SHORT COMMUNICATION
Near-Peer Teaching Strategy in a Large Human Anatomy Course: Perceptions of Near-Peer Instructors ndez, Juan Manuel Carmona Pulido, Roberto Isaac De la Garza Chapa, Cynthia Guadalupe Reyes-Herna zquez, Ricardo Daniel Alcala Briones, Perla Marina Plasencia Banda, Ruth Patricia Serna Va Eliud Enrique Villarreal Silva, Guillermo Jacobo Baca, Oscar de la Garza Castro, ~ a,* Santos Guzma n Lo pez Rodrigo Enrique Elizondo Oman Department of Human Anatomy, School of Medicine, Autonomous University of Nuevo Leon, Monterrey, Mexico
Near-peer teaching (NPT) is a strategy in which senior students assume the instructor role with junior peers (mentees). Senior students develop unique skills and knowledge through NPT, an experience which extends their learning beyond content mastery. Different teaching modules featuring NPT were utilized in the human anatomy course at the School of Medicine, Autonomous University of Nuevo Leon in Monterrey, Mexico. Modules included: Theory, Clinical Hour, Imaging Anatomy, and Laboratory. The aim of this study was to assess instructor participants’ perceptions on the benefits of the NPT strategy in the anatomy classroom. A survey was administered to anatomy course instructors who utilized NPT strategies during winter, fall, and spring semesters of the 2012–2013 school year. A total of 120 instructors were enrolled in the study. There were different perceptions of instructors’ roles. Theory and Imaging Anatomy instructors considered themselves to be information providers and resource developers, whereas Clinical Hour and Laboratory instructors saw themselves more as facilitators, role models, and planners. All instructors’ opinions on the benefits of NPT were positive. Thus, in this article, the authors find NPT to be a strategy that promotes self-learning, a vital C 2014 American Association of Anatomists. skill. Anat Sci Educ 8: 189–193. V Key words: gross anatomy education; medical education; anatomy course; teaching strategies; teaching modules; near-peer teaching; instructors
INTRODUCTION Peer-assisted learning (PAL) is a technique defined as the development of skills and knowledge through the support and help of people who are from the same social group (sharing one condition, for example, being medical students) (Topping and Ehly, 1998; Ross and Cameron, 2007). Peer teaching and learning is an effective educational intervention for health science students in clinical placements (Secomb, 2007), and it has
~ a, Department of *Correspondence to: Dr. Rodrigo E. Elizondo-Oman Human Anatomy, School of Medicine, Autonomous University of Nuevo ~ o s/n. Col. Mitras Centro, C.P. Leon. Ave. Madero y Dr. Aguirre Pequen xico. E-mail: [email protected] 64460 Monterrey, N.L. Me Received 9 October 2013; Revised 7 May 2014; Accepted 22 July 2014. Published online 9 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/ase.1484 C 2014 American Association of Anatomists V
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been considered by many curricula to be an appropriate strategy for providing learning opportunities through teaching. PAL has been used extensively in anatomy courses, and its value has been recognized as a learning strategy (Nnodim, 1997; Krych et al., 2005; Nieder et al., 2005; Youdas et al., 2008). PAL has been used informally for more than three decades in medical education (Wagner, 1982; Costello, 1989; Gibson and Campbell, 2000; Hill et al., 2010); however, in recent years, the regulatory processes dictating the dissemination of the model have gained great international interest. There are different ways of implementing PAL. One such method has senior students act as instructors to other junior students, a tutoring model which has been called near-peer teaching (NPT), (Evans and Cuffe, 2009). NPT differs from traditional peer teaching because the academic seniority of the participants (usually 1–4 years more advanced). In the United Kingdom and the United States, NPT has been used in anatomy laboratories (Rengier et al., 2010). NPT instructors assist professors to lead, motivate, and monitor student learning in the laboratory. This approach allows the student
Anat Sci Educ 8:189–193 (2015)
to learn and at the same time, helps the instructor to develop mentoring skills. In 2011, our department designed and implemented a human anatomy course with NPT. The course was divided into four learning modules: Theory, Clinical Hour (CH), Imaging Anatomy (IA), and Laboratory (LAB). Lectures as part of the Theory module lasted for one hour daily, five days a week, and were delivered in a traditional format. The CH module focused on case discussion based on clinical reasoning and morphological diagnosis, whereas the IA module focused on the identification, description, and comparison of anatomical structures in different imaging studies. Instructors and teachers were involved in both CH and IA modules. Dissections and prosections were performed in the laboratory under instructor supervision. At the end of the course, a satisfaction survey was administered to students (mentees) to gather perceptions on the course. The results indicated an overall positive opinion in all the measured characteristics (Duran et al., 2012). The aim of this study was to investigate NPT instructors’ self-perceived role among different modules used in the human anatomy course.
METHODS This study has been approved by the ethical committee of the Autonomous University of Nuevo Leon. This descriptive cross-sectional study consisted of a survey administered to the anatomy course instructors who utilized NPT strategies during winter, fall and spring semesters of the 2012–2013 school year. A total of 120 instructors were enrolled in the study. The anatomy course lasted for 18 weeks and used multiple learning modules: Theory, which was a daily lecture, and three weekly discussion sessions called Clinical Hour, Imaging Anatomy, and Laboratory. The discussion sessions were conducted in small groups of six to seven students per instructor.
Participants Instructors were respondents to a call for second-year through fifth-year medical students interested to serve as instructors for one of the learning modules. Inclusion criteria required an overall grade point average > 8.0. The roles considered for instructors included: (1) theory instructor, (2) clinical hour instructor, (3) imaging anatomy instructor, and (4) laboratory instructor. Following established criteria for NPT instructors, we required that students spend at minimum 12 hours per week participating in course activities and all training sessions (Lachman et al., 2013). Department teachers conducted the selection and training of instructors. Every week, instructors were trained for two hours in content areas prior to meeting with the students. This training was provided by a subject specialist teacher, and the review of each topic involved defining and standardizing material to be reviewed with the students. Each instructor was assigned to a role related to their academic year. Eligible theory instructors were second-year medical students who had successfully completed the anatomy course. Theory instructors were trained to assist the tenured professor and to provide personalized and group counseling to students as required. Clinical Hour instructors were second- or 190
third-year medical students trained to present and discuss clinical cases. Clinical Hour instructors led discussions for each team. Each case was aimed at understanding the anatomical basis of disease, with the goal of instructing students in how to establish a morphological diagnosis (ElizondoOma~ na et al., 2010). Imaging Anatomy instructors were third- or fourth-year medical students trained to identify, describe and compare anatomical structures with different imaging methods. Imaging Anatomy instructors led discussion for each team. Laboratory instructors were fifth-year medical students who had received training in basic and advanced surgical skills. Laboratory instructors facilitated workshops on cadavers and anatomical parts used for prosection. Teachers, who had many years of anatomy teaching experience, were responsible for the lectures and also participated in the practical laboratory sessions. Teachers led the lectures, with some involvement of students and Theory instructors. During the Clinical Hour, Imaging Anatomy, and Laboratory practice sessions, teachers assumed the role of general supervisor. The Clinical Hour, Imaging Anatomy, and Laboratory practice sessions were designed as discussion sessions led by the instructors. Discussions sessions aimed to develop basic (i.e., identification, description, comparison, and classification) and advanced intellectual skills (i.e., analysis and synthesis) as part of the clinical reasoning process to reach a morphological diagnosis—the main competency of the Human Anatomy course.
Instrument and Statistical Analysis At the end of each course, instructors were asked to answer an anonymous survey regarding the self-perceived role they played with the students and the way in which PAL had influenced their role. The survey asked instructors to select the role with which they most identified. Instructor perceptions were obtained by indicating agreement or disagreement with statements using a 10-point Likert scale (where 10 represented “completely agree” and 1 “strongly disagree”). Surveys also collected demographic data (i.e., gender, age, and place of residence). The frequencies of identified roles were reported, along with the means and standard deviations of responses to questions with the Likert scale scoring.
RESULTS Of 120 instructors participating in the study, 53% were male, 41% were female, and the remaining 6% did not specify a gender. The average age of all instructors was 20.48 6 1.22 years. The modes for age of instructors in the different modules: 19 years for Theory, 20 years for Clinical Hour, 21 years for Imaging Anatomy, and 22 years for Laboratory. Self-perceived role identification was a reflection of the roles and activities performed by the instructors in each course area (Fig. 1). Seventy-six percent of Theory instructors identified as information providers, 10% identified as role models, 7% as facilitators, 5% as advisors, and 2% as resource developers. Forty-four percent of Clinical Hour instructors viewed themselves as information providers 36% as facilitators and 20% as role models. Forty-eight percent of Imaging Anatomy ndez et al. Reyes-Herna
instructors identified as information providers, 31% as resource developers, 13% as facilitators, and 4% as role models and planners. Finally, Laboratory instructors identified themselves with all roles, predominantly with 26% identifying as role models. Survey evaluations collected instructors’ opinions regarding their participation in the course (Table 1). Overall, instructors perceived that their participation benefited both themselves as well as their mentees. Most instructors agreed they felt comfortable in their role and believed that all medical students should learn how to teach through NPT, or a similar program.
DISCUSSION
Figure 1. Perceived major role for instructors in each of teaching/learning modules during human anatomy course.
Learning and teaching are two key activities of a medical doctor. Doctors must transmit knowledge to students and with colleagues. Doctors always teach when they explain a diagnosis or care plan to a patient (Bulte et al., 2007). Traditionally, there are few opportunities for medical students to learn teaching skills (Neagar et al., 2013), so incorporating teaching techniques into the medical school curriculum can help to reinforce positive attitudes aimed at teaching. Additionally, teaching opportunities prepare students to pursue self-learning independently. By teaching, students learn to direct their communication skills toward the effective transfer of knowledge to their colleagues and patients. Training students at this stage of their studies to participate in teaching activities encourages a deeper learning of the subject with opportunities to teach. Thus, students learn twice (Annis, 1983; Evans and Cuffe, 2009). A recent study by Erie et al. showed that students who participated in an anatomy-based student-as-teacher (SAT) session achieved core competencies of a medical educator and felt prepared for the teaching demands of residency (Erie et al., 2013). Bulte et al. (2007) reported the perceptions of instructors (nearpeer teachers) and found that instructors perceived themselves
Table 1. Near-Peer Instructors’ Self-Perceptions about Near-Peer Teaching Program Theory, mean (6SD)
Clinical hour, mean (6SD)
Imaging anatomy, mean (6SD)
Laboratory, mean (6SD)
I was comfortable in my role as instructor
9.60 (60.72)
9.81 (60.43)
8.74 (61.64)
9.78 (60.54)
I think students benefit greatly from my teaching
9.36 (60.70)
9.48 (60.90)
8.77 (61.31)
9.50 (61.47)
I learned a lot about teaching techniques
9.18 (61.6)
9.18 (61.03)
7.81 (61.80)
9.57 (60.87)
I learned a lot about the subject while teaching
9.70 (60.59)
9.16 (61.21)
7.55 (61.86)
9.82 (61.28)
I would choose to be part of peer-assisted learning again
9.36 (61.00)
9.65 (60.67)
8.71 (61.47)
9.83 (60.44)
All medical students should learn how to teach
9.78 (60.95)
9.83 (60.33)
9.59 (60.72)
9.87 (60.25)
Statementa
a
Statements were rated on a 10-point Likert scale (1 5 strongly disagree, 10 5 completely agree).
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191
to be facilitators, role models and information providers. However, in our study, the perceptions differed by learning module. Theory instructors identified themselves as information providers, perhaps because the lecture format of the sessions did not offer them much opportunity to interact with students as mentors. In the discussion sessions (CH, IA, and LAB), there was a change in instructors’ perceptions about their role. The dominant identified role in CH was the facilitator role. In IA, the dominant identity was resource developer. Finally, LAB mostly identified themselves as role models, planners and facilitators. These differences show that among the laboratory instructors there was more active participation and a stronger sense of responsibility and involvement with the students than with the theory instructors, largely due to the inherent format of class sessions. An instructor’s responsibility to learn and acquire a deeper understanding of their subject to discuss, explain and teach involves the self-learning process, a feature essential for achieving meaningful learning. We believe that NPT training allows not only for the adjustment of course content reviewed at each session but also of the teaching–learning method. Therefore, instructors’ perception of their role changes as they better understand their involvement. The survey also collected instructor opinions on personal benefits and the benefits obtained for all the students. Bulte et al. (2007) reported a consistently positive perception of NPT in their study. Nelson et al. (2013) reported that the implementation of NPT in the teaching of junior medical students appears to benefit both students and their near-peer colleagues. It is important to mention that in our study, similar with these others, the peer tutor and peer mentee enjoyed the experience (Robinson et al., 2010). In the present study, many instructors stated that they felt comfortable in their role, believed that students benefited from their teaching. They learned more about the subject matter than they would have otherwise, and 90% would choose to participate again in PAL. Notably, instructors gave the lowest scores to how well they learned teaching techniques, compared to other assertions. This suggests that improved training should be directed toward reviewing the thematic content and also to strengthening teaching strategies. Training sessions for the instructors were considered the main area for improved discussion of the material with subject specialist teachers. Structured training is essential for proper facilitation of discussion sessions. It is important to note that NPT can fail if there is no supervision, or of the teaching of the teachers is poor (Reyes et al., 2014). There is evidence to suggest that participating student– teachers benefit academically and professionally but the longterm effects of peer-teaching programs during medical school remain poorly understood and future research should aim to investigate the longitudinal benefits of NPT (Yu et al., 2011). We believe that the opportunity to acquire knowledge about learning strategies as a medical student increases communication skills and knowledge transfer not only between students but also with colleagues and, importantly, with patients.
CONCLUSIONS The instructors who participated as NPTs had a positive perception of their intervention in all areas of the course. Thematic content training is critical to the success of programs like these, but it is also necessary to strengthen teaching tech192
niques so that NPT instructors are able to achieve the maximum benefit for their mentees.
NOTES ON CONTRIBUTORS CYNTHIA GUADALUPE REYES HERNANDEZ, M.D., is involved in research at the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. She is interested in medical education research and also in research related to the human vascular system. JUAN MANUEL CARMONA CORONADO, M.D., is an associate medical doctor in the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He is interested in medical education research related to student performance in gross anatomy laboratory sessions. ROBERTO ISAAC DE LA GARZA CHAPA, M.D., is coordinator of instructor activities in the theory area of the Human Anatomy Department of the School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He is interested in medical education research related to learning and retaining anatomical knowledge. RUTH PATRICIA SERNA VAZQUEZ, M.D., is the coordinator of instructor activities in the clinical hour area of the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. She is interested in medical education research related to case-based learning in human anatomy. BRIONES, M.D., is coorRICARDO DANIEL ALCALA dinator of instructor activities in the Laboratory area, Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He is interested in medical education research related to teaching anatomy in the laboratory setting. PERLA MARINA PLASENCIA BANDA, M.D., is the coordinator of instructor activities in the imaging anatomy area of the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. She is interested in research related to utilizing imaging in anatomy education. ELIUD ENRIQUE VILLARREAL SILVA, M.D., is an associate professor in the Department of Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He teaches anatomy to undergraduate and graduate students and is interested in medical educational research. GUILLERMO JACOBO BACA, M.D., is an associate professor in the Department of Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He teaches anatomy to undergraduate and graduate students and is involved in medical education research. ~ RODRIGO ENRIQUE ELIZONDO OMANA, M.D., Ph.D., is a tenured professor and research coordinator in the Department of Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He teaches anatomy to undergraduate and graduate students and is a level I researcher in the National System of Researchers in Mexico. LOPEZ, SANTOS GUZMAN M.D., Ph.D., is a tenured professor and head of the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo ndez et al. Reyes-Herna
Leon, Monterrey, Nuevo Leon, Mexico. He teaches anatomy to undergraduate and graduate students and is a level I researcher in the National System of Researchers in Mexico. LITERATURE CITED Annis LE. 1983. The processes and effects of peer tutoring. Hum Learn J Practical Res Appl 2:39–47. Buckley S, Zamora J. 2007. Effects of participation in a cross year peer tutoring programme in clinical examination skills on volunteer tutors’ skills and attitudes towards teachers and teaching. BMC Med Educ 7:20. Bulte C, Betts A, Garner K, Durning S. 2007. Student teaching: Views of student near-peer teachers and learners. Med Teach 29:583–590. Costello J. 1989. Learning from each other: Peer teaching and learning in student nurse training. Nurse Educ Today 9:203–206. Duran CE, Bahena EN, Rodrıguez Mde L, Baca GJ, Uresti AS, ElizondoOma~ na RE, L opez SG. 2012. Near-peer teaching in an anatomy course with a low faculty-to-student ratio. Anat Sci Educ 5:171–176. Elizondo-Oma~ na RE, Morales-G omez JA, Morquecho-Espinoza O, HinojosaAmaya JM, Villarreal-Silva EE, Garcıa-Rodrıguez Mde L, Guzm an-L opez S. 2010. Teaching skills to promote clinical reasoning in early basic sciences courses. Anat Sci Educ 3:267–271. Erie AJ, Starkman SJ, Pawlina W, Lachman N. 2013. Developing medical students as teachers: An anatomy-based student-as-teacher program with emphasis on core teaching competencies. Anat Sci Educ 6:385–392. Evans DJ, Canavan A. 2008. Designing a clinical skills programme: A partnership between students, patients and faculty. Int J Clin Skills 2:130–134. Evans DJ, Cuffe T. 2009. Near-peer teaching in anatomy: An approach for deeper learning. Anat Sci Educ 2:227–233. Gibson DR, Campbell RM. 2000. The role of cooperative learning in the training of junior hospital doctors: A study of pediatric senior house officers. Med Teach 22:297–300. Hill E, Liuzzi F, Giles J. 2010. Peer-assisted learning from three perspectives: Student, tutor and co-ordinator. Clin Teach 7:244–246. 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.
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Lachman N, Christensen KN, Pawlina W. 2013. Anatomy teaching assistants: Facilitating teaching skills for medical students through apprenticeship and mentoring. Med Teach 35:e919–e925. Nieder GL, Parmelee DX, Stolfi A, Hudes PD. 2005. Team-based learning in a medical gross anatomy and embryology course. Clin Anat 18:56–63. Naeger DM, Conrad M, Nguyen J, Kohi MP, Webb EM. 2013. Students teaching students: Evaluation of a "near-peer" teaching experience. Acad Radiol 20: 1177–1182. Nelson AJ, Nelson SV, Linn AM, Raw LE, Kildea HB, Tonkin AL. 2013. Tomorrow’s educators . . . today? Implementing near-peer teaching for medical students. Med Teach 35:156–159. Nnodim JO. 1997. A controlled trial of peer-teaching in practical gross anatomy. Clin Anat 10:112–117. Rengier F, Rauch PJ, Partovi S, Kirsch J, Nawrotzki R. 2010. A three-day anatomy review course taught by senior peers effectively prepares junior students for their national anatomy exam. Ann Anat 192:396–399. Reyes CG, Elizondo-Oma~ na RE, Dela Garza O, Guzm an S. 2014. Near-peer teaching (NPT): The importance of process evaluation. Med Educ Online 19: 24583. Robinson Z, Hazelgrove-Planel E, Edwards Z, Siassakos D. 2010. AMEE guide supplements: Peer-assisted learning: A planning and implementation framework. Guide supplement 30.7—Practical application. Med Teach 32: e366–e368. Ross MT, Cameron HS. 2007. Peer-assisted learning: A planning and implementation framework: AMEE guide no. 30. Med Teach 29:527–545. Secomb J. 2007. A systematic review of peer teaching and learning in clinical education. J Clin Nurs 17:703–716. Topping KJ, Ehly SW (Editors). 1998. Peer-assisted Learning. 1st Ed. Mahwah NJ: Lawrence Erlbaum Associates. 371 p. Wagner L. 1982. Peer Teaching: Historical Perspectives. 1st Ed. Westport, CT: Greenwood Press. 266 p. Youdas JW, Hoffarth BL, Kohlwey SR, Kramer CM, Petro JL. 2008. Peer teaching among physical therapy students during human gross anatomy: Perceptions of peer teachers and students. Anat Sci Educ 1:199–206. Yu TC, Wilson NC, Singh PP, Lemanu DP, Hawken SJ, Hill AG. 2011. Medical students-as-teachers: A systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract 23:157–172.
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Near-Peer Teaching Strategy in a Large Human Anatomy Course: Perceptions of Near-Peer Instructors ndez, Juan Manuel Carmona Pulido, Roberto Isaac De la Garza Chapa, Cynthia Guadalupe Reyes-Herna zquez, Ricardo Daniel Alcala Briones, Perla Marina Plasencia Banda, Ruth Patricia Serna Va Eliud Enrique Villarreal Silva, Guillermo Jacobo Baca, Oscar de la Garza Castro, ~ a,* Santos Guzma n Lo pez Rodrigo Enrique Elizondo Oman Department of Human Anatomy, School of Medicine, Autonomous University of Nuevo Leon, Monterrey, Mexico
Near-peer teaching (NPT) is a strategy in which senior students assume the instructor role with junior peers (mentees). Senior students develop unique skills and knowledge through NPT, an experience which extends their learning beyond content mastery. Different teaching modules featuring NPT were utilized in the human anatomy course at the School of Medicine, Autonomous University of Nuevo Leon in Monterrey, Mexico. Modules included: Theory, Clinical Hour, Imaging Anatomy, and Laboratory. The aim of this study was to assess instructor participants’ perceptions on the benefits of the NPT strategy in the anatomy classroom. A survey was administered to anatomy course instructors who utilized NPT strategies during winter, fall, and spring semesters of the 2012–2013 school year. A total of 120 instructors were enrolled in the study. There were different perceptions of instructors’ roles. Theory and Imaging Anatomy instructors considered themselves to be information providers and resource developers, whereas Clinical Hour and Laboratory instructors saw themselves more as facilitators, role models, and planners. All instructors’ opinions on the benefits of NPT were positive. Thus, in this article, the authors find NPT to be a strategy that promotes self-learning, a vital C 2014 American Association of Anatomists. skill. Anat Sci Educ 8: 189–193. V Key words: gross anatomy education; medical education; anatomy course; teaching strategies; teaching modules; near-peer teaching; instructors
INTRODUCTION Peer-assisted learning (PAL) is a technique defined as the development of skills and knowledge through the support and help of people who are from the same social group (sharing one condition, for example, being medical students) (Topping and Ehly, 1998; Ross and Cameron, 2007). Peer teaching and learning is an effective educational intervention for health science students in clinical placements (Secomb, 2007), and it has
~ a, Department of *Correspondence to: Dr. Rodrigo E. Elizondo-Oman Human Anatomy, School of Medicine, Autonomous University of Nuevo ~ o s/n. Col. Mitras Centro, C.P. Leon. Ave. Madero y Dr. Aguirre Pequen xico. E-mail: [email protected] 64460 Monterrey, N.L. Me Received 9 October 2013; Revised 7 May 2014; Accepted 22 July 2014. Published online 9 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/ase.1484 C 2014 American Association of Anatomists V
Anatomical Sciences Education
MARCH/APRIL 2015
been considered by many curricula to be an appropriate strategy for providing learning opportunities through teaching. PAL has been used extensively in anatomy courses, and its value has been recognized as a learning strategy (Nnodim, 1997; Krych et al., 2005; Nieder et al., 2005; Youdas et al., 2008). PAL has been used informally for more than three decades in medical education (Wagner, 1982; Costello, 1989; Gibson and Campbell, 2000; Hill et al., 2010); however, in recent years, the regulatory processes dictating the dissemination of the model have gained great international interest. There are different ways of implementing PAL. One such method has senior students act as instructors to other junior students, a tutoring model which has been called near-peer teaching (NPT), (Evans and Cuffe, 2009). NPT differs from traditional peer teaching because the academic seniority of the participants (usually 1–4 years more advanced). In the United Kingdom and the United States, NPT has been used in anatomy laboratories (Rengier et al., 2010). NPT instructors assist professors to lead, motivate, and monitor student learning in the laboratory. This approach allows the student
Anat Sci Educ 8:189–193 (2015)
to learn and at the same time, helps the instructor to develop mentoring skills. In 2011, our department designed and implemented a human anatomy course with NPT. The course was divided into four learning modules: Theory, Clinical Hour (CH), Imaging Anatomy (IA), and Laboratory (LAB). Lectures as part of the Theory module lasted for one hour daily, five days a week, and were delivered in a traditional format. The CH module focused on case discussion based on clinical reasoning and morphological diagnosis, whereas the IA module focused on the identification, description, and comparison of anatomical structures in different imaging studies. Instructors and teachers were involved in both CH and IA modules. Dissections and prosections were performed in the laboratory under instructor supervision. At the end of the course, a satisfaction survey was administered to students (mentees) to gather perceptions on the course. The results indicated an overall positive opinion in all the measured characteristics (Duran et al., 2012). The aim of this study was to investigate NPT instructors’ self-perceived role among different modules used in the human anatomy course.
METHODS This study has been approved by the ethical committee of the Autonomous University of Nuevo Leon. This descriptive cross-sectional study consisted of a survey administered to the anatomy course instructors who utilized NPT strategies during winter, fall and spring semesters of the 2012–2013 school year. A total of 120 instructors were enrolled in the study. The anatomy course lasted for 18 weeks and used multiple learning modules: Theory, which was a daily lecture, and three weekly discussion sessions called Clinical Hour, Imaging Anatomy, and Laboratory. The discussion sessions were conducted in small groups of six to seven students per instructor.
Participants Instructors were respondents to a call for second-year through fifth-year medical students interested to serve as instructors for one of the learning modules. Inclusion criteria required an overall grade point average > 8.0. The roles considered for instructors included: (1) theory instructor, (2) clinical hour instructor, (3) imaging anatomy instructor, and (4) laboratory instructor. Following established criteria for NPT instructors, we required that students spend at minimum 12 hours per week participating in course activities and all training sessions (Lachman et al., 2013). Department teachers conducted the selection and training of instructors. Every week, instructors were trained for two hours in content areas prior to meeting with the students. This training was provided by a subject specialist teacher, and the review of each topic involved defining and standardizing material to be reviewed with the students. Each instructor was assigned to a role related to their academic year. Eligible theory instructors were second-year medical students who had successfully completed the anatomy course. Theory instructors were trained to assist the tenured professor and to provide personalized and group counseling to students as required. Clinical Hour instructors were second- or 190
third-year medical students trained to present and discuss clinical cases. Clinical Hour instructors led discussions for each team. Each case was aimed at understanding the anatomical basis of disease, with the goal of instructing students in how to establish a morphological diagnosis (ElizondoOma~ na et al., 2010). Imaging Anatomy instructors were third- or fourth-year medical students trained to identify, describe and compare anatomical structures with different imaging methods. Imaging Anatomy instructors led discussion for each team. Laboratory instructors were fifth-year medical students who had received training in basic and advanced surgical skills. Laboratory instructors facilitated workshops on cadavers and anatomical parts used for prosection. Teachers, who had many years of anatomy teaching experience, were responsible for the lectures and also participated in the practical laboratory sessions. Teachers led the lectures, with some involvement of students and Theory instructors. During the Clinical Hour, Imaging Anatomy, and Laboratory practice sessions, teachers assumed the role of general supervisor. The Clinical Hour, Imaging Anatomy, and Laboratory practice sessions were designed as discussion sessions led by the instructors. Discussions sessions aimed to develop basic (i.e., identification, description, comparison, and classification) and advanced intellectual skills (i.e., analysis and synthesis) as part of the clinical reasoning process to reach a morphological diagnosis—the main competency of the Human Anatomy course.
Instrument and Statistical Analysis At the end of each course, instructors were asked to answer an anonymous survey regarding the self-perceived role they played with the students and the way in which PAL had influenced their role. The survey asked instructors to select the role with which they most identified. Instructor perceptions were obtained by indicating agreement or disagreement with statements using a 10-point Likert scale (where 10 represented “completely agree” and 1 “strongly disagree”). Surveys also collected demographic data (i.e., gender, age, and place of residence). The frequencies of identified roles were reported, along with the means and standard deviations of responses to questions with the Likert scale scoring.
RESULTS Of 120 instructors participating in the study, 53% were male, 41% were female, and the remaining 6% did not specify a gender. The average age of all instructors was 20.48 6 1.22 years. The modes for age of instructors in the different modules: 19 years for Theory, 20 years for Clinical Hour, 21 years for Imaging Anatomy, and 22 years for Laboratory. Self-perceived role identification was a reflection of the roles and activities performed by the instructors in each course area (Fig. 1). Seventy-six percent of Theory instructors identified as information providers, 10% identified as role models, 7% as facilitators, 5% as advisors, and 2% as resource developers. Forty-four percent of Clinical Hour instructors viewed themselves as information providers 36% as facilitators and 20% as role models. Forty-eight percent of Imaging Anatomy ndez et al. Reyes-Herna
instructors identified as information providers, 31% as resource developers, 13% as facilitators, and 4% as role models and planners. Finally, Laboratory instructors identified themselves with all roles, predominantly with 26% identifying as role models. Survey evaluations collected instructors’ opinions regarding their participation in the course (Table 1). Overall, instructors perceived that their participation benefited both themselves as well as their mentees. Most instructors agreed they felt comfortable in their role and believed that all medical students should learn how to teach through NPT, or a similar program.
DISCUSSION
Figure 1. Perceived major role for instructors in each of teaching/learning modules during human anatomy course.
Learning and teaching are two key activities of a medical doctor. Doctors must transmit knowledge to students and with colleagues. Doctors always teach when they explain a diagnosis or care plan to a patient (Bulte et al., 2007). Traditionally, there are few opportunities for medical students to learn teaching skills (Neagar et al., 2013), so incorporating teaching techniques into the medical school curriculum can help to reinforce positive attitudes aimed at teaching. Additionally, teaching opportunities prepare students to pursue self-learning independently. By teaching, students learn to direct their communication skills toward the effective transfer of knowledge to their colleagues and patients. Training students at this stage of their studies to participate in teaching activities encourages a deeper learning of the subject with opportunities to teach. Thus, students learn twice (Annis, 1983; Evans and Cuffe, 2009). A recent study by Erie et al. showed that students who participated in an anatomy-based student-as-teacher (SAT) session achieved core competencies of a medical educator and felt prepared for the teaching demands of residency (Erie et al., 2013). Bulte et al. (2007) reported the perceptions of instructors (nearpeer teachers) and found that instructors perceived themselves
Table 1. Near-Peer Instructors’ Self-Perceptions about Near-Peer Teaching Program Theory, mean (6SD)
Clinical hour, mean (6SD)
Imaging anatomy, mean (6SD)
Laboratory, mean (6SD)
I was comfortable in my role as instructor
9.60 (60.72)
9.81 (60.43)
8.74 (61.64)
9.78 (60.54)
I think students benefit greatly from my teaching
9.36 (60.70)
9.48 (60.90)
8.77 (61.31)
9.50 (61.47)
I learned a lot about teaching techniques
9.18 (61.6)
9.18 (61.03)
7.81 (61.80)
9.57 (60.87)
I learned a lot about the subject while teaching
9.70 (60.59)
9.16 (61.21)
7.55 (61.86)
9.82 (61.28)
I would choose to be part of peer-assisted learning again
9.36 (61.00)
9.65 (60.67)
8.71 (61.47)
9.83 (60.44)
All medical students should learn how to teach
9.78 (60.95)
9.83 (60.33)
9.59 (60.72)
9.87 (60.25)
Statementa
a
Statements were rated on a 10-point Likert scale (1 5 strongly disagree, 10 5 completely agree).
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to be facilitators, role models and information providers. However, in our study, the perceptions differed by learning module. Theory instructors identified themselves as information providers, perhaps because the lecture format of the sessions did not offer them much opportunity to interact with students as mentors. In the discussion sessions (CH, IA, and LAB), there was a change in instructors’ perceptions about their role. The dominant identified role in CH was the facilitator role. In IA, the dominant identity was resource developer. Finally, LAB mostly identified themselves as role models, planners and facilitators. These differences show that among the laboratory instructors there was more active participation and a stronger sense of responsibility and involvement with the students than with the theory instructors, largely due to the inherent format of class sessions. An instructor’s responsibility to learn and acquire a deeper understanding of their subject to discuss, explain and teach involves the self-learning process, a feature essential for achieving meaningful learning. We believe that NPT training allows not only for the adjustment of course content reviewed at each session but also of the teaching–learning method. Therefore, instructors’ perception of their role changes as they better understand their involvement. The survey also collected instructor opinions on personal benefits and the benefits obtained for all the students. Bulte et al. (2007) reported a consistently positive perception of NPT in their study. Nelson et al. (2013) reported that the implementation of NPT in the teaching of junior medical students appears to benefit both students and their near-peer colleagues. It is important to mention that in our study, similar with these others, the peer tutor and peer mentee enjoyed the experience (Robinson et al., 2010). In the present study, many instructors stated that they felt comfortable in their role, believed that students benefited from their teaching. They learned more about the subject matter than they would have otherwise, and 90% would choose to participate again in PAL. Notably, instructors gave the lowest scores to how well they learned teaching techniques, compared to other assertions. This suggests that improved training should be directed toward reviewing the thematic content and also to strengthening teaching strategies. Training sessions for the instructors were considered the main area for improved discussion of the material with subject specialist teachers. Structured training is essential for proper facilitation of discussion sessions. It is important to note that NPT can fail if there is no supervision, or of the teaching of the teachers is poor (Reyes et al., 2014). There is evidence to suggest that participating student– teachers benefit academically and professionally but the longterm effects of peer-teaching programs during medical school remain poorly understood and future research should aim to investigate the longitudinal benefits of NPT (Yu et al., 2011). We believe that the opportunity to acquire knowledge about learning strategies as a medical student increases communication skills and knowledge transfer not only between students but also with colleagues and, importantly, with patients.
CONCLUSIONS The instructors who participated as NPTs had a positive perception of their intervention in all areas of the course. Thematic content training is critical to the success of programs like these, but it is also necessary to strengthen teaching tech192
niques so that NPT instructors are able to achieve the maximum benefit for their mentees.
NOTES ON CONTRIBUTORS CYNTHIA GUADALUPE REYES HERNANDEZ, M.D., is involved in research at the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. She is interested in medical education research and also in research related to the human vascular system. JUAN MANUEL CARMONA CORONADO, M.D., is an associate medical doctor in the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He is interested in medical education research related to student performance in gross anatomy laboratory sessions. ROBERTO ISAAC DE LA GARZA CHAPA, M.D., is coordinator of instructor activities in the theory area of the Human Anatomy Department of the School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He is interested in medical education research related to learning and retaining anatomical knowledge. RUTH PATRICIA SERNA VAZQUEZ, M.D., is the coordinator of instructor activities in the clinical hour area of the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. She is interested in medical education research related to case-based learning in human anatomy. BRIONES, M.D., is coorRICARDO DANIEL ALCALA dinator of instructor activities in the Laboratory area, Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He is interested in medical education research related to teaching anatomy in the laboratory setting. PERLA MARINA PLASENCIA BANDA, M.D., is the coordinator of instructor activities in the imaging anatomy area of the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. She is interested in research related to utilizing imaging in anatomy education. ELIUD ENRIQUE VILLARREAL SILVA, M.D., is an associate professor in the Department of Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He teaches anatomy to undergraduate and graduate students and is interested in medical educational research. GUILLERMO JACOBO BACA, M.D., is an associate professor in the Department of Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He teaches anatomy to undergraduate and graduate students and is involved in medical education research. ~ RODRIGO ENRIQUE ELIZONDO OMANA, M.D., Ph.D., is a tenured professor and research coordinator in the Department of Anatomy, School of Medicine of the Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico. He teaches anatomy to undergraduate and graduate students and is a level I researcher in the National System of Researchers in Mexico. LOPEZ, SANTOS GUZMAN M.D., Ph.D., is a tenured professor and head of the Department of Human Anatomy, School of Medicine of the Autonomous University of Nuevo ndez et al. Reyes-Herna
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