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Rheumatology Advance Access originally published online on March 17, 2008
Rheumatology 2008 47(5):652-655; doi:10.1093/rheumatology/ken048
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© The Author 2008. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Undergraduate rheumatology: can peer-assisted learning by medical students deliver equivalent training to that provided by specialist staff?

K. Graham, J. M. Burke and M. Field

Faculty of Medicine, Medical School, The Wolfson Medical School Building, University of Glasgow, University Avenue, Glasgow G12 8QQ, Scotland.

Correspondence to: M. Field, Wolfson Medical School Building, University of Glasgow, University Avenue, Glasgow G12 8QQ, Scotland. E-mail: m.field{at}clinmed.gla.ac.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 
Objective. This study addressed whether medical students using peer-assisted learning (PAL) can deliver training comparable with didactic teaching provided by a specialist.

Methods. Twelve senior students were trained in PAL and the gait, arms, legs, spine (GALS) screening technique for musculoskeletal system (MSS) examination. The students recruited and trained 45 year-2 students in the use of GALS. Nineteen students were recruited by a physiotherapist for GALS training tutorials. Trainee responses were compared by analysis of pre/post training confidence (using 100 mm visual analogue scale), course experience questionnaires (using a 5-point Likert scale) including free text comments, and in end of year examinations.

Results. Trainee confidence increased after PAL training from 3.7 to 89.9 (P < 0.0001). There were no significant differences in confidence levels from student trainees after PAL when compared with expert-led teaching. Results from course experience questionnaires demonstrated benefits in all parameters investigated with all students recommending PAL training. No differences between PAL and expert-led training were observed. Free-text comments showed that PAL-trained students perceived that this learning technique has potential to be applied to other areas of training, an observation not raised by expert-trained students. Examination results revealed that PAL-trained and expert-tutored students were respectively, 1.4 and 1.3 times more likely to pass the MSS examination, when compared with students undertaking standard training (P < 0.002 and P = 0.0001, respectively).

Conclusion. PAL is a useful adjunct to musculoskeletal clinical skills training. Students using PAL techniques offered a comparable level of training with that provided by an expert.

KEY WORDS: Peer assisted learning, Undergraduate education, Clinical skills in rheumatology, Student tutors, Physiotherapist tutors, GALS


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Acknowledgements
 References
 
Patients presenting as emergency cases are inadequately investigated for musculoskeletal diseases [1, 2]. Undergraduate training guidelines recommend the inclusion of rheumatological competencies in curricula [3], but when clinical disciplines are compared, students remain less confident in dealing with patients with musculoskeletal system (MSS) problems [4]. The challenge remains how best to raise the priority of the MSS in training to enhance undergraduate learning.

One approach is to encourage development of additional skills in the context of rheumatology. Peer-assisted learning (PAL), where students study a subject and subsequently teach it to others [5, 6] could be helpful. In addition to the added educational input, PAL enhances useful qualities (confidence building, teamwork and teaching skills) for personal development, which are endorsed by the GMC [7]. However, there has been only limited application of PAL in the context of clinical skills training [8, 9].

Examination of the MSS has been simplified by the development of the gait, arms, legs and spine (GALS) screen [10], which has been shown to be a valuable tool for standardizing student training. A study of PAL demonstrated that senior students using GALS could enhance junior students’ clinical examination skills, as well as boosting examination performance [11]. Few studies have addressed whether students can deliver as efficient a programme of clinical skills training as teaching by qualified staff.

This study hypothesized that medical students, using PAL can produce comparable training in MSS clinical examination skills as didactic teaching by specialists.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Acknowledgements
 References
 
Standard clinical skills training in Glasgow
GALS is introduced in the second semester in year 2 for students as standard MSS examination technique [10]. Initially, this is undertaken on fellow students and supervised by trained tutors. Subsequently, GALS is used when examining patients with MSS problems during clinical attachments.

Training student trainers for PAL
The PAL training module in GALS, and educational techniques, was made available to all students in years 3–5 as a student selected component (SSC). Three groups of student volunteers trained in this SSC (n1 = 3, n2 = 3 and n3 = 6), and each recruited volunteers at various stages of the year-2 curriculum, for PAL training (n1 = 20, n2 = 14, n3 = 11).

For each student trainer the GALS training module consisted of:

Week 1. Literature review and training in educational theory and generation of a paper on PAL and small group teaching.
Week 2. Observation of the GALS video, practising techniques and critically reviewing performance under supervision. Volunteers from year 2 were recruited by advertising using posters in teaching sessions and by e-mail to the year group.
Week 3. First 2 h PAL training session for year-2 volunteer trainees. Written consent was obtained before training.
Week 4. Second 2 h PAL training session.
Week 5. Submission of dissertation reflecting on PAL and the training programme.

Specialist group
Specialist-led GALS training was offered by a physiotherapist in the second semester of year-2 to a 4th group of student volunteers (n4 = 19) in a 2-h didactic format. Advertising for this session used posters and e-mail, similar to that for PAL groups

Evaluation of training
Evaluation of the student trainees from PAL-led or expert-led sessions were assessed using confidence levels pre/post training (100 mm visual analogue scale) and course experience questionnaires (5-point Likert scale), including free text comments [12, 13].

Objective structured clinical examination data
All year-2 students undergo an objective structured clinical examination (OSCE) that includes an MSS station assessing students in their use of GALS. This allowed comparison of pass rates obtained by students trained by their peers, the specialist and those after standard training alone. Examiners were trained using videos of students at different standards and were unaware of which students had received additional training.

Ethical approval for the study was obtained from the University of Glasgow Ethics Committee, Scotland.

Analysis
Statistical analyses were processed using SPSS 11.5.0 for Windows® (SPSS Inc.). Free text comments were categorized by themes. The Bonferroni correction was applied to correct for errors resulting from multiple comparisons [14].


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Acknowledgements
 References
 
Demography
Trainers contacted the entire year-2 cohort of 245 students, 45 (18%) volunteered to receive additional MSS training by PAL, and 19 (8%) from the specialist. The female : male ratios were 64 : 36, 70 : 30 and 64 : 36, respectively. The remaining 181 students underwent standard training alone. The ratio of undergraduate to postgraduate entrants for the entire year, PAL-led and specialist-led were: 87 : 13, 85 : 15 and 89 : 11, respectively. The numbers of trainees that signed up for additional training in each of the four groups were similar (20, 14, 11 and 19). No students participated in both PAL and expert-led training.

Confidence
Groups 1–3 took part in student-led PAL training and Group 4 in didactic physiotherapist-led teaching. Table 1 shows levels of pre- and post-confidence in all five parameters of GALS, for each group. Analysis by Kruskal–Wallis and Mann–Whitney U-tests showed a lower pre-training confidence from Group 1 students (P < 0.0001). In comparison with Groups 2–4, Group 1 had received no standard curriculum tuition in use of GALS prior to their PAL training. Groups 2–4 showed similar levels of pre-training confidence.


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  		TABLE 1. Pre- and post-training confidence levels as measured by student participants using a 100 mm visual analogue scale

 
All students improved in confidence after getting trained in using each GALS component irrespective of learning technique (Wilcoxon signed rank test; P < 0.0001). Although Group 1 had a lower pre-training confidence level all four groups had similar post-training confidence levels.

Course evaluation questionnaire data (including free-text comments)
The course evaluation questionnaires (CEQs) were returned by 33/45 (73%) of year-2 students following PAL training, and 19/19 (100%) from the expert-trained group. Results (Table 2) showed that almost all trainees agreed/strongly agreed that they had improved their confidence in use of GALS and their ability to apply knowledge to new situations. In addition, positive views were also demonstrated in the ability of student trainers to act as educators, organizers and deliverers of helpful feedback. After applying the Bonferroni correction [14], there were no statistical differences in responses to any questions between groups when analysed by Mann–Whitney U-test.


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  		TABLE 2. Outcomes from CEQ data evaluating student's additional training—shows the results from each of the specific questions

 
Free-text responses were received from 14/33 (42%) of PAL trained students, and all 19 (100%) from the expert-led group. Responses were collated into three categories (Table 3). Not all students passed comments on each category. Students from both groups perceived that the training format worked well producing significant gains to participating in extra training. However, the two groups differed in areas for improvement. While PAL students made no comments about the need for extra resources, the expert-led trainees requested additional materials—‘we may forget what we have learnt—handouts please’. In comparison, the PAL trainees requested more learning in the PAL style—‘would have been useful to cover more than just MSS’—comments not recorded by the expert-led group.


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  		TABLE 3. Outcomes from CEQ data evaluating student's additional training—shows the themes consolidated from the free-text comments on the CEQ

 
OSCE data
In end-of-year OSCE examinations all year-2 students (n = 245) completed a station-assessing performance in lower limb examination using GALS. After standard curriculum training, 111/181 (61%) achieved a pass at this station. Following additional training, the pass rate rose for the students who had undertaken extra training, which rose to 39/45 (87%) after PAL (P = 0.002), and 16/19 (84%) after expert-led tuition (P < 0.0001) with odds ratios of >1.4 and >1.3, respectively. There were no differences between pass rates after PAL or expert-led training.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Acknowledgements
 References
 
These data confirm previous studies [9, 11] showing that PAL provides a useful adjunct to standard curriculum GALS training. However, this article extends these observations by comparing responses from students undergoing tuition from their peers with those trained in a didactic session by an expert. Both groups of students are equally confident in using GALS to examine the MSS. CEQs and free-text comments reveal a similar degree of group benefit following tuition through PAL or by the expert. Data show that student trainers organized PAL sessions well, provided good explanations, encouraged questions and gave valuable feedback again to a similar level to that from a specialist. In addition, students undergoing PAL do as well as those trained by the specialist in the end-of-year OSCE MSS station, being 1.4 times more likely to pass as compared with 1.3 for those trained by the expert. Two previous studies of clinical skill training have compared PAL and faculty-led teaching [8, 15]. In both, PAL was at least as equivalent to teaching by specialists.

Undergraduate training in rheumatology is being increasingly undertaken by paramedical staff [16, 17], and trained patients [18, 19]. In didactic teaching sessions, both were as proficient as medical tutors. This study extends this principle and suggests that interested, trained students could equally well take on clinical skills training using PAL. It could be argued that extra tuition, irrespective of method of delivery, improves student confidence and performance, which could explain the lower performance of the group without additional tuition. However, these data do show differences between the extra training techniques and provide some evidence that added benefits accrue following participation in PAL.

PAL does necessitate a longer duration of training to allow students to practice and view their technique and correct their own mistakes through the interactions that PAL encourages [20]. No such peer-learning takes place during didactic teaching, which being unidirectional, can be carried out over a shorter interval. However, when asked how their training experience could be improved, expert-taught students requested more information (e.g. handouts), implying a dependence on the tutor for learning. This is a common outcome following didactic teaching, but was not raised by any student from the PAL-trained group. In comparison, participating in PAL, helping and being helped by one another in a relatively non-threatening environment, allows students to identify that PAL has the potential to be applied to other areas of training—a feature not suggested by students in the expert-led group.

Two other observations were raised by this study. First, analysis of the trainees’ confidence in the three PAL groups showed that the pre-training confidence was lower in those from Group 1. Quite fortuitously, this cohort was recruited during the first semester in year 2, before standard curriculum GALS training. The other PAL cohorts (Groups 2/3) had higher pre-training confidence scores, being recruited after their first exposure to GALS. Comparison of pre-training confidence from Group 1 with Groups 2/3 implies that routine GALS training raises student confidence in their ability to examine the MSS [21]. Despite no experience in use of the GALS screen, the first cohort attained similar levels of post-training confidence to the groups who had received standard training. It does remain to be elucidated exactly what level a student's confidence can reach immediately after routine GALS training, and how this changes with time. Nevertheless, this raises the possibility that student trainers could use PAL to deliver standard GALS curriculum and not just as an adjunct to training.

Second, there is the issue of recruitment. Some studies have used selection by academic performance [8] or financial incentives [22, 23] to entice students into PAL training. In order to provide all students with the opportunity to participate in PAL, those taking part were volunteers in this study. While self-selection could encourage the more gifted or the more challenged students to apply, the demographics suggest that the cohorts are similar, which reinforces data from previous studies where students were not pre-selected [9, 11]. However, conclusive evidence that self-selection does not influence outcomes will only result from a randomized study incorporating PAL into the standard curriculum. Despite the potential criticisms, the results from the study do show benefits in rheumatology expertise, as well as providing an opportunity for students to reflect on their personal development. Furthermore, this learning opportunity will also provide a useful experience for inclusion in the foundation year application forms.

Any extra training will improve exposure to that topic, but PAL by providing a positive, interactive learning opportunity in a less threatening environment than didactic teaching, affords a richer experience. Since career choices are usually based on previous positive experience [24] and PAL is regarded as one such, its application to the study of the MSS can only encourage recruitment into rheumatology. However, longer-term studies are required to confirm this hypothesis.

Formula


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
References
 
The authors would like to thank the medical students who participated in this study.

Funding: Arthritis Research Campaign has provided funding for K.G. as part of this project.

Disclosure statement: The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 

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Submitted 15 August 2007; revised version accepted 21 January 2008.
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This Article
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