Peer Teaching

Evaluating peer teaching about chronic disease Sylvia Guenther, Narelle Shadbolt and Chris Roberts, Sydney Medical School-Northern (Hornsby), The University of Sydney, New South Wales, Australia Tyler Clark, Office of Medical Education, The University of Sydney, New South Wales, Australia

SUMMARY Background: The primary care areas of priority (PCAP) activity was developed to engage medical students in learning about chronic disease management in a clinical context from their peers. It is one of several summative assessment tasks that occur during a primary care community term rotation in a graduate-entry medical programme. We evaluated the acceptability and effectiveness of the PCAP activity as a combined teaching, learning and assessment innovation. Methods: Evaluation and assessment data from students who rotated through the four

community term blocks during the 2011–2012 academic year was analysed using both qualitative and quantitative methods. Results: Analysis indicated that 89 per cent (n = 148/166) of responding students rated the PCAP as satisfactory, good or excellent. The marking rubric contained 11 assessable components, including teaching skills, mastery of clinical knowledge, developing a management plan, disease prevention and health promotion opportunities, identifying patient safety issues, the impact of the clinical presentation on the patient and family, and consideration of

health equity factors. Analysis of the assessment scores indicated that the majority of students achieved the specified learning outcomes. Discussion: The PCAP peer teaching activity was an acceptable and effective format for teaching about the management of chronic conditions in the community, and is adaptable to other teaching contexts. Students enjoyed teaching and being taught by their peers, and assessment results indicated that they developed their clinical knowledge as well as their teaching ability regarding chronic disease management.

PCAP peer teaching activity is an effective format for teaching about the management of chronic conditions in the community

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Optimal management in the community will result in better outcomes for patients

INTRODUCTION

T

he growing burden of chronic disease is a significant challenge to the health systems of many countries, and is predicted to increase substantially in the future.1 In the US in 2009, 78 per cent of total health spending was used for chronic illness care, and it has been estimated that two-thirds of deaths globally will result from chronic disease by 2015.1,2 In Australia more than 80 per cent of people aged over 65 years have three or more long-term conditions, and more than 50 per cent of general practice consultations concern chronic disease management.3,4 Accordingly, the Australian Government has targeted specific common chronic conditions as National Health Priority Areas (Box 1),3 to reduce the burden of illness in the community.3

There has been international recognition of a training gap relating to developing competencies in the contemporary management of chronic conditions within medical school curriculum.5–8 In community and primary care placements, students develop knowledge and understanding of the management of chronic illness and its impact on the patient, their family and the wider community.5–8 This

Box 1. Australian National Health Priority Areas3 • Arthritis and musculoskeletal conditions

experience is complementary to that of acute illness seen in hospitals.5,7 Although some teaching programmes regarding chronic illness within community settings have been described, there is room for new initiatives that will engage students, have wide applicability and are linked with assessment, to drive learning.5–8 The University of Sydney Medical programme is a 4–year postgraduate course that includes the early integration of clinical experiences. From the third year, students rotate through core medical, surgical and specialty blocks. The 8–week Community block provides students with an immersive general practice experience in rural and urban locations. In a combination of guided experiential learning, structured teaching, interactive and reflective activities students develop the skills and understanding to work in diverse communities in Australia and beyond.

• Asthma • Cancer control • Cardiovascular health • Diabetes • Injury prevention and control • Mental health • Obesity

A curriculum review in 2010 provided an opportunity to develop a new assessment activity, the primary care areas of priority (PCAP), as a component of the new integrated summative assessment for the Community block. Peer teaching, in which there is growing international interest, was chosen

as a vehicle for the PCAP as it provides numerous benefits for students, including motivation for learning, knowledge acquisition and retention, as well as developing confidence and communication skills.9–11 Each student prepared a 1–hour teaching session based on a randomly allocated case that was derived from one of the eight National Health Priority Areas (Box 1).3 To ensure that the curriculum was covered, each student also participated in seven peer presentations. Students were encouraged to promote discussion by using interactive small group teaching methods that included activities such as quizzes, videos and drama. The presentation was observed and assessed by an academic tutor, who provided content feedback when required. A briefing on how to prepare and present PCAPs was held for students during orientation to support the development of their teaching skills. Further support included resources on an e–learning platform and guidance regarding the case history. Specific learning outcomes guided the integration of clinical knowledge with topics such as: comorbidities; psychosocial contextual factors; disease prevention and health promotion strategies;

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Percent of students (n = 166)

facilitated the development of clinical knowledge. The students enjoyed teaching others, working as a team and being taught by their peers. Their comments reflected gaining teaching experience and the students enjoyed the interactive nature of the presentations. Unhelpful

Needs improvement

Satisfactory

Good

Excellent

Students teaching students make the presentations more engaging and memorable.

Figure 1. Student satisfaction with the primary care areas of priority (PCAP) teaching session

Percent of students (n = 257)

The students valued that the teaching session was embedded in the clinical environment

The students valued that the teaching session was embedded in the clinical environment of general practice.

30 25 20 15

Engaging in the real world…implementation of theoretical knowledge.

10 5 0

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99

100

PCAP mark as raw percent Pass mark 50 Distinction mark 75

The students-as-teachers identified that they learned about their own PCAP topic in great detail, which was reinforced by teaching the material.

Figure 2. Distribution of total student scores

health equity issues, such as the comparison of rural versus urban areas; risk assessment; and the application of clinical guidelines into the presentation. In this context we sought to investigate the acceptability and effectiveness of this novel peer teaching activity regarding the management of chronic conditions in the community.

METHODS The PCAP teaching session was evaluated for the whole-year cohort of students (n = 260) at the end of each of the four community term rotations (n = 60–70) in the 2011–2012 academic year. We used a survey instrument consisting of a five-point Likert scale questionnaire and collected qualitative comments to enrich our understanding of the student experience. Assessment results were analysed using SPSS 19 (SPSS Inc., Chicago, IL, USA).

An existing collection of de-identified evaluation data that was completed anonymously was used, which fulfilled the Sydney University Human Research Ethics Committe (HREC) criteria of negligible risk, and therefore did not require formal ethical approval.

RESULTS Evaluation data were available from 69.2 per cent (n = 180/260) of students. A total of 89 per cent (n = 148/166) of students who responded to how they perceived the PCAP as a learning experience rated the PCAP peer teaching and learning session as satisfactory, good or excellent (Figure 1), with the convention in our school that ‘satisfactory’ is positive. Analysis of student comments revealed that the PCAP was considered to be a good learning experience that developed the student’s teaching skills and

I thought doing a presentation was a great way to learn the information required. The students-as-learners frequently identified that the teaching sessions and handouts enabled a number of topics to be presented thoroughly, which was useful for the students and especially for revision. Improvements to the activity that were suggested by 51 per cent (n = 85/166) of students were primarily about aspects of the process, including the timing of the activity and clarifying the instructions given to the students. The PCAP marking rubric contained 11 assessable components (Appendix 1 available online). Figure 2 shows the distribution of student scores, indicating that the majority of

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The PCAP is adaptable to other teaching contexts to suit the student’s stage

students achieved the specified learning outcomes regarding teaching skills and clinical knowledge, as the total student scores showed a mean of 79.5 per cent (SD 10.7%), with 71 per cent (n = 183/257) achieving a distinction or higher. (Three students either deferred or withdrew from the program).

teaching presentation, and lead an informed discussion. Students highlighted that teaching colleagues and working as a group provided motivation to prepare well for the other students.9,10 The PCAP learning and teaching session has an additional driver for learning, as it is a summative assessment task.9

DISCUSSION Our results indicate that the students found the PCAP session to be an acceptable and effective learning activity, as most students were able to demonstrate that they had achieved their learning outcomes regarding chronic disease management. The positive level of student satisfaction with the PCAP activity reflects the ‘enthusiasm’ for peer teaching reported widely in the literature.11,12 These subjective outcomes ‘help to indicate student support, co-operation and satisfaction’, which contribute to the success of the community term programme.11 The interactive small group teaching style provided a safe learning environment, and learning was also facilitated by the student-teachers providing teaching that was both cognitively and socially compatible for the learners.9 The benefits of peer teaching for student-teachers have been well described, and it is often stated that ‘to teach is to learn twice’.9–12 The student’s qualitative comments and assessment results support the literature findings that ‘preparing to teach and actively teaching’ has a positive effect on the student teacher’s learning outcomes, as there are beneficial effects on the acquisition and length of retention of knowledge.9,10,11,13 This was complemented by the development of teaching skills, as students were required to do more than usual when studying: they had to develop and deliver a

The PCAP could be adapted to address the identified international need for medical education in other medical schools regarding chronic illness.5–8 The format is flexible and effective when used in urban and remote areas, and is adaptable to other teaching contexts to suit the student’s stage, the varying educational needs of undergraduate and postgraduate curricula, and to highlight different regional health priorities. It is feasible for other clinical schools to provide as it uses a hybrid format incorporating e–resources and an academic staff member is only required for assessment of the presentation. A strength of this article is that, as far as we are aware, this is the first report on a peer teaching and learning assessment activity regarding chronic disease management in the community. Furthermore, the data were anonymous and collected electronically by the clinical school, which enabled the students to give honest feedback and minimized the risk of survey bias. Although this report is limited to data from one year and from a single site across one cohort, future evaluation could compare data from consecutive years and include deeper reflection from the students as learners and as teachers.

CONCLUSION The PCAP peer teaching activity was an acceptable and effective

format for teaching and learning about the management of chronic conditions in the community, and can be adapted to other teaching contexts. Students enjoyed teaching and being taught by their peers, and assessment results indicated that they developed their clinical knowledge as well as teaching ability in the areas targeted by National Health Priority Areas in chronic disease management.3 REFERENCES 1. Bodenheimer T, Chen E, Bennett HD. Confronting The Growing Burden Of Chronic Disease: Can The U.S. Health Care Workforce Do The Job? Health Aff 2009;28:64–74. 2. World Health Organization. Preventing Chronic Diseases: a vital investment. Available at http://www.who.int/chp/ chronic_disease_report/contents/ part1.pdf. Accessed on 15 January 2014. 3. Australian Government Department of Health Chronic disease. Chronic diseases are leading causes of death and disability in Australia. Available at http://www.health.gov. au/internet/main/publishing.nsf/ Content/chronic. Accessed on 14 January 2014. 4. Australian Government Department of Health and Ageing Building a 21st Century Primary Health Care System: Australia’s First National Primary Health Care Strategy, 2010. Available at http://www.yourhealth.gov.au/ internet/yourhealth/publishing. nsf/Content/3EDF5889BEC00D98C A2579540005F0A4/$File/ 6552%20NPHC%201205.pdf. Accessed on 14 January 2014. 5. Holman H. Chronic disease—the need for a new clinical education. JAMA 2004;292:1057–1059. 6. Diederiks JPM, Bosma H, Van Eijk JTM, Van Santen M, Scherpbier A, Van Der Vleuten C. Chronic patients in undergraduate education: didactic value as perceived by students. Med Educ 2006;40:787–791. 7. Nair B, Finucane P. Reforming medical education to enhance the management of chronic disease. Medical Journal of Australia 2003;179:257–259.

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8. McKinlay E, McBain L, Gray B. Teaching and learning about chronic conditions management for undergraduate medical students: utilizing the patient-asteacher approach. Chronic Illness 2009;5:209–218.

11. Yu T–C, Wilson NC, Singh P, Lemanu DP, Hawken SJ, Hill AG. Medical students-as-teachers: a systematic review of peerassisted teaching during medical school. Adv Med Educ Pract 2011;2:157–172.

9. Ten Cate O, Durning S. Dimensions and psychology of peer teaching in medical education. Med Teach 2007;29:546–552.

12. Ross MT, Cameron HS. Peer assisted learning: a planning and implementation framework: AMEE guide no. 30. Med Teach 2007;29:527–545.

10. Ten Cate O, Durning S. Peer teaching in medical education: twelve reasons to move from theory to practice. Med Teach 2007;29:591–599.

13. Gregory A, Walker I, McLaughlin K, Peets A. Both preparing to teach and teaching positively impact learning outcomes for peer teachers. Med Teach 2011;33:e417–e422.

SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at http://onlinelibrary.wiley.com/ doi/10.1111/tct.12211/suppinfo Appendix S1. Community Specialty Block: PCAP Marking Sheet.

The PCAP could be adapted to address the identified international need for medical education in other medical schools regarding chronic illness

Corresponding author’s contact details: Dr Sylvia Guenther, Sydney Medical School - Northern (Hornsby), Building 3, Hornsby Ku-ring-gai Hospital, Palmerston Road, Hornsby, NSW 2077, Australia. E-mail: [email protected]

Funding: None. Conflict of interest: None. Ethical approval: All data used were part of an existing collection of de-identified data that was completed anonymously and contained no identifiable information. Sydney University HREC has confirmed that the project falls into the ‘negligible risk with non-identifiable data’ category, and does not require formal ethical approval. doi: 10.1111/tct.12211

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Evaluating peer teaching about chronic disease.

The primary care areas of priority (PCAP) activity was developed to engage medical students in learning about chronic disease management in a clinical...
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