:1088–1089.

Uhari M, Renko M, Soini H. 2003. Experiences of using an interactive audi-ence response system in lectures. BMC Med Educ 3:12.

Wolff-Burke M. 2005. Clinical instructors’ descriptions of physical therapiststudent professional behaviors. J Phys Ther Educ 19:67–75.

Yeager VL. 1981. Peer teaching in gross anatomy. J Med Educ 56:922.

Yeager VL, Young PA. 1992. Peer teaching in gross anatomy at St. Louis Uni-versity. Clin Anat 5:304–310.

Youdas JW, Krause DA, Hellyer NJ, Hollman JH, Rindflesch AB. 2007. Per-ceived usefulness of reciprocal peer teaching among doctor of physical therapystudents in the gross anatomy laboratory. J Phys Ther Educ 21:30–38.

Youdas JW, Hoffarth BL, Kohlwey SR, Kramer CM, Petro JL. 2008. Peerteaching among physical therapy students during human gross anatomy: per-ceptions of peer teachers and students. Anat Sci Educ 1:199–206.

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