2012; 34: 957–959

SHORT COMMUNICATION

Peer assisted learning in surgical skillslaboratory training: A pilot study

J.H. BEARD, P. O’SULLIVAN, B.J.A. PALMER, M. QIU & E.H. KIM

UCSF, USA

Abstract

Background: Peer assisted learning (PAL) has been rarely investigated in surgical skills training.

Aims: Describe feedback residents give peers on surgical skills with and without guidelines, determine the association between

feedback and actual performance, evaluate resident satisfaction with PAL.

Method: Participants evaluated peers using a validated knot-tying checklist and provided feedback on suturing without a

guideline. Feedback comments were coded by type and an expert scored performance of each participant. Residents completed a

satisfaction questionnaire.

Results: Comments were generally specific. Feedback was twice as likely with the use of a guideline. Specific feedback correlated

significantly with expert knot-tying score but not suturing score. Most participants felt peer feedback was helpful and were

motivated to practice surgical skills after PAL sessions.

Conclusions: Surgical residents can provide high quality specific feedback to peers on surgical skills using performance

guidelines. Further exploration of effective PAL methodology in surgical skills laboratory training is needed.

Introduction

Informal peer teaching is at the core of general surgical

education in the United States. Inside and out of the operating

room, senior residents educate and shape the development of

juniors through role-modeling, direct instruction, and feed-

back. Although peer assisted learning (PAL) is emerging as a

valuable tool in medical education, there has been little

investigation of the formal use of PAL in the development of

surgical skills.

Peer teachers are thought to be ‘‘cognitively congruent’’

with their students and thus theoretically better than experts at

understanding the knowledge and skill level of their trainees

(Lockspeiser et al. 2008). This similarity in educational

experience and technical skill levels between student and

teacher can enhance motivation and achievement through

modeling of attainable learning objectives (Ross & Cameron

2007). In addition, PAL promotes the development of the tutor

as a teacher, a lifelong skill required of academic physicians.

Finally, PAL can solidify the knowledge and skill of the tutor

through the instruction of others in a supported, socially

stimulating learning environment (Gibson & Campbell 2000).

A recent randomized comparison of resident versus peer

medical student teaching during an operating room introduc-

tion course demonstrated better technical performance by

students in the peer-teaching group (Graziano 2011). Evans

and colleagues found that peer assessment scores reflect

expert trainer scores more accurately that surgeon self-

assessment in dental extraction (Evans et al. 2007). In addition

to being accurate, the authors suggest that peer assessment

may encourage honest reflection on skills, increased

collaboration, and teamwork. Although the use of guidelines

in PAL has been advocated in the literature, there are no

definitive studies on the issue (Ross & Cameron 2007).

We piloted a PAL program in our surgical skills lab. The

aims of this study were: describe the nature of feedback

residents give each other on basic surgical skills with and

without guidelines, determine an association between peer

feedback an actual performance, and evaluate resident satis-

faction with PAL.

Methods

We conducted this descriptive study at the Surgical Skills Lab

of the University of California, San Francisco (UCSF). The

UCSF Committee on Human Research certified the study as

exempt from review. Thirty-three general surgery residents in

their first year of training participated in the knot-tying session,

while twenty residents participated in the suturing session.

During the sessions, residents either completed a series of two

handed knots or a simple suturing exercise and received peer

feedback upon completion of the task. Participants were

instructed on the use of a previously validated Knot-tying

Checklist for feedback in the knot-tying session (Kim 2011).

There were no guidelines given for the suturing session. PAL

sessions were videotaped. Care was taken to ensure anonym-

ity of the participants.

Researchers transcribed and coded each participant com-

ment as global positive, specific positive, global negative and

specific negative following a previously employed methodol-

ogy (Kruidering et al. 2009). Global comments were defined as

Correspondence: Jessica H. Beard, 513 Parnassus Ave, S-321, San Francisco, CA 94143-0470, USA. Tel: 713.818.1870; fax: 415.502.1259;

email: jessica.beard@ucsfmedctr.org

ISSN 0142–159X print/ISSN 1466–187X online/12/110957–959 � 2012 Informa UK Ltd. 957DOI: 10.3109/0142159X.2012.706340

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feedback related to overall impression of the activity, while

specific comments included feedback on particular technical

aspects of performance. An attending surgeon scored resident

performance using the validated Knot-tying Checklist and a

separate suturing checklist. Residents completed an anony-

mous satisfaction questionnaire.

We used SPSS Version 17.0 for data analysis. Differences

between the mean number of each type of peer comment in

the knot-tying and suturing categories were identified using a

t-test. We calculated Pearson correlations to determine the

relationship between peer feedback and expert scores.

Results

Most peer feedback was either specific positive (34%) or

specific negative (41%) but rarely global positive (23%) or

global negative (2%). ‘‘Your [knot-tying] distance was perfect’’

represents an example of a specific positive comment while

‘‘You didn’t gather the suture’’ is an example of a specific

negative comment.

Table 1 illustrates the mean number of types of comments

in the knot-tying and suturing PAL sessions. On average, peer

teachers made 7.18 comments (95% CI: 5.55–8.81) during the

knot-tying sessions using a teaching guide and 3.25 comments

(95% CI: 2.53–3.97) during the suturing sessions, which were

unguided. The amount of feedback in knot-tying sessions

using a guideline more than doubled when compared to

suturing sessions without teaching guidelines (p5 0.001).

Specific positive and negative comments were also more

common than global comments in the knot-tying group.

In the knot-tying group, expert score was positively

associated with the proportion of specific positive feedback

(r¼ 0.48, p¼ 0.003) and negatively associated with the

proportion of specific negative feedback (r¼�0.35,

p¼ 0.028). There was no significant association identified

between expert suturing score and peer feedback (positive

comments: r¼�0.03, p¼ 0.46; negative comments: r¼�0.08,

p¼ 0.38).

Most participants (88.5%) felt the PAL sessions were helpful

in pointing out technical abilities while 65.7% of residents felt

more confident with their technical skills upon completion of

the exercises. Residents (80.0%) felt motivated to practice their

surgical skills at home after the PAL session, and 71.4% noted

an increased sense of peer camaraderie. 42.8% of participants

stated that the PAL session engendered a feeling of anxiety to

perform well.

Discussion

In this pilot study, we created a picture of peer feedback in the

context of our surgical skills training laboratory. We found that

residents generally provided specific feedback to peers in PAL

sessions. Participants rarely made global negative comments,

which would likely be of little use in peer instruction and may

serve to create a hostile learning environment. Although the

correlations are modest, our results show that with the

assistance of a guideline on knot-tying tasks, peer teachers

did indeed provide accurate and specific feedback.

The PAL sessions provided a unique opportunity for

residents to assess their skills in the larger context of their

peers. We found that PAL may even stimulate independent

learning and foster motivation to practice skills outside of the

lab. Despite a potentially competitive learning environment,

the majority of PAL participants endorsed a sentiment of

resident camaraderie after the sessions, a feeling that could

translate to stronger team relationships in the realm of patient

care. Finally, nearly half of the residents identified feelings of

stress associated with the PAL activity, which can aid in

memory formation and reinforce learning at low levels

(Friedlander et al. 2011). Higher levels of anxiety may be

detrimental to learning, and further investigation into stress

effects of peer learning is warranted.

Our findings contrast with the sentinel study on peer

teaching in surgery by Rogers et al. (2000). In this study,

addition of peer collaboration to a computer-based knot-tying

curriculum had a negative impact on first year medical

students’ ability to tie knots. Differences in design and

outcome measurement may explain the divergent results of

our studies. While the endpoint of the Rogers study was

performance, we focused on the quality and accuracy of peer

feedback. In addition, Rogers et al grouped peers in pairs,

which may increase the risk of faulty interpretation of

instructions on knot-tying. Our peer groups included three to

five participants to ensure appropriate group communication.

Finally, Rogers et al evaluated the performances of first year

medical students after a single 45 minute session. Our partic-

ipants were first year residents with more practical experience

with basic surgical skills than novice medical students.

Therefore PAL may be more productive at more advanced

stages of technical skills acquisition.

This study has limitations. We compared two different

surgical skills in the PAL sessions, using a guideline for the PAL

exercise on knot-tying and no guideline for the suturing

session. Participants may have been more comfortable giving

feedback in the knot-tying PAL session owing to an inherent

greater complexity of suturing. Thus peer teacher facility with

each skill may have influenced the number and type of

feedback comments, making it difficult to extrapolate the

effect of the guideline itself. In addition, the suture scoring

system used by the expert in our study has not been validated

in this population of surgical residents, which may have further

influenced the relationship between guideline use and expert

scoring.

Table 1. Comment types in knot-tying and suturing PAL activities.

Mean number of comments (95% CI)

Comment typeKnot-tying/guide

usedSuturing/no guide

used p-value

Global positive 1.16 (0.78, 1.58) 0.85 (0.40, 1.30) 0.20

Specific positive 3.24 (2.13, 4.35) 0.90 (0.39, 1.41) 0.002

Global negative 0.09 (�0.09, 0.27) 0.15 (�0.02, 0.32) 0.66

Specific negative 2.67 (1.79, 3.55) 1.35 (0.92, 1.78) 0.008

Total comments 7.18 (5.55, 8.81) 3.25 (2.53, 3.97) 50.001

J.H. Beard et al.

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Conclusions

Surgical residents can provide high quality specific feedback to

peers on surgical skills using performance guidelines. Given

the satisfaction with PAL and quality of peer feedback, we

recommend developing guidelines for peer assessment of

surgical skills along with further exploration of effective peer

teaching methodology in surgical skills laboratory training.

Declaration of interest: The authors report no declarations

of interest.

Notes on contributors

JESSICA H. BEARD, MD, MPH is a general surgery resident at UCSF.

PATRICIA O’SULLIVAN, EdD is Professor of Medicine and Director of

Research and Development in Medical Education at UCSF.

BARNARD PALMER, MD, MEd completed general surgery residency at

UCSF-East Bay program and is an Endocrine Surgery fellow at Mount Sinai

School of Medicine.

MARY QIU is a medical student at UCSF.

EDWARD H KIM, MD is Assistant Professor of Surgery and Director of the

Surgical Skills Lab at UCSF.

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