|ORIGINAL RESEARCH ARTICLE
|Year : 2014 | Volume
| Issue : 1 | Page : 4-9
Medical faculty opinions of peer tutoring
Joy R. Rudland1, Sarah C. Rennie2
1 Faculty of Medicine, Faculty Education Unit, University of Otago, Dunedin, Otago, NewZealand
2 Registrar, Department of Surgical Sciences, Southland District Health Board Dunedin Public Hopsital, Dunedin, Otago, NewZealand
|Date of Web Publication||11-Jun-2014|
Prof. Joy R. Rudland
Faculty of Medicine, University of Otago, Dunedin, Otago
Source of Support: None, Conflict of Interest: None
Context and objectives: Peer tutoring is a well-researched and established method of learning defined as 'a medical student facilitating the learning of another medical student'. While it has been adopted in many medical schools, other schools may be reluctant to embrace this approach. The attitude of the teaching staff, responsible for organizing and or teaching students in an undergraduate medical course to formal peer teaching will affect how it is introduced and operationalized. This study elicits faculty opinions on how best to introduce peer tutoring for medical students. Methods: Structured telephone interviews were recorded, transcribed and analyzed using thematic analysis. The interviews were with medically qualified staff responsible for organizing or teaching undergraduate medical students at a New Zealand medical school. Six questions were posed regarding perceived advantages and disadvantages of peer tutoring and how the school and staff could support a peer-tutoring scheme if one was introduced. Findings: Staff generally supported the peer tutoring concept, offering a safe environment for learning with its teachers being so close in career stage to the learners. They also say disadvantages when the student-teachers imparted wrong information and when schools used peer tutoring to justify a reduction in teaching staff. Subjects felt that faculty would be more accepting of peer tutoring if efforts were made to build staff 'buy in' and empowerment, train peer tutors and introduce a solid evaluation process. Conclusions: Staff of our school expressed some concerns about peer tutoring that are not supported in the literature, signaling a need for better communication about the benefits and disadvantages of peer tutoring.
Keywords: Curriculum development, peer tutoring, qualitative, staff opinion
|How to cite this article:|
Rudland JR, Rennie SC. Medical faculty opinions of peer tutoring. Educ Health 2014;27:4-9
| Introduction|| |
Peer tutoring, or peer-assisted learning, is a well-established educational strategy used in settings from preschool to postgraduate  including medical education. , Involving "people from similar social groupings who are not professional teachers, helping each other to learn, and learning themselves",  it has been piloted and adopted by many undergraduate medical schools globally. ,,,
The acknowledged benefits of peer tutoring include increased cognitive development among tutored medical students ,,, and gains in practical areas including dissection,  communication,  resuscitation,  history and examination  and injection techniques.  A meta-analysis compared 10 studies  on the relative academic performance of staff-tutored and peer-tutored students: Five found no difference in students' performance, four showed mixed results, and in one the peer-tutored students performed better. Tutoring has also been shown to improve tutors' knowledge of the content area taught and knowledge of how to teach. , Tutors perceive themselves to be more intrinsically motivated, more actively engaged with the learning environment and more confident than non-tutoring colleagues. ,
Despite the evidence of educational benefits of peer learning and the fact that many institutions are finding ways to develop creative applications, other schools are failing to adopt or even explore this method of learning. When our medical school in New Zealand informally suggested using peer tutoring, some senior staff expressed concerns. Possibly because peer tutoring seldom involves medical staff members, their attitudes about peer learning are not often researched. , However, understanding medical staff opinions is critical to successfully managing a change in a school's educational approaches, specifically in this case implementing formal peer tutoring. This study aimed to gauge medical staff perceptions of the advantages and disadvantages of peer tutoring and of the support required to successfully introduce peer tutoring into our school.
| Methods|| |
A structured questionnaire was created for this study's interviews. It was distributed to subjects before a telephone interview. The subjects were medically qualified members of the teaching staff at one of two under graduate medical schools in New Zealand. The school offers an integrated curriculum design with early clinical and community contact and the use of small group learning in a number of settings. There is peer-to-peer learning inherent in small group learning but routinely a tutor is present. Interview questions were as follows:
- How would you define "peer tutoring"? If required, the term was clarified using a standard definition, "a medical student facilitating the learning of another medical student".
- Are you aware of any medical student peer tutoring occurring in your school?
- Do you have any personal experience of medical student peer tutoring when you were an undergraduate?
- What are the advantages and disadvantages of peer tutoring?
- If peer tutoring was introduced at this medical school, what type of support do you think the students being tutors would require to ensure that the scheme was successful?
- What support would the staff need to ensure their acceptance of a peer-tutoring scheme?.
Recruitment of interviewees
The study was approved by the University's category B ethics application. Forty medical staff members from across the undergraduate medical course were invited by letter to participate. These staff were all experienced members of staff, consultant grade or above, in a variety of disciplines representing the main content area of the undergraduate course. Ten staff members declined to be part of the study. The remaining 30 agreeable respondents were e-mailed up to three times to arrange interview times, with up to three telephone calls or pages to follow up those who failed to respond. Interviews for 17 could not be scheduled due to lack of availability or interest. The 13 staff members who were available and willing to take part received e-mails confirming details and all consented to participate in the study.
Data collection and analysis
Verbatim transcripts of the recorded interviews were produced by a transcriber and checked for accuracy by a researcher. Corrected transcripts were analyzed using the qualitative method of thematic analysis  using ATLAS.ti to facilitate the process. The analytical categories were derived from the data inductively,  with codes summarizing the content ascribed to text using the words of participants where appropriate. The initial codes were then grouped into clusters and themes identified and reviewed. The transcripts were coded by a second researcher. Face to face discussions were held to discuss the coding; limited differences were identified and considered, and a consensus reached.
| Findings|| |
Of the 13 subjects, 5 were female, 6 were aged between 40 and 49 years, 5 were aged between 50 and 59 and 2 were aged over 60. A range of disciplines was represented including Public Health, Pathology, Obstetrics and Gynecology, General Practice, Medical and Surgical specialties and Pediatrics. After eight interviews it was felt that saturation had been reached. However, a further five interviews had been planned and were conducted. No new issues were raised during these interviews although they served to support previous comments. Questions 2-4 are reported individually, the data from question 5 and 6 is combined as common concepts emerged.
Definition of medical student peer tutoring (question 1)
Twelve participants shared our definition of peer learning as "A medical student facilitating the learning of another medical student"; it was clarified with the one participant whose initial understanding was different.
Peer tutoring in the medical school (question 2)
Staff were generally unaware of peer tutoring by undergraduate medical students but gave examples of informal peer tutoring:
- "…I'm not aware of it occurring officially. we're dealing with small groups which are split into two …often if their time overruns and I'm rotating around a variety of groups, if I get back I'll sometimes find that the first group have explained to the second group their understanding of the topic. So it does happen that those sort of informal or spontaneous level, but it's not actually part of the structured part of the course as and intentional sort of formalized component."
Ten of those interviewed felt that peer tutoring had a place in the undergraduate medical curriculum; two were unsure, one felt it had no place and should occur only in the postgraduate setting.
Personal experience of peer tutoring (question 3)
Peer tutoring was generally perceived as relatively new; only one participant had experienced peer tutoring as an undergraduate.
- "I went through the old system, go forth and multiply. no such thing as peer tutoring."
Advantages and disadvantages of peer tutoring (question 4)
Subjects' responses could be usefully grouped into advantages and disadvantages of peer tutors for tutees, tutors, medical staff, the medical school and others.
The advantages to tutees of peer tutoring were perceived to be that it provided a safe and effective learning environment given the narrow distance between tutee and tutor, who had just recently experienced the curriculum him or herselves. The perceived disadvantages were that tutees were sometimes given misinformation and sometimes exposed to poor teaching. For tutors, the benefits were seen as enhancing their own learning and developing their teaching skills. The disadvantages included overload of the tutor, who could feel that they are over their heads in what they were asked to teach. For the school's regular teaching staff, the main perceived advantage was identifying areas that required greater emphasis by staff in the formal curriculum; the disadvantage was perceived to be undermining their roles as teachers.
Introducing peer tutoring (question 5 and 6)
From the thematic analysis the responses were categorized in three groups: Planning, implementation and evaluation.
The subjects felt that the following points needed to be addressed in the planning phase:
- Evidence for the benefit of peer tutoring (to staff and students)
"I think some information about whether there's an evidence-base for this. You know I think people are really keen to embrace new initiatives in the curriculum if there is pretty strong evidence that the initiative will benefit students."
- Consider the institutional culture:
"Because it really - to develop this situation, you've really got to develop a whole new mindset."
- Articulation of the intended outcomes associated with the program
The purpose of the peer tutoring needed to be clearly articulated [Table 1].
|Table 1: Advantages and disadvantages for the stakeholder groups (illustrative comments)|
Click here to view
- Staff buy-in and empowerment:
"… make sure that people are very well-informed about it, that they perhaps look at ways that they can develop it themselves. Or with support, with people giving support to them, but rather than it being imposed upon them".
- Infrastructure support:
"… you know - there'd probably need to be a convenor or somebody like that."
- Area and be clear about the:
- Area of teaching (theoretical/clinical).
Content of teaching was felt to be the imperative of teachers
"These are the areas which I think you can offer assistance. And these are the areas you should stay out of. And there needs to be a very close link between the peer person and the senior teachers who coordinate whatever program it is that they're running."
Interestingly, several staff felt that peer tutors should focus on clinical and practical skills rather than knowledge:
"You know, doing things like taking blood and putting in drips and things."
- Year of tutoring.
The year of education of students acting as tutors was considered important:
"… Whereas they could have quite a role in either fifth or sixth year, or fourth year in talking with or teaching the second or third year."
- Nature of teaching (new material or review).
An opinion was also expressed that peer tutors should not be introducing new concepts, but rather focus and revise what the students had already been taught:
"… And a fifth year student could be very helpful with helping them practising those things which they've been taught by somebody else."
- Type of the teaching (facilitation, etc.). A few comments referred to the type of teaching expected:
… the role that they play whether its facilitating or trying to be the expert."
- Selection of tutors and tutees, and whether it should be voluntary or based on ability
"I mean I think it would be best if it was a voluntary thing really and that they offered or - yeah - to give it a try or whatever it is. If you can impose it upon people, I don't know."
There was also a sense that the peers would have to be vetted for suitability as a tutor.
- "Not all students would make good tutors."
There was also a feeling that students could perhaps self select their peer tutor.
- "… so you might want to sort of either make the group a little bit bigger and allow people to choose their peers."
- Staff and students should be briefed about the program
"I think they would need a really good briefing as to what peer tutoring is about and some sort of advice and help in sort of running those groups."
- Offer initial and ongoing support that should be provided to tutors:
"I think having the basic kit available to deliver the tutorial with really just working hard on what's available to bone up on the knowledge and make themselves comfortable and conversant with the materials they've got would really be the key thing here."
- Basic skills training - content and process of tutoring
"Certainly a little induction course. "
"A workshop could be run."
- Ongoing support
"Uhm I think they would need to know that they could, you know, ask for back up or advice from staff members, you know, whenever they needed it. And get quite rapid - quite a rapid response. So they weren't left being a little bit uncertain about the material that they were trying to teach to somebody else for example."
- Peer support
- "That they could meet (other peers) on a regular basis and discuss their problems, it would mainly be for half an hour on a Thursday evening, at five o'clock or whatever."
Evaluation Phase (on-going and after implementation)
- Evaluate and run initially as a pilot
"… including feedback from the students themselves as to whether they thought it was worthwhile."
"It would have to be run as a pilot, get buy-in."
- Value the tutors. Valuing tutors was felt to be important with the concept of awards espoused.
"But you could perhaps say this is something in a way of an honor that is bestowed on only certain students. And maybe that's the right way to do it. You give them a sort of - you haven't just passed, but you've actually achieved junior tutor status."
| Discussion|| |
We were encouraged to learn that most medical teaching staff in our school understood what peer tutoring is and its possible benefits, and felt that it has an appropriate role in undergraduate medical education. While most staff had not directly experienced peer tutoring, some had recognized that within the school's current programs small group learning (without a staff member) was a form of within-year peer tutoring. They identified that spontaneous and serendipitous peer tutoring was often a part of students' strategy for preparing for examinations. 
While staff members identified some of the advantages noted previously in other studies, ,,, they were unaware of research highlighting comparable or better examination performance by peer-tutored students than non-peer-tutored students, and demonstrating better class attendance by student tutors.  Peer tutoring has also been found to reduce the anxiety of academically weak tutees  and improve the confidence of tutors.  These further advantages can be communicated to promote acceptance of peer tutoring by increasing staff understanding of its benefits.
Staff concerns about inaccurate information and poor delivery by inexperienced tutors are supported by a minority of studies, which found poorer performance by peer-tutored students. , Staff also feared negative social interactions during tutoring sessions: Students not respecting the peer tutor (no research supports this), poor group dynamics, or students becoming 'involved' with their tutor. To reduce staff anxieties, these issues must be clearly addressed when introducing peer tutoring.
The concern over the tutor's lack of clinical and teaching experience has not been identified in the literature , to our knowledge. Studies found no difference between student performance in clinical skills acquisition in peer-led and staff-led sessions. , The danger of tutoring interfering with the tutor's other work and causing stress for tutors, who may feel out of their depth, is a real concern. This may be addressed with a voluntary system for supporting peer tutors that includes a process by which tutors may withdraw from being a tutor (as opposed to allowing only abrupt termination of tutor's involvement and no opportunity for feedback and support.
We had not expected to hear that faculty would feel that peer tutoring could enhance staff-student communications, enable more feedback to faculty about students with problems and raise general course issues. That tutors would report to faculty on issues found with their peers is a seldom reported concept. As one of peer tutoring's main benefits is the openness and trust between peers, the authors would not recommend that student tutors be placed in the uncomfortable position of reporting concerns about their peers.
Another disadvantage, which teachers would 'lose control' of the learning program, is perhaps a misperception. While teachers facilitate learning, students control their own learning, and the institution aims to develop the student into an independent practitioner as well as learner. The development of the student's teaching role would give the student greater independence, supporting the value of ensuring students learn how to learn rather than just learning 'content'.
Peer tutoring should enhance the skills of both parties, supplementing professional teaching within a range of methods to develop the learner's attributes. It is not appropriate to regard it as a cheap option using students as a "useful resource" to free up staff time. As students can feel that their fees cover 'proper teachers', peer tutoring should be introduced with an explanation that it is being adopted as an educationally beneficial approach for both the tutors and those tutored. Moreover, freed up staff time weighs against time required to train peer tutors.
Most staff felt that peer tutoring was best for practical and clinical skills rather than for students sharing knowledge with each other. It is not clear why this concerned them.
Subjects felt that peer tutoring should be voluntary for both tutors and tutored students. Against this, doctors are expected to teach.  In New Zealand medically qualified teachers are important to the training of the future medical workforce.  The reported gap between clinical teachers' perceived self-rated and required competence as a teacher indicates the teaching role should be supported and enhanced.  Students themselves recognize that they need training in teaching  and that this training improves confidence.  However, compulsory tutoring may undermine the basic premise that enthusiasm for teaching influences its effectiveness.  We advocate voluntary peer tutoring and the need for good organization, possibly a coordinator of peer-tutoring, recognizing the acknowledged need for training and support for tutors. ,
Any innovation should be evaluated on process, satisfaction levels of all parties, and impact on students' learning. Innovation also requires administrative support, resources, access to staff, training in educational methods, recognition and clearly understood objectives. The introduction of peer tutoring should take account the institutional culture, including the governance structure and existing educational paradigm.
| References|| |
|1.||Topping KJ. Peer assessment between students in college and university. Rev Educ Res 1998;68:249-76. |
|2.||Ten Cate O, During S. Peer teaching in medical education: Twelve reasons to move from theory to practice. Med Teach 2007;29:591-9. |
|3.||Pasquinelli LM, Greenberg LW. A review of medical schools programs that train medical students as teachers (MED-SATS). Teach Learn Med 2008;20:73-81. |
|4.||Topping KJ. The effectiveness of peer tutoring in further and higher education: A typology and review of the literature. High Educ 1996;32:321-45. |
|5.||Schaffer JL, Wile MZ, Griggs RC. Students teaching students: A medical school peer tutorial programme. Med Educ 1990;24:336-43. |
|6.||Nestel D, Kidd J. Peer tutoring in patient-centred interviewing skills: Experience of a project for first-year students. Med Teach 2003;25:398-403. |
|7.||Barnes HV, Albanese M, Schroeder J, Reiter S. Senior medical students teaching the basic skills of history and physical examination. J Med Educ 1978;53:432-4. |
|8.||Trevino FM, Eiland DC. Evaluation of a basic science, peer tutorial program for first- and second-year medical students. J Med Educ 1980;55:952-3. |
|9.||Steele DJ, Medder JD, Turner P. A comparison of learning outcomes and attitudes in student- versus faculty-led problem-based learning: An experimental study. Med Educ 2000;34:23-9. |
|10.||Parkinson M. The effect of peer assisted learning support (PALS) on performance in mathematics and chemistry. Innov Educ Teach Int 2009;46:381-92. |
|11.||Nnodim JO. A controlled trial of peer-teaching in practical gross anatomy. Clin Anat 1997;10:112-7. |
|12.||Perkins GD, Hulme J, Bion JF. Peer-led resuscitation training for healthcare students: A randomised controlled study. Intensive Care Med 2002;28:698-700. |
|13.||Weyrich P, Celebi N, Schrauth M, Möltner A, Lammerding-Köppel M, Nikendei C. Peer-assisted versus faculty staff-led skills laboratory training: A randomised controlled trial. Med Educ 2009;43:113-20. |
|14.||Santee J, Garavalia L. Peer tutoring programs in health professions schools. Am J Pharm Educ 2006;70:70. |
|15.||Benware CA, Deci El. Quality of learning with an active verus passive motivational set. Am Ed Res J 1984;21:755-65. |
|16.||Haist SA, Wilson JF, Brigham NL, Fosson SE, Blue AV. Comparing fourth-year medical students with faculty in the teaching of physical examination skills to first-year students. Acad Med 1998;73:198-200. |
|17.||Wadoodi A, Crosby JR. Twelve tips for peer-assisted learning: A classic concept revisited. Med Teach 2002;24:241-4. |
|18.||Ross MT, Cameron HS. Peer assisted learning: A planning and implementation framework: AMEE Guide no. 30. Med Teach 2007;29:527-45. |
|19.||Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77-101. |
|20.||Pope C, Ziebland S, Mays N. Qualitative research in health care: Analysing qualitative data. BMJ 2000;320:114-6. |
|21.||Rudland J, Wilkinson T, Smith-Han K, Thompson-Fawcett M. "You can do it late at night or in the morning. You can do it at home, I did it with my flatmate." The educational impact of an OSCE. Med Teach 2008;30:206-11. |
|22.||Moust JH, De Volder ML, Nuy HJ. Peer teaching and higher level cognitive learning outcomes in problem-based learning. High Educ 1989;18:737-42. |
|23.||Haist SA, Wilson JF, Fosson SE, Brigham NL. Are fourth-year medical students effective teachers of the physical examination to first-year medical students? J Gen Intern Med 1997;12:177-81. |
|24.||BMA. Doctors as Teachers. BMA Marketing and Publications; 2006. |
|25.||Grant JR. Changing postgraduate medical education: A commentary from the United Kingdom. Med J Aust 2007;186 (7 Suppl):S9-13. |
|26.||McCann LJ, Naden G, Child S. Doctors as teachers: What do they think? N Z Med J 2009;122:16-22. |
|27.||Bardach NS, Vedanthan R, Haber RJ. 'Teaching to Teach': Enhancing fourth year medical students' teaching skills. Med Educ 2003;37:1031-2. |
|28.||Field M, Burke J, Lloyd D, McAllister D. Peer-assisted learning in clinical examination. Lancet 2004;363:490-1. |
|29.||Martens MJ, Duvivier RJ, van Dalen J, Verwijnen GM, Scherpbier AJ, van der Vleuten CP. Student views on the effective teaching of physical examination skills: A qualitative study. Med Educ 2009;43:184-91. |
|30.||Merglen A, Agoritsas T, Nendaz MR. A student-initiated, undergraduate, peer teaching skills programme. Med Educ 2008;42:1139-40. |