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Bildung im Gesundheitswesen / Education In Health Care
Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective夽 Tutorielle Vermittlung klinisch-praktischer Fertigkeiten im Skills-Lab: Komplexität, Relevanz und Lehrkompetenz aus ärztlicher, tutorieller und studentischer Sicht Jan Lauter, Sylvie Branchereau, Wolfgang Herzog, Till Johannes Bugaj, Christoph Nikendei ∗ Centre for Psychosocial Medicine, University Hospital Heidelberg, Department of General Internal Medicine and Psychosomatics, Heidelberg, Germany
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Article History: Received: 14 October 2016 Received in revised form: 27 January 2017 Accepted: 3 March 2017 Available online: xxx
Keywords: procedural skills skills lab peer-teaching medical education
a b s t r a c t Background: In current medical curricula, the transfer of procedural skills has received increasing attention. Skills lab learning and tutor-led teaching have become an inherent part of all medical curricula at German medical faculties. In 2011, the initial basis for the classification of clinical skills in medical school was created by the German Association for Medical Education (GMA) Committee’s consensus statement on procedural skills. As a recommendation for medical curricula, the National Competency-based Catalogue of Learning Objectives (NKLM, 2015) lists procedural skills according to their curriculum integration and competency level. However, classification in regard to the perceived complexity, relevance, or teaching competency is still lacking. Objective: The present study aimed to investigate procedural skills taught at the Medical Faculty of Heidelberg in regard to their complexity, relevance, and required teaching skills. To achieve this aim (1) the specific procedural skills in terms of complexity, that is, the degree of difficulty, and (2) the perceived relevance of taught procedural skills for studying and subsequent medical profession as well as (3) the personal preparation and required teaching skills were assessed in medical teachers, tutors and students. Method: During the winter semester 2014/2015, the evaluations of all medical teachers, student tutors, and medical students in the skills lab teaching departments of internal medicine, surgery, pediatrics, gynecology, and otorhinolaryngology at the Medical Faculty of Heidelberg were assessed via a quantitative cross-sectional questionnaire survey using 7-point Likert scales. The questionnaire comprised four item sets concerning 1) demographic details, 2) procedural skill complexity, 3) practical relevance, and 4) required preparation and teaching skills. Descriptive, quantitative analysis was used for questionnaire data. Results: The survey included the data from 17 of 20 physicians (return rate: 85 %), 10 of 10 student tutors (return rate: 100 %) and a total of 406 of 691 students (return rate: 58.8 %). In terms of complexity and relevance, no major differences between medical teachers, tutors, and students were found. Procedural skills, assigned to the competence level of final year medical education in the NKLM, were also perceived as more complex than other skills. All skills were considered as equally relevant, and student tutors were seen to have equally competent teaching skills as experienced medical teachers. Conclusion: This study largely underpins the NKLM’s classification of procedural skills. The complexity assessment allows for conclusions to be drawn as to which skills are perceived to require particularly intensive training. Finally, our study corroborates extant findings that student tutors are apt at teaching procedural skills if they have been properly trained.
夽 Ethical approval was granted by the ethic committee of the University of Heidelberg (S-423/2014). ∗ Corresponding author: Adj. Prof. Dr. med. Christoph Nikendei, MD, MME-D, Centre for Psychosocial Medicine, University Hospital Heidelberg, Department of General Internal Medicine and Psychosomatics, Thibautstraße 4, 69115 Heidelberg, Germany. E-mail: [email protected] (C. Nikendei). http://dx.doi.org/10.1016/j.zefq.2017.03.005 1865-9217/
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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Artikel-Historie: Eingegangen: 14. Oktober 2016 Revision eingegangen: 27. Januar 2017 Akzeptiert: 3. März 2017 Online gestellt: xxx
Schlüsselwörter: Klinisch-praktische Fertigkeiten Skills-lab studentische Tutoren medizinische Ausbildung
z u s a m m e n f a s s u n g Hintergrund: Das Vermitteln klinisch-praktischer Fertigkeiten erzielt in den medizinischen Curricula eine immer größere Aufmerksamkeit. An den Medizinischen Fakultäten der Bundesrepublik Deutschland gehört das Skills-Lab sowie der tutorengeleitete Unterricht mittlerweile zum obligaten Bestandteil eines jeden medizinischen Curriculums. 2011 wurde durch ein Konsensusstatement des GMA-Ausschusses für praktische Fertigkeiten eine erste Grundlage zur Klassifizierung klinischer Fertigkeiten im Medizinstudium geschaffen. Im Nationalen Kompetenzbasierten Lernzielkatalog (NKLM, 2015) werden praktische Fertigkeiten schließlich nach ihrer Einbindung ins Curriculum und einer Kompetenzebene gelistet und als Empfehlung für Medizinische Curricula dargeboten. Eine Klassifizierung nach der wahrgenommenen Komplexität, der eingeschätzten Relevanz oder einer Lehrkompetenz steht jedoch aus. Fragestellung: Ziel der vorliegenden Studie war es vor diesem Hintergrund die an der Medizinischen Fakultät Heidelberg gelehrten klinisch-praktischen Fertigkeiten auf ihre Komplexität, Relevanz und erforderlichen Lehrkompetenz hin zu untersuchen. Hierfür sollten (1) spezifische klinisch-praktische Fertigkeiten in Hinblick auf Komplexität, das heißt dem Grad der Schwierigkeit sowie (2) die Relevanz der unterrichteten klinisch-praktischen Fertigkeiten für das Studium und den späteren Arztberuf und (3) die persönliche Vorbereitung und Lehrkompetenz, für die Vermittlung praktischen Fertigkeiten jeweils von Seiten der ärztlichen Dozenten, studentischen Tutoren und Studierenden angeben werden. Methode: Über das Wintersemester 2014/2015 wurden die Einschätzungen sämtlicher ärztlichen Dozenten, studentische Tutoren und medizinischen Studierenden im Skills-Lab Unterricht der Fachbereiche Innere Medizin, Chirurgie, Pädiatrie, Gynäkologie und Hals-Nasen-Ohrenheilkunde an der Medizinischen Fakultät Heidelberg durch eine quantitative Querschnittsfragebogenerhebung mittels 7 Punkt Likert-Skalen erhoben. Der Fragebogen enthält vier Fragekomplexe zu 1) demographischen Angaben, 2) Einschätzung der Komplexität der klinisch-praktischen Fertigkeiten 3) Bewertung ihrer Relevanz und 4) Vorbereitung und Lehrkompetenz beim Unterrichten praktischer Fertigkeiten. Die Daten wurden deskriptiv ausgewertet und nach ihren Häufigkeiten und Mittelwerten angegeben. Ergebnisse: In Hinblick auf Komplexität und Relevanz gibt es keine gravierenden Unterschiede zwischen ärztlichen Dozenten, studentischen Tutoren und Studierenden. Jene praktischen Fertigkeiten, die im NKLM der Kompetenzebene des Praktischen Jahr zugeordnet werden, werden in der vorliegenden Untersuchung ebenfalls komplexer als andere Fertigkeiten empfunden. Alle Fertigkeiten werden als gleichermaßen relevant angesehen und die studentischen Tutoren werden im Unterrichten gleichermaßen kompetent erlebt wie ärztliche Dozenten. Schlussfolgerung: Die im NKLM dargebotene Einordnung klinisch-praktischer Fertigkeiten wird durch diese Untersuchung zum Teil untermauert. Die Einschätzungen zum Grad der Komplexität lässt Rückschlüsse darauf zu, welche Fertigkeiten besonders trainingsintensiv sind. Schließlich wird einmal mehr angedeutet, dass studentische Tutoren im unterrichten klinisch-praktischer Fertigkeiten ebenso gut geeignet sind wenn sie vorher ausreichend geschult wurden.
Introduction Medical competencies, such as communication skills and procedural skills, play a crucial role in medical education. At the majority of German medical faculties, skills labs have become a mandatory part of any medical curriculum when it comes to teaching procedural skills [1–4]. In skills labs, procedural skills are practiced on simulation models before the procedures are performed on real-life patients. From a scientific perspective, training results for procedural skills taught in skills labs have been proven to be effective [1,5,6], transferable to bedside [7] and consistent over time [8]. In regard to teaching procedural skills, peer-assisted learning (PAL), that is imparting knowledge or skills by means of student tutors, has received increasing interest. Currently, all German medical faculties have come to employ student tutors for teaching procedural skills [1]. Extant literature supports this approach: several randomized controlled studies on skills lab training have been able to show that student tutors and medical teacher are on a par [9–11], if tutors have received adequate and sufficient training previously [12–14]. In 2011, the German Association for Medical Education‘s (dt.: Gesellschaft für Medizinische Ausbildung, GMA) Committee on procedural skills created the initial basis for the classification of procedural skills in a consensus statement [15], in which all listed procedural skills are categorized in regard to their core or elective competence and a recommendation to whether respective skill mastery should be achieved before starting clerkship,
final year training, or post gradual training, is given. Creating an effective impetus for action, these recommendations were largely adopted by the National Competency-based Catalogue of Learning Objectives (NKLM) [16] in 2015. Similar to the GMA’s consensus statement, the NKLM provides guidance to at which study stage (pre-clinical, clinical, clerkship, post graduate training or scientific level) the teaching of particular procedural skills should be included in the medical curriculum and which respective competency levels are recommended (‘‘factual knowledge’’, ‘‘practical knowledge’’, ‘‘practice under guidance’’, ‘‘independent practice’’). Thus, the NKLM provides both medical curriculum recommendations and guidance on the longitudinal integration of procedural skills in medical school. However, neither the NKLM nor the GMA’s consensus statement provides a classification of procedural skills with regard to their perceived complexity, relevance, and the required teaching skills. Even though these aspects promise to deliver the necessary information needed for the more in-depth development of medical curricula, such as the planning of additional procedural skill labs as well as the preparation and training of medical teacher and student tutors for procedural lessons. Against this background, the present study aimed to investigate procedural skills taught at the Medical Faculty of Heidelberg in regard to their complexity, relevance, and required teaching skills to obtain detailed knowledge for the planning of additional skills lab classes as well as teacher and tutor training. To achieve this aim (1) the specific procedural skills in terms of complexity, that is, the degree of difficulty, and (2) the perceived relevance of taught
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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procedural skills for study and subsequent medical profession as well as (3) the personal preparation and required teaching skills were assessed in medical teachers, student tutors and students. Method Study design The present study is a prospective, descriptive questionnaire study which was conducted in the period from October 2014 to January 2015 at the University Hospital of Heidelberg.
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Medical teacher sample Usually, physicians from the respective departments are used for teaching, in accordance with normal German university teaching obligations. In most departments, skills lab heads offer special procedural skill teaching trainings to medical teachers. In addition, optional training in didactic skills for simulation-based teaching is offered [18]. In the present study, all medical teachers, who taught one or more procedural skill (n = 17) in one of the lessons listed in Table 1 during the winter semester 2014/2015, were surveyed. As the same teachers were often used repeatedly for the same class, the sample size is small for each specialty area.
Curricular framework of skills-lab training
Student tutor sample
As part of the Heidelberg Curriculum Medicinale (HeiCuMed), medical students learn procedural skills in a longitudinal approach. Skills lab training spans the entire preclinical and clinical stage of their medical education [2]. While basic procedural skills, such as blood drawing, are taught on a voluntary basis and evaluated in formative procedural evaluations at preclinical stage, procedural skills training is a mandatory part of specialized teaching at clinical stage and procedural examinations are graded. In general, mandatory classes are taught by medical teacher and additional, facultative, tutor-led training sessions are offered for all subject areas. However, in pediatrics, half of the mandatory procedural skills classes and in gynecology all procedural skills training is tutor-led. While the obligatory classes are mandatory for all students, the additional traning sessions usually are attendend by the half of all students [17].
All PAL tutors (n = 10) were employed by the Interdisciplinary longitudinal Skills Lab Curriculum [2] and taught all procedural skills predefined in the HeiCuMed (see Table 1). All tutors, who taught in the WS 2014/2015, were in the sixth to tenth semester of medical studies, but not every tutor taught all skills. The tutors were trained by specialists of the respective disciplines for all procedural skills before they led facultative or mandatory classes [13]. Advanced study stage procedural skills, such as in pediatrics, gynecology, and otorhinolaryngology, were preferably taught by five especially experienced tutors from the eighth to tenth semester. Medical student sample All medical students (n = 406), who attended classes in one of the subject areas listed above (see Table 1) and took part in respective
Table 1 skills lab training during the clinical stage of medical education at the University Hospital of Heidelberg, Germany. Medical department
Procedural skill
Teacher-led (Yes/No) N
Tutor-led (Yes/No) N
Students N
Internal medicine Block I 6-7 Semester
Blood drawing
Gynecol. examination
No
Obstetrics
No
Lumbar puncture
Yes N=5 Yes N=5 Yes N=2 Yes N=5
Yes N = 10 Yes N = 10 Yes N = 10 Yes N = 10 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 No
N = 156
breast examination
Yes N=7 Yes N=7 Yes N=7 Yes N=5 Yes N=6 Yes N=6 Yes N=2 Yes N=2 Yes N=2 Yes N=2 No
Gastric tube IV Cannula ECG recording
Surgery Block II 6-7 Semester OtorhinolaryngologyBlock III 8-9 Semester
Catheterisation Surgical suture Otoscopy Anterior rhinoscopy Posterior rhinoscopy Indirect laryngoscopy
Gynecology Block IV 8-9 Semester
Pediatrics Block IV 8-9 Semester
Bladder puncture Resuscitation initial pediatric examination
N = 148
N = 123
N = 132
N = 132
Yes No No
N = total population per semester of teachers, tutors and students.
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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4 Table 2 Return rate and demographic details. Medical Departments
Teachers
Tutors
Students
N
Age (M)
Male/ female
Return rate (in %)
N
Age (mean)
Male/ female
Return rate (in %)
Semester (M)
N
Age (Mean)
Male/ female
Return rate (in %)
Semester (M)
Internal medicine
6
37
85%
10
24
7
96
23
7
46
83%
4
26
100%
8
76
24
51,4%
6
25%
4
26
100%
9
75
25
56,4%
9,5
-
4
26
100%
9
82
25
62,1
9
83%
5
26
100%
8
77
25
M = 33 F = 52 M = 11 F = 27 M = 10 F = 15 M = 21 F = 36 M = 28 F = 28
61,5%
5
M=4 F=6 M=1 F=1 M=2 W=2 M=2 F=2 M=2 F=4
100%
Surgery
M=3 F=4 M=4 F=2 M=1 F=0 -
58,3
9
Otorhinolaryngology
1
m.d
Gynecology
-
-
Pediatrics
5
30
*
M=3 F=2
N = total number of sample, M = median. * missing data.
skills lab trainings during the winter semester 2014/15 as part of their medical curriculum, were surveyed. Measures In order to obtain a classification of complexity and relevance of procedural skills from medical teachers, student tutors and medical students, an expert panel (n = 3) active in teaching research developed an instrument which was used in all skills lab lessons at the Medical Faculty of Heidelberg in the winter semester 2014 / 15. Five cognitive interviews were conducted to test the uniformity of comprehension with respect to the questions included. In addition, we conducted a paper-based pre-test with based on a sample of 20 medical students. In addition to general demographic information on age, sex, number of semesters, or medical professional experience, teaching experience for both teachers and tutors was assessed. Medical Teachers’, tutors’, and students’ perceived 1) degree of difficulty as well as 2) the perceived relevance for medical practice was assessed via 7-point Likert scales for each procedural skill taught in the respective skills lab classes: ‘‘As how easy/difficult do you evaluate this procedural skill’’ and ‘‘As how relevant do you consider the procedural skill for medical practice’’. 3) The medical teachers’ and tutors’ self-perceived competence was assessed with one item regarding ‘‘perceived own competence in the implementation of the procedural skill’’ on the one hand, and with an item regarding their perceived didactic ‘‘competence in teaching procedural skills’’ on the other hand, again via a 7-point Likert scale ranging from 1 = very good to 7 = very bad. In addition, teachers and tutors were asked whether they had been ‘‘specially trained for teaching’’ the procedural skills (yes / no) and whether they had participated in any other trainings (Yes / No / If yes, which ones?). In regard to the teachers’ and tutors’ teaching skills, students were also asked to evaluate ‘‘how well the teacher’s / tutor’s knowledge of the skills were’’ and ‘‘how well they had taught the procedural skills’’ via 7-point Likert scale ranging from 1 = very good to 7 = very bad. Study implementation The questionnaire survey was carried out in the winter semester 2014/15 in all skills lab classes of the above-identified subject areas (see Table 1). In a pen and paper approach, questionnaires were distributed to all teachers, tutors, and students directly after classes and collected again immediately after completion. Medical teachers and tutors, who led classes several times in a semester, recompleted the questionnaire after each class.
Statistical analysis Data were analyzed descriptively using SPSS (Version 22; SPSS Inc., Chicago, IL., USA) and are displayed according to frequency, mean values and standard deviations. Results Socio-demographic sample description and questionnaire return rate In the said study period, a total of 20 doctors from all of the departments listed above were available for teaching procedural skills. Data from 17 of the 20 physicians (55% male and 45% female) were recorded in the study, which is equivalent to a response rate of 85%. On average, teachers had been working as a doctor for 5 years and had engaged in the teaching of procedural skills for 18 months. One third of all physicians surveyed held a specialist qualification for their area of expertise. A questionnaire return rate of 100% was achieved for the 10 student tutors (60% male and 40% female) working for the Interdisciplinary Longitudinal Skills Lab Curriculum during the winter semester. The mean age was 23 years and the tutors were in the 7th semester on average. In the winter semester 2014/2015, all 691 students, attending departments in which procedural skills were taught, were invited to participate in our study. A total of 406 students participated, which is equivalent to a questionnaire return rate of 58.8%. 60% of the surveyed students were female and 40% male. The average age was 24.3 years (SD = 2.86 M = 24) see Table 2. Procedural skill complexity Table 3 shows the perceived complexity of taught procedural skills from teacher, tutor, and student perspective. In all three surveyed groups, the assessment of the procedural skills’ complexity was relatively homogenous and only few procedural skills were assessed entirely differently by one of the three groups. In detail, tutors evaluated the recording of an ECG as much easier (M = 1.4) as compared to medical teachers (M = 3.3) or students (M = 3.4), while bladder catheterization was evaluated as much more complex (M = 3.5) by tutors as compared to teachers (M = 2) or students (M = 2.9). Considered longitudinally, a slight increase in the complexity of procedural skills over the course of clinical deployment was perceived. While procedural skills of internal medicine and surgery taught in the sixth and seventh semesters achieved means between
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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Table 3 Procedural skills‘ complexity. Medical department
Internal medicine Block I 6-7 Semester Surgery Block II 6-7 Semester Otorhinolaryngology Block III 8-9 Semester Gynecology Block IV 8-9 Semester Pediatrics Block IV 8-9 Semester
Procedural skills
Teachers
Tutors
Students
N
M
SD
N
M
SD
N
M
SD
Blood drawing Gastric tube IV Cannula ECG recording Catheterisation
6 6 6 5 4
2,4 4,0 3,8 3,3 2
0,89 0,70 0,83 1,37 0
10 10 10 10 4
2,5 3,0 3,5 1,4 3,5
0,86 0,92 0,83 0,41 1,07
96 96 96 76 68
3,1 3,2 4,1 3,4 2,9
0,96 0,85 1,06 1,24 0,68
Surgical suture Otoscopy Anterior rhinoscopy Posterior rhinoscopy Indirect laryngoscopy breast examination Gynecol. examination Obstetrics Lumbar puncture Bladder puncture Resuscitation initial pediatric examination
5
3 3 2 5 5 3,75 3,75 3,75 4,25
1
4 4 4 4 4 4 4 4 5 5 5 5
3,5 4 1,5 5,5 5,3 1,5 3 4,5 3 -
0,89 0,58 1,35 0,75 0,98 0,83 0,25 1,01 0,74 -
76 75 75 75 75 82 82 82 77 77 77 77
4,2 3,5 2,5 4,3 4,5 3,1 3,5 4,3 4,1 3,6 4 4
1,01 1,47 1,21 1,46 1,47 1,14 1,12 1,33 1,10 0,97 1,13 1,11
1 1 1 5 5 2 5
0,0 0,0 0,0 0,96 0,5 0,96 0,5
N = total number of sample / M = median / SD = standard deviation. 1 = very easy / 4 = moderate / 7 = very difficult.
2.5 and 4 in regard to their complexity, the perceived difficulty increases in the eighth and ninth semester, in which procedural skills of otorhinolaryngology, gynecology and pediatrics are taught, with means between 3 and 5 (with the exception of the anterior rhinoscopy and the breast examination, which were both classified as relatively as ‘‘easy’’). The only procedural skills consistently evaluated as ‘‘difficult’’ (M > 4) on the 7-point Likert scale were procedural skills regarding otorhinolaryngology. The posterior rhinoscopy and indirect laryngoscopy were considered as the most difficult skills by all three groups. Procedural skills relevance for medical practice Regarding the procedural skills’ relevance for medical practice, all areas were evaluated as highly relevant (see Table 4). The procedural skills of internal medicine (blood drawing M = 1, permanent venous catheter placement M = 1–2, ECG recording M = 1–2) were evaluated as the most relevant skills by all three groups surveyed, whereas the two skills of otorhinolaryngology, posterior rhinoscopy (M = 3 to 4.5) and indirect rhinoscopy (M = 2.7 to 4.5), while still appearing to be important, were perceived as least relevant as compared to the rest of the taught procedural skills from the other medical departments. Skills from gynecology as well as pediatrics, surgery and internal medicine were considered as relevant or even very relevant for medical practice and no grave differences could be found between the surveyed groups (see Table 4) Procedural skill teaching compentence Medical teachers (M = 1.9, SD = 1.38, all medical teachers from all medical departments) and student tutors (M = 1.87, SD = 1.49, all tutors) felt equally competent in teaching procedural skills. No differences between the respective departments could be found. Similarly, the tutors and teacher evaluated their own perceived competence in the application of the relevant procedural skills as consistently ‘‘very good’’ to ‘‘good’’. This view is shared by the students who perceived both medical teachers and student tutors as extremely competent across all medical departments. While about half of all medical teachers (53%) had previously attended a facultative teacher training in didactics within the frame of an comprehensive faculty development training enfolding 120 teaching lessons on different didactical methods in
communication, presentation, examination and practical teaching [18], only about one in four (26%) had been specifically trained in the respective procedures taught in the skills-lab training of the faculty. In contrast, all tutors reported to have been specially trained in the procedural skills they taught in skills lab classes beforehand.
Discussion The results of this study show no major differences in the perceived complexity of the described procedural skills between the three groups surveyed, that is, between medical teachers, student tutors, and students. Over the course of the curriculum, students only perceived a slight increase in the complexity of procedural skills. This could be explained by the fact that students had acquired more experience with procedural skills during the course of their studies, thus, making skill implementation easier as the syllabus progressed. However, the slight increase in the level of difficulty can also be seen as a sign for the successful longitudinal integration of the procedures in the curriculum as complexity slowly increases over time seemingly without overtaxing students’ learning abilities. When comparing the taught procedural skills with the NKLM‘s recommendations [16], it is striking that most skills evaluated as more complex by students (M ≥ 4), specifically, Rhinoskopie (Otorhinolaryngology), surgical suture (Surgery), gynecological examination, obstetrics, initial pediatric examination and pediatric lumbar puncture, are classified as third level competencies (‘‘independent practice’’) and recommended for the clinical clerkship syllabus. Hence, the data supports the recommendations made by the NKLM on classifying more complex procedures at a higher competency level. Simultaneously, the complexity assessment allows conclusions to be drawn as to which skills are perceived to require particularly intensive training. In regard to perceived relevance, our data shows no major differences between the three groups of respondents except in the specific field of urology und ear-nose-throat where tutors have classified the skills less relevant than medical-teachers and students. In fact, that these procedures can be regarded as more consultant related competencies, that are probably more relevant when working or intensely have a focus on this. The specific fields of urology and ear-nose-throat medicine might be less relevance when tutors are interested in a more general practitioner orientated medical education. Interestingly, medical teachers and tutors as well as
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Table 4 Procedural skills‘ relevance for medical practice. Medical department
Internal medicine Block I 6-7 Semester Surgery Block II 6-7 Semester Otorhinolaryngology Block III 8-9 Semester
Gynecology Block IV 8-9 Semester Pediatrics Block IV 8-9 Semester
Procedural skills
Teachers
Tutors
Students
N
M
SD
N
M
SD
N
M
SD
Blood drawing Gastric tube IV Cannula ECG recording Catheterisation Surgical suture
6 6 6 5 4 5
1 2,2 1 1 1,6 1,6
0,0 0,89 0 0 0,56 0,56
10 10 10 10 4 4
1,2 2,3 1,2 2 4 2
0,15 0,56 0,15 0,85 0,56 0,78
96 96 96 76 68 76
1,1 1,9 1,1 1,1 1,7 1,4
0,42 0,94 0,36 0,2 0,79 0,57
Otoscopy Anterior rhinoscopy Posterior rhinoscopy Indirect laryngoscopy breast examination Gynecol. examination Obstetrics Lumbar puncture Bladder puncture Resuscitation initial pediatric examination
1 1 1 1 5 5 5 5
2 2 3 3 1,5 2 1 2,25
0,0 0,0 0,0 1 0,82 0 0,96
4 4 4 4 4 4 4 5 5 5 5
1,5 2 4,5 4,5 2 3 1 1,5 3 1 2,5
0,87 1,04 1,21 0,94 0,0 0,0 0,0 1,13 0,89 0,0 1,07
75 75 75 75 82 82 82 77 77 77 77
2,5 2,8 3,1 2,7 1,8 2,5 1,9 1,4 1,7 1,2 1,4
1,59 1,09 1,21 1,05 0,86 1,45 1,07 0,71 1,01 0,44 0,72
N = total number of sample / M = median / SD = standard deviation. 1 = very relevant / 4 = moderate / 7 = very irrelevant.
students perceived the taught procedural skills as ‘‘highly relevant’’ across the curriculum. Only otorhinolaryngological skills were considered as less important as compared to procedural skills from departments by all three groups. This may be related to the fact that these can be considered as very complex procedures going beyond the common action radius of the established general practitioners. Accordingly, more training may be required to achieve mastery and possibly may only be desired and achieved by students particularly interested in this field of medicine. In line with this argumentation, one would expect these skills to be classified differently by the NKLM, that is, that they should not be classed as procedures in which routine independent performance should be attained but that the learning target of observed implementation should suffice. However, interested students should still be able to acquire these more specialized and complex skills in facultative advanced level skills lab classes, as provided by ‘‘Advanced Skills’’ courses at the University of Heidelberg [17]. At first glance, it may seem striking that student tutors evaluated themselves as equally competent in the implementation and teaching of procedural as medical faculty staff. Considering that all student tutors have received specialized training in the skills that they teach themselves, while only about one in four medical teachers reported to have been specifically trained in the respective procedures, could give (partial) explanation to the tutors’ high level of perceived expertise in dealing with and teaching procedural skills. Hence, our data corroborates extant findings that student tutors are apt at teaching procedural skills, if they have been properly trained [9–11]. Finally, these results show that the longitudinal integration of the described procedural skills are practical and not perceived as too difficult or viewed as irrelevant in any way. Here, students’ evaluations in regard to complexity offer important insight as to which skills require additional, more in-depth training sessions. It seems advisable that the more complex a skill is construed by students, the more likely the provision of facultative training sessions and more frequent repetition and refresher classes will be conducive. However, the congruence of corresponding test formats, in the sense of constructive alignment [19] and the parallelism to clinical courses and clerkships also seems to be particularly important for successful curricular integration, as, given this, acquired procedural skills can be tested at bedside. In contrast, little known is about skill acquisition consistence over time [8]. However, it can be assumed
that skills should be trained at intervals of at least once a year and that more complex procedures require more frequent repetition and practice [8]. Again, our findings on teaching competency demonstrate how important adequate teacher trainings are [13,18] and that tutors, with appropriate training [12] in teaching procedural skills, are in no way inferior to medical faculty staff teachers [9–11]. Moreover, due to social and cognitive congruence, student tutors often find it easier to respond to students’ needs and specific requirements [20,21]. Limitations There was no formal validation of the survey Instrument undertaken. As data were analyzed descriptively, only limited comparative assertions can be made. However, the study is based on a very high number of evaluations from students actively engaged in the medical curriculum and therefore representative of lived teaching practice. Due to the sometimes very small number of cases in the medical teacher and student tutor sample, no meaningful statistical analyzes could be carried out, which limits scientific validity. Hence, no further statements relating to, for example, the impact of training or age on the teaching expertise for procedural skills can be made. Nevertheless, this study is a first step towards gaining insight on how procedural skills might be classified in regard to their complexity and relevance form the medical teachers’, tutors’, and students’ perspective. Conclusion This study largely underpins the NKLM’s recommendation for the longitudinal classification of more complex procedural skills at the clinical-practical stage of medical education. The complexity assessment allows conclusions to be drawn as to which skills are perceived to require particularly intensive training, although it must be noted that that none of the surveyed procedural skills were considered to be too difficult by students. The fact that the investigated clinical skills were considered to be highly relevant by respective teachers, tutors, and students suggests a successful selection of the taught procedural skills in the current medical curriculum. In regard to skills perceived as less relevant for
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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medical practice, additional facultative classes (called ‘‘Advanced Skills’’ in the Heidelberg medical curriculum) seem advisable offering interested students the possibility of deepening their knowledge. Finally, our study corroborates extant findings that student tutors are apt at teaching procedural skills, if they have been properly trained. Moreover, due to social and cognitive congruence, student tutors often find it easier to respond to students’ needs. Conflict of interest The authors declare that they are not aware if any competing interests.
[9]
[10]
[11]
[12]
[13]
References [1] Blohm M, Lauter J, Branchereau S, Krautter M, Kohl-Hackert N, Junger J, Herzog W, Nikendei C. ‘‘Peer-assisted learning’’ (PAL) in the Skills-Lab–an inventory at the medical faculties of the Federal Republic of Germany. GMS Zeitschrift fur medizinische Ausbildung 2015;32. Doc10. [2] Kruppa E, Junger J, Nikendei C. [Innovative teaching and examination methods–taking stock at German medical faculties]. Dtsch Med Wochenschr 2009;134:371–2. [3] Segarra LM SA, Weih M, Hahn EG, Schmidt A. Der Einsatz von medizinischen Trainingszentren für die Ausbildung zum Arzt in Deutschland, Österreich und der deutschsprachigen Schweiz. GMS Zeitschrift fur medizinische Ausbildung 2008;25. DOC 80. [4] Bugaj TJ NC. Practical Clinical Training in Skills Labs: Theory and Practice. GMS J Med Educ 2016;33:21. [5] Lynagh M, Burton R, Sanson-Fisher R. A systematic review of medical skills laboratory training: where to from here? Medical education 2007;41: 879–87. [6] Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. Jama 2011;306:978–88. [7] Lund F, Schultz JH, Maatouk I, Krautter M, Moltner A, Werner A, Weyrich P, Junger J, Nikendei C. Effectiveness of IV cannulation skills laboratory training and its transfer into clinical practice: a randomized, controlled trial. PloS one 2012;7:e32831. [8] Herrmann-Werner A, Nikendei C, Keifenheim K, Bosse HM, Lund F, Wagner R, Celebi N, Zipfel S, Weyrich P. ‘‘Best practice’’ skills lab training vs. a ‘‘see one, do one’’ approach in undergraduate medical education: an RCT on
[14]
[15]
[16] [17]
[18]
[19] [20]
[21]
7
students’ long-term ability to perform procedural clinical skills. PloS one 2013;8:e76354. Weyrich P, Celebi N, Schrauth M, Moltner A, Lammerding-Koppel M, Nikendei C. Peer-assisted versus faculty staff-led skills laboratory training: a randomised controlled trial. Medical education 2009;43:113–20. Hudson JN, Tonkin AL. Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients. Medical education 2008;42:901–8. Tolsgaard MG, Gustafsson A, Rasmussen MB, Hoiby P, Muller CG, Ringsted C. Student teachers can be as good as associate professors in teaching clinical skills. Medical teacher 2007;29:553–7. Heni M, Lammerding-Koppel M, Celebi N, Shiozawa T, Riessen R, Nikendei C, Weyrich P. Focused didactic training for skills lab student tutors - which techniques are considered helpful? GMS Zeitschrift fur medizinische Ausbildung 2012;29. Doc41. Blohm M, Krautter M, Lauter J, Huber J, Weyrich P, Herzog W, Junger J, Nikendei C. Voluntary undergraduate technical skills training course to prepare students for clerkship assignment: tutees’ and tutors’ perspectives. BMC medical education 2014;14:71. Ringel N, Burmann BM, Fellmer-Drueg E, Roos M, Herzog W, Nikendei C, Wischmann T, Weiss C, Eicher C, Engeser P, Schultz JH, Junger J. [Integrated Peer Teaching of Communication and Clinical Skills How to Train Student Tutors?]. Psychotherapie, Psychosomatik, medizinische Psychologie 2015;65: 288–95. Schnabel KP BP, Breuer G, Fichtner A, Karsten G, Kujumdshiev S, Schmidts M, Stosch C. Konsensusstatement ‘‘Praktische Fertigkeiten im Medizinstudium’’ – ein Positionspapier des GMA-Ausschusses für praktische Fertigkeiten. GMS Zeitschrift fur medizinische Ausbildung 2011;28:12. M.M.F.d.B.D.e. V., Nationaler Kompetenzbasierter Lernzielkatalog Medizin (NKLM) (2015). Buss B, Krautter M, Moltner A, Weyrich P, Werner A, Junger J, Nikendei C. Can the ’assessment drives learning’ effect be detected in clinical skills training?– implications for curriculum design and resource planning. GMS Zeitschrift fur medizinische Ausbildung 2012;29. Doc70. Roos M KM, Kirschfink M, Koch E, Jünger J, Strittmatter-Hausbold V, Steiner T. Developing medical educators - a mixed method evaluation of teaching education program. Med Educ Online 2014;27. Biggs J., T. C., Teaching for Quality Learning at University: What the students does., Open University Press/McGraw Hill, Maidenhead:, 2007. Lockspeiser TM OSP, Teherani A, Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ Theory Pract 2008;13:12. Yu TC WN, Singh PP, Lemanu DP, Hawken SJ, Hill AG. Medical students-asteachers: a systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract 2011;2:16.
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Bildung im Gesundheitswesen / Education In Health Care
Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective夽 Tutorielle Vermittlung klinisch-praktischer Fertigkeiten im Skills-Lab: Komplexität, Relevanz und Lehrkompetenz aus ärztlicher, tutorieller und studentischer Sicht Jan Lauter, Sylvie Branchereau, Wolfgang Herzog, Till Johannes Bugaj, Christoph Nikendei ∗ Centre for Psychosocial Medicine, University Hospital Heidelberg, Department of General Internal Medicine and Psychosomatics, Heidelberg, Germany
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Article History: Received: 14 October 2016 Received in revised form: 27 January 2017 Accepted: 3 March 2017 Available online: xxx
Keywords: procedural skills skills lab peer-teaching medical education
a b s t r a c t Background: In current medical curricula, the transfer of procedural skills has received increasing attention. Skills lab learning and tutor-led teaching have become an inherent part of all medical curricula at German medical faculties. In 2011, the initial basis for the classification of clinical skills in medical school was created by the German Association for Medical Education (GMA) Committee’s consensus statement on procedural skills. As a recommendation for medical curricula, the National Competency-based Catalogue of Learning Objectives (NKLM, 2015) lists procedural skills according to their curriculum integration and competency level. However, classification in regard to the perceived complexity, relevance, or teaching competency is still lacking. Objective: The present study aimed to investigate procedural skills taught at the Medical Faculty of Heidelberg in regard to their complexity, relevance, and required teaching skills. To achieve this aim (1) the specific procedural skills in terms of complexity, that is, the degree of difficulty, and (2) the perceived relevance of taught procedural skills for studying and subsequent medical profession as well as (3) the personal preparation and required teaching skills were assessed in medical teachers, tutors and students. Method: During the winter semester 2014/2015, the evaluations of all medical teachers, student tutors, and medical students in the skills lab teaching departments of internal medicine, surgery, pediatrics, gynecology, and otorhinolaryngology at the Medical Faculty of Heidelberg were assessed via a quantitative cross-sectional questionnaire survey using 7-point Likert scales. The questionnaire comprised four item sets concerning 1) demographic details, 2) procedural skill complexity, 3) practical relevance, and 4) required preparation and teaching skills. Descriptive, quantitative analysis was used for questionnaire data. Results: The survey included the data from 17 of 20 physicians (return rate: 85 %), 10 of 10 student tutors (return rate: 100 %) and a total of 406 of 691 students (return rate: 58.8 %). In terms of complexity and relevance, no major differences between medical teachers, tutors, and students were found. Procedural skills, assigned to the competence level of final year medical education in the NKLM, were also perceived as more complex than other skills. All skills were considered as equally relevant, and student tutors were seen to have equally competent teaching skills as experienced medical teachers. Conclusion: This study largely underpins the NKLM’s classification of procedural skills. The complexity assessment allows for conclusions to be drawn as to which skills are perceived to require particularly intensive training. Finally, our study corroborates extant findings that student tutors are apt at teaching procedural skills if they have been properly trained.
夽 Ethical approval was granted by the ethic committee of the University of Heidelberg (S-423/2014). ∗ Corresponding author: Adj. Prof. Dr. med. Christoph Nikendei, MD, MME-D, Centre for Psychosocial Medicine, University Hospital Heidelberg, Department of General Internal Medicine and Psychosomatics, Thibautstraße 4, 69115 Heidelberg, Germany. E-mail: [email protected] (C. Nikendei). http://dx.doi.org/10.1016/j.zefq.2017.03.005 1865-9217/
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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Artikel-Historie: Eingegangen: 14. Oktober 2016 Revision eingegangen: 27. Januar 2017 Akzeptiert: 3. März 2017 Online gestellt: xxx
Schlüsselwörter: Klinisch-praktische Fertigkeiten Skills-lab studentische Tutoren medizinische Ausbildung
z u s a m m e n f a s s u n g Hintergrund: Das Vermitteln klinisch-praktischer Fertigkeiten erzielt in den medizinischen Curricula eine immer größere Aufmerksamkeit. An den Medizinischen Fakultäten der Bundesrepublik Deutschland gehört das Skills-Lab sowie der tutorengeleitete Unterricht mittlerweile zum obligaten Bestandteil eines jeden medizinischen Curriculums. 2011 wurde durch ein Konsensusstatement des GMA-Ausschusses für praktische Fertigkeiten eine erste Grundlage zur Klassifizierung klinischer Fertigkeiten im Medizinstudium geschaffen. Im Nationalen Kompetenzbasierten Lernzielkatalog (NKLM, 2015) werden praktische Fertigkeiten schließlich nach ihrer Einbindung ins Curriculum und einer Kompetenzebene gelistet und als Empfehlung für Medizinische Curricula dargeboten. Eine Klassifizierung nach der wahrgenommenen Komplexität, der eingeschätzten Relevanz oder einer Lehrkompetenz steht jedoch aus. Fragestellung: Ziel der vorliegenden Studie war es vor diesem Hintergrund die an der Medizinischen Fakultät Heidelberg gelehrten klinisch-praktischen Fertigkeiten auf ihre Komplexität, Relevanz und erforderlichen Lehrkompetenz hin zu untersuchen. Hierfür sollten (1) spezifische klinisch-praktische Fertigkeiten in Hinblick auf Komplexität, das heißt dem Grad der Schwierigkeit sowie (2) die Relevanz der unterrichteten klinisch-praktischen Fertigkeiten für das Studium und den späteren Arztberuf und (3) die persönliche Vorbereitung und Lehrkompetenz, für die Vermittlung praktischen Fertigkeiten jeweils von Seiten der ärztlichen Dozenten, studentischen Tutoren und Studierenden angeben werden. Methode: Über das Wintersemester 2014/2015 wurden die Einschätzungen sämtlicher ärztlichen Dozenten, studentische Tutoren und medizinischen Studierenden im Skills-Lab Unterricht der Fachbereiche Innere Medizin, Chirurgie, Pädiatrie, Gynäkologie und Hals-Nasen-Ohrenheilkunde an der Medizinischen Fakultät Heidelberg durch eine quantitative Querschnittsfragebogenerhebung mittels 7 Punkt Likert-Skalen erhoben. Der Fragebogen enthält vier Fragekomplexe zu 1) demographischen Angaben, 2) Einschätzung der Komplexität der klinisch-praktischen Fertigkeiten 3) Bewertung ihrer Relevanz und 4) Vorbereitung und Lehrkompetenz beim Unterrichten praktischer Fertigkeiten. Die Daten wurden deskriptiv ausgewertet und nach ihren Häufigkeiten und Mittelwerten angegeben. Ergebnisse: In Hinblick auf Komplexität und Relevanz gibt es keine gravierenden Unterschiede zwischen ärztlichen Dozenten, studentischen Tutoren und Studierenden. Jene praktischen Fertigkeiten, die im NKLM der Kompetenzebene des Praktischen Jahr zugeordnet werden, werden in der vorliegenden Untersuchung ebenfalls komplexer als andere Fertigkeiten empfunden. Alle Fertigkeiten werden als gleichermaßen relevant angesehen und die studentischen Tutoren werden im Unterrichten gleichermaßen kompetent erlebt wie ärztliche Dozenten. Schlussfolgerung: Die im NKLM dargebotene Einordnung klinisch-praktischer Fertigkeiten wird durch diese Untersuchung zum Teil untermauert. Die Einschätzungen zum Grad der Komplexität lässt Rückschlüsse darauf zu, welche Fertigkeiten besonders trainingsintensiv sind. Schließlich wird einmal mehr angedeutet, dass studentische Tutoren im unterrichten klinisch-praktischer Fertigkeiten ebenso gut geeignet sind wenn sie vorher ausreichend geschult wurden.
Introduction Medical competencies, such as communication skills and procedural skills, play a crucial role in medical education. At the majority of German medical faculties, skills labs have become a mandatory part of any medical curriculum when it comes to teaching procedural skills [1–4]. In skills labs, procedural skills are practiced on simulation models before the procedures are performed on real-life patients. From a scientific perspective, training results for procedural skills taught in skills labs have been proven to be effective [1,5,6], transferable to bedside [7] and consistent over time [8]. In regard to teaching procedural skills, peer-assisted learning (PAL), that is imparting knowledge or skills by means of student tutors, has received increasing interest. Currently, all German medical faculties have come to employ student tutors for teaching procedural skills [1]. Extant literature supports this approach: several randomized controlled studies on skills lab training have been able to show that student tutors and medical teacher are on a par [9–11], if tutors have received adequate and sufficient training previously [12–14]. In 2011, the German Association for Medical Education‘s (dt.: Gesellschaft für Medizinische Ausbildung, GMA) Committee on procedural skills created the initial basis for the classification of procedural skills in a consensus statement [15], in which all listed procedural skills are categorized in regard to their core or elective competence and a recommendation to whether respective skill mastery should be achieved before starting clerkship,
final year training, or post gradual training, is given. Creating an effective impetus for action, these recommendations were largely adopted by the National Competency-based Catalogue of Learning Objectives (NKLM) [16] in 2015. Similar to the GMA’s consensus statement, the NKLM provides guidance to at which study stage (pre-clinical, clinical, clerkship, post graduate training or scientific level) the teaching of particular procedural skills should be included in the medical curriculum and which respective competency levels are recommended (‘‘factual knowledge’’, ‘‘practical knowledge’’, ‘‘practice under guidance’’, ‘‘independent practice’’). Thus, the NKLM provides both medical curriculum recommendations and guidance on the longitudinal integration of procedural skills in medical school. However, neither the NKLM nor the GMA’s consensus statement provides a classification of procedural skills with regard to their perceived complexity, relevance, and the required teaching skills. Even though these aspects promise to deliver the necessary information needed for the more in-depth development of medical curricula, such as the planning of additional procedural skill labs as well as the preparation and training of medical teacher and student tutors for procedural lessons. Against this background, the present study aimed to investigate procedural skills taught at the Medical Faculty of Heidelberg in regard to their complexity, relevance, and required teaching skills to obtain detailed knowledge for the planning of additional skills lab classes as well as teacher and tutor training. To achieve this aim (1) the specific procedural skills in terms of complexity, that is, the degree of difficulty, and (2) the perceived relevance of taught
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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procedural skills for study and subsequent medical profession as well as (3) the personal preparation and required teaching skills were assessed in medical teachers, student tutors and students. Method Study design The present study is a prospective, descriptive questionnaire study which was conducted in the period from October 2014 to January 2015 at the University Hospital of Heidelberg.
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Medical teacher sample Usually, physicians from the respective departments are used for teaching, in accordance with normal German university teaching obligations. In most departments, skills lab heads offer special procedural skill teaching trainings to medical teachers. In addition, optional training in didactic skills for simulation-based teaching is offered [18]. In the present study, all medical teachers, who taught one or more procedural skill (n = 17) in one of the lessons listed in Table 1 during the winter semester 2014/2015, were surveyed. As the same teachers were often used repeatedly for the same class, the sample size is small for each specialty area.
Curricular framework of skills-lab training
Student tutor sample
As part of the Heidelberg Curriculum Medicinale (HeiCuMed), medical students learn procedural skills in a longitudinal approach. Skills lab training spans the entire preclinical and clinical stage of their medical education [2]. While basic procedural skills, such as blood drawing, are taught on a voluntary basis and evaluated in formative procedural evaluations at preclinical stage, procedural skills training is a mandatory part of specialized teaching at clinical stage and procedural examinations are graded. In general, mandatory classes are taught by medical teacher and additional, facultative, tutor-led training sessions are offered for all subject areas. However, in pediatrics, half of the mandatory procedural skills classes and in gynecology all procedural skills training is tutor-led. While the obligatory classes are mandatory for all students, the additional traning sessions usually are attendend by the half of all students [17].
All PAL tutors (n = 10) were employed by the Interdisciplinary longitudinal Skills Lab Curriculum [2] and taught all procedural skills predefined in the HeiCuMed (see Table 1). All tutors, who taught in the WS 2014/2015, were in the sixth to tenth semester of medical studies, but not every tutor taught all skills. The tutors were trained by specialists of the respective disciplines for all procedural skills before they led facultative or mandatory classes [13]. Advanced study stage procedural skills, such as in pediatrics, gynecology, and otorhinolaryngology, were preferably taught by five especially experienced tutors from the eighth to tenth semester. Medical student sample All medical students (n = 406), who attended classes in one of the subject areas listed above (see Table 1) and took part in respective
Table 1 skills lab training during the clinical stage of medical education at the University Hospital of Heidelberg, Germany. Medical department
Procedural skill
Teacher-led (Yes/No) N
Tutor-led (Yes/No) N
Students N
Internal medicine Block I 6-7 Semester
Blood drawing
Gynecol. examination
No
Obstetrics
No
Lumbar puncture
Yes N=5 Yes N=5 Yes N=2 Yes N=5
Yes N = 10 Yes N = 10 Yes N = 10 Yes N = 10 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 Yes N=4 No
N = 156
breast examination
Yes N=7 Yes N=7 Yes N=7 Yes N=5 Yes N=6 Yes N=6 Yes N=2 Yes N=2 Yes N=2 Yes N=2 No
Gastric tube IV Cannula ECG recording
Surgery Block II 6-7 Semester OtorhinolaryngologyBlock III 8-9 Semester
Catheterisation Surgical suture Otoscopy Anterior rhinoscopy Posterior rhinoscopy Indirect laryngoscopy
Gynecology Block IV 8-9 Semester
Pediatrics Block IV 8-9 Semester
Bladder puncture Resuscitation initial pediatric examination
N = 148
N = 123
N = 132
N = 132
Yes No No
N = total population per semester of teachers, tutors and students.
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4 Table 2 Return rate and demographic details. Medical Departments
Teachers
Tutors
Students
N
Age (M)
Male/ female
Return rate (in %)
N
Age (mean)
Male/ female
Return rate (in %)
Semester (M)
N
Age (Mean)
Male/ female
Return rate (in %)
Semester (M)
Internal medicine
6
37
85%
10
24
7
96
23
7
46
83%
4
26
100%
8
76
24
51,4%
6
25%
4
26
100%
9
75
25
56,4%
9,5
-
4
26
100%
9
82
25
62,1
9
83%
5
26
100%
8
77
25
M = 33 F = 52 M = 11 F = 27 M = 10 F = 15 M = 21 F = 36 M = 28 F = 28
61,5%
5
M=4 F=6 M=1 F=1 M=2 W=2 M=2 F=2 M=2 F=4
100%
Surgery
M=3 F=4 M=4 F=2 M=1 F=0 -
58,3
9
Otorhinolaryngology
1
m.d
Gynecology
-
-
Pediatrics
5
30
*
M=3 F=2
N = total number of sample, M = median. * missing data.
skills lab trainings during the winter semester 2014/15 as part of their medical curriculum, were surveyed. Measures In order to obtain a classification of complexity and relevance of procedural skills from medical teachers, student tutors and medical students, an expert panel (n = 3) active in teaching research developed an instrument which was used in all skills lab lessons at the Medical Faculty of Heidelberg in the winter semester 2014 / 15. Five cognitive interviews were conducted to test the uniformity of comprehension with respect to the questions included. In addition, we conducted a paper-based pre-test with based on a sample of 20 medical students. In addition to general demographic information on age, sex, number of semesters, or medical professional experience, teaching experience for both teachers and tutors was assessed. Medical Teachers’, tutors’, and students’ perceived 1) degree of difficulty as well as 2) the perceived relevance for medical practice was assessed via 7-point Likert scales for each procedural skill taught in the respective skills lab classes: ‘‘As how easy/difficult do you evaluate this procedural skill’’ and ‘‘As how relevant do you consider the procedural skill for medical practice’’. 3) The medical teachers’ and tutors’ self-perceived competence was assessed with one item regarding ‘‘perceived own competence in the implementation of the procedural skill’’ on the one hand, and with an item regarding their perceived didactic ‘‘competence in teaching procedural skills’’ on the other hand, again via a 7-point Likert scale ranging from 1 = very good to 7 = very bad. In addition, teachers and tutors were asked whether they had been ‘‘specially trained for teaching’’ the procedural skills (yes / no) and whether they had participated in any other trainings (Yes / No / If yes, which ones?). In regard to the teachers’ and tutors’ teaching skills, students were also asked to evaluate ‘‘how well the teacher’s / tutor’s knowledge of the skills were’’ and ‘‘how well they had taught the procedural skills’’ via 7-point Likert scale ranging from 1 = very good to 7 = very bad. Study implementation The questionnaire survey was carried out in the winter semester 2014/15 in all skills lab classes of the above-identified subject areas (see Table 1). In a pen and paper approach, questionnaires were distributed to all teachers, tutors, and students directly after classes and collected again immediately after completion. Medical teachers and tutors, who led classes several times in a semester, recompleted the questionnaire after each class.
Statistical analysis Data were analyzed descriptively using SPSS (Version 22; SPSS Inc., Chicago, IL., USA) and are displayed according to frequency, mean values and standard deviations. Results Socio-demographic sample description and questionnaire return rate In the said study period, a total of 20 doctors from all of the departments listed above were available for teaching procedural skills. Data from 17 of the 20 physicians (55% male and 45% female) were recorded in the study, which is equivalent to a response rate of 85%. On average, teachers had been working as a doctor for 5 years and had engaged in the teaching of procedural skills for 18 months. One third of all physicians surveyed held a specialist qualification for their area of expertise. A questionnaire return rate of 100% was achieved for the 10 student tutors (60% male and 40% female) working for the Interdisciplinary Longitudinal Skills Lab Curriculum during the winter semester. The mean age was 23 years and the tutors were in the 7th semester on average. In the winter semester 2014/2015, all 691 students, attending departments in which procedural skills were taught, were invited to participate in our study. A total of 406 students participated, which is equivalent to a questionnaire return rate of 58.8%. 60% of the surveyed students were female and 40% male. The average age was 24.3 years (SD = 2.86 M = 24) see Table 2. Procedural skill complexity Table 3 shows the perceived complexity of taught procedural skills from teacher, tutor, and student perspective. In all three surveyed groups, the assessment of the procedural skills’ complexity was relatively homogenous and only few procedural skills were assessed entirely differently by one of the three groups. In detail, tutors evaluated the recording of an ECG as much easier (M = 1.4) as compared to medical teachers (M = 3.3) or students (M = 3.4), while bladder catheterization was evaluated as much more complex (M = 3.5) by tutors as compared to teachers (M = 2) or students (M = 2.9). Considered longitudinally, a slight increase in the complexity of procedural skills over the course of clinical deployment was perceived. While procedural skills of internal medicine and surgery taught in the sixth and seventh semesters achieved means between
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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Table 3 Procedural skills‘ complexity. Medical department
Internal medicine Block I 6-7 Semester Surgery Block II 6-7 Semester Otorhinolaryngology Block III 8-9 Semester Gynecology Block IV 8-9 Semester Pediatrics Block IV 8-9 Semester
Procedural skills
Teachers
Tutors
Students
N
M
SD
N
M
SD
N
M
SD
Blood drawing Gastric tube IV Cannula ECG recording Catheterisation
6 6 6 5 4
2,4 4,0 3,8 3,3 2
0,89 0,70 0,83 1,37 0
10 10 10 10 4
2,5 3,0 3,5 1,4 3,5
0,86 0,92 0,83 0,41 1,07
96 96 96 76 68
3,1 3,2 4,1 3,4 2,9
0,96 0,85 1,06 1,24 0,68
Surgical suture Otoscopy Anterior rhinoscopy Posterior rhinoscopy Indirect laryngoscopy breast examination Gynecol. examination Obstetrics Lumbar puncture Bladder puncture Resuscitation initial pediatric examination
5
3 3 2 5 5 3,75 3,75 3,75 4,25
1
4 4 4 4 4 4 4 4 5 5 5 5
3,5 4 1,5 5,5 5,3 1,5 3 4,5 3 -
0,89 0,58 1,35 0,75 0,98 0,83 0,25 1,01 0,74 -
76 75 75 75 75 82 82 82 77 77 77 77
4,2 3,5 2,5 4,3 4,5 3,1 3,5 4,3 4,1 3,6 4 4
1,01 1,47 1,21 1,46 1,47 1,14 1,12 1,33 1,10 0,97 1,13 1,11
1 1 1 5 5 2 5
0,0 0,0 0,0 0,96 0,5 0,96 0,5
N = total number of sample / M = median / SD = standard deviation. 1 = very easy / 4 = moderate / 7 = very difficult.
2.5 and 4 in regard to their complexity, the perceived difficulty increases in the eighth and ninth semester, in which procedural skills of otorhinolaryngology, gynecology and pediatrics are taught, with means between 3 and 5 (with the exception of the anterior rhinoscopy and the breast examination, which were both classified as relatively as ‘‘easy’’). The only procedural skills consistently evaluated as ‘‘difficult’’ (M > 4) on the 7-point Likert scale were procedural skills regarding otorhinolaryngology. The posterior rhinoscopy and indirect laryngoscopy were considered as the most difficult skills by all three groups. Procedural skills relevance for medical practice Regarding the procedural skills’ relevance for medical practice, all areas were evaluated as highly relevant (see Table 4). The procedural skills of internal medicine (blood drawing M = 1, permanent venous catheter placement M = 1–2, ECG recording M = 1–2) were evaluated as the most relevant skills by all three groups surveyed, whereas the two skills of otorhinolaryngology, posterior rhinoscopy (M = 3 to 4.5) and indirect rhinoscopy (M = 2.7 to 4.5), while still appearing to be important, were perceived as least relevant as compared to the rest of the taught procedural skills from the other medical departments. Skills from gynecology as well as pediatrics, surgery and internal medicine were considered as relevant or even very relevant for medical practice and no grave differences could be found between the surveyed groups (see Table 4) Procedural skill teaching compentence Medical teachers (M = 1.9, SD = 1.38, all medical teachers from all medical departments) and student tutors (M = 1.87, SD = 1.49, all tutors) felt equally competent in teaching procedural skills. No differences between the respective departments could be found. Similarly, the tutors and teacher evaluated their own perceived competence in the application of the relevant procedural skills as consistently ‘‘very good’’ to ‘‘good’’. This view is shared by the students who perceived both medical teachers and student tutors as extremely competent across all medical departments. While about half of all medical teachers (53%) had previously attended a facultative teacher training in didactics within the frame of an comprehensive faculty development training enfolding 120 teaching lessons on different didactical methods in
communication, presentation, examination and practical teaching [18], only about one in four (26%) had been specifically trained in the respective procedures taught in the skills-lab training of the faculty. In contrast, all tutors reported to have been specially trained in the procedural skills they taught in skills lab classes beforehand.
Discussion The results of this study show no major differences in the perceived complexity of the described procedural skills between the three groups surveyed, that is, between medical teachers, student tutors, and students. Over the course of the curriculum, students only perceived a slight increase in the complexity of procedural skills. This could be explained by the fact that students had acquired more experience with procedural skills during the course of their studies, thus, making skill implementation easier as the syllabus progressed. However, the slight increase in the level of difficulty can also be seen as a sign for the successful longitudinal integration of the procedures in the curriculum as complexity slowly increases over time seemingly without overtaxing students’ learning abilities. When comparing the taught procedural skills with the NKLM‘s recommendations [16], it is striking that most skills evaluated as more complex by students (M ≥ 4), specifically, Rhinoskopie (Otorhinolaryngology), surgical suture (Surgery), gynecological examination, obstetrics, initial pediatric examination and pediatric lumbar puncture, are classified as third level competencies (‘‘independent practice’’) and recommended for the clinical clerkship syllabus. Hence, the data supports the recommendations made by the NKLM on classifying more complex procedures at a higher competency level. Simultaneously, the complexity assessment allows conclusions to be drawn as to which skills are perceived to require particularly intensive training. In regard to perceived relevance, our data shows no major differences between the three groups of respondents except in the specific field of urology und ear-nose-throat where tutors have classified the skills less relevant than medical-teachers and students. In fact, that these procedures can be regarded as more consultant related competencies, that are probably more relevant when working or intensely have a focus on this. The specific fields of urology and ear-nose-throat medicine might be less relevance when tutors are interested in a more general practitioner orientated medical education. Interestingly, medical teachers and tutors as well as
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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Table 4 Procedural skills‘ relevance for medical practice. Medical department
Internal medicine Block I 6-7 Semester Surgery Block II 6-7 Semester Otorhinolaryngology Block III 8-9 Semester
Gynecology Block IV 8-9 Semester Pediatrics Block IV 8-9 Semester
Procedural skills
Teachers
Tutors
Students
N
M
SD
N
M
SD
N
M
SD
Blood drawing Gastric tube IV Cannula ECG recording Catheterisation Surgical suture
6 6 6 5 4 5
1 2,2 1 1 1,6 1,6
0,0 0,89 0 0 0,56 0,56
10 10 10 10 4 4
1,2 2,3 1,2 2 4 2
0,15 0,56 0,15 0,85 0,56 0,78
96 96 96 76 68 76
1,1 1,9 1,1 1,1 1,7 1,4
0,42 0,94 0,36 0,2 0,79 0,57
Otoscopy Anterior rhinoscopy Posterior rhinoscopy Indirect laryngoscopy breast examination Gynecol. examination Obstetrics Lumbar puncture Bladder puncture Resuscitation initial pediatric examination
1 1 1 1 5 5 5 5
2 2 3 3 1,5 2 1 2,25
0,0 0,0 0,0 1 0,82 0 0,96
4 4 4 4 4 4 4 5 5 5 5
1,5 2 4,5 4,5 2 3 1 1,5 3 1 2,5
0,87 1,04 1,21 0,94 0,0 0,0 0,0 1,13 0,89 0,0 1,07
75 75 75 75 82 82 82 77 77 77 77
2,5 2,8 3,1 2,7 1,8 2,5 1,9 1,4 1,7 1,2 1,4
1,59 1,09 1,21 1,05 0,86 1,45 1,07 0,71 1,01 0,44 0,72
N = total number of sample / M = median / SD = standard deviation. 1 = very relevant / 4 = moderate / 7 = very irrelevant.
students perceived the taught procedural skills as ‘‘highly relevant’’ across the curriculum. Only otorhinolaryngological skills were considered as less important as compared to procedural skills from departments by all three groups. This may be related to the fact that these can be considered as very complex procedures going beyond the common action radius of the established general practitioners. Accordingly, more training may be required to achieve mastery and possibly may only be desired and achieved by students particularly interested in this field of medicine. In line with this argumentation, one would expect these skills to be classified differently by the NKLM, that is, that they should not be classed as procedures in which routine independent performance should be attained but that the learning target of observed implementation should suffice. However, interested students should still be able to acquire these more specialized and complex skills in facultative advanced level skills lab classes, as provided by ‘‘Advanced Skills’’ courses at the University of Heidelberg [17]. At first glance, it may seem striking that student tutors evaluated themselves as equally competent in the implementation and teaching of procedural as medical faculty staff. Considering that all student tutors have received specialized training in the skills that they teach themselves, while only about one in four medical teachers reported to have been specifically trained in the respective procedures, could give (partial) explanation to the tutors’ high level of perceived expertise in dealing with and teaching procedural skills. Hence, our data corroborates extant findings that student tutors are apt at teaching procedural skills, if they have been properly trained [9–11]. Finally, these results show that the longitudinal integration of the described procedural skills are practical and not perceived as too difficult or viewed as irrelevant in any way. Here, students’ evaluations in regard to complexity offer important insight as to which skills require additional, more in-depth training sessions. It seems advisable that the more complex a skill is construed by students, the more likely the provision of facultative training sessions and more frequent repetition and refresher classes will be conducive. However, the congruence of corresponding test formats, in the sense of constructive alignment [19] and the parallelism to clinical courses and clerkships also seems to be particularly important for successful curricular integration, as, given this, acquired procedural skills can be tested at bedside. In contrast, little known is about skill acquisition consistence over time [8]. However, it can be assumed
that skills should be trained at intervals of at least once a year and that more complex procedures require more frequent repetition and practice [8]. Again, our findings on teaching competency demonstrate how important adequate teacher trainings are [13,18] and that tutors, with appropriate training [12] in teaching procedural skills, are in no way inferior to medical faculty staff teachers [9–11]. Moreover, due to social and cognitive congruence, student tutors often find it easier to respond to students’ needs and specific requirements [20,21]. Limitations There was no formal validation of the survey Instrument undertaken. As data were analyzed descriptively, only limited comparative assertions can be made. However, the study is based on a very high number of evaluations from students actively engaged in the medical curriculum and therefore representative of lived teaching practice. Due to the sometimes very small number of cases in the medical teacher and student tutor sample, no meaningful statistical analyzes could be carried out, which limits scientific validity. Hence, no further statements relating to, for example, the impact of training or age on the teaching expertise for procedural skills can be made. Nevertheless, this study is a first step towards gaining insight on how procedural skills might be classified in regard to their complexity and relevance form the medical teachers’, tutors’, and students’ perspective. Conclusion This study largely underpins the NKLM’s recommendation for the longitudinal classification of more complex procedural skills at the clinical-practical stage of medical education. The complexity assessment allows conclusions to be drawn as to which skills are perceived to require particularly intensive training, although it must be noted that that none of the surveyed procedural skills were considered to be too difficult by students. The fact that the investigated clinical skills were considered to be highly relevant by respective teachers, tutors, and students suggests a successful selection of the taught procedural skills in the current medical curriculum. In regard to skills perceived as less relevant for
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
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medical practice, additional facultative classes (called ‘‘Advanced Skills’’ in the Heidelberg medical curriculum) seem advisable offering interested students the possibility of deepening their knowledge. Finally, our study corroborates extant findings that student tutors are apt at teaching procedural skills, if they have been properly trained. Moreover, due to social and cognitive congruence, student tutors often find it easier to respond to students’ needs. Conflict of interest The authors declare that they are not aware if any competing interests.
[9]
[10]
[11]
[12]
[13]
References [1] Blohm M, Lauter J, Branchereau S, Krautter M, Kohl-Hackert N, Junger J, Herzog W, Nikendei C. ‘‘Peer-assisted learning’’ (PAL) in the Skills-Lab–an inventory at the medical faculties of the Federal Republic of Germany. GMS Zeitschrift fur medizinische Ausbildung 2015;32. Doc10. [2] Kruppa E, Junger J, Nikendei C. [Innovative teaching and examination methods–taking stock at German medical faculties]. Dtsch Med Wochenschr 2009;134:371–2. [3] Segarra LM SA, Weih M, Hahn EG, Schmidt A. Der Einsatz von medizinischen Trainingszentren für die Ausbildung zum Arzt in Deutschland, Österreich und der deutschsprachigen Schweiz. GMS Zeitschrift fur medizinische Ausbildung 2008;25. DOC 80. [4] Bugaj TJ NC. Practical Clinical Training in Skills Labs: Theory and Practice. GMS J Med Educ 2016;33:21. [5] Lynagh M, Burton R, Sanson-Fisher R. A systematic review of medical skills laboratory training: where to from here? Medical education 2007;41: 879–87. [6] Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. Jama 2011;306:978–88. [7] Lund F, Schultz JH, Maatouk I, Krautter M, Moltner A, Werner A, Weyrich P, Junger J, Nikendei C. Effectiveness of IV cannulation skills laboratory training and its transfer into clinical practice: a randomized, controlled trial. PloS one 2012;7:e32831. [8] Herrmann-Werner A, Nikendei C, Keifenheim K, Bosse HM, Lund F, Wagner R, Celebi N, Zipfel S, Weyrich P. ‘‘Best practice’’ skills lab training vs. a ‘‘see one, do one’’ approach in undergraduate medical education: an RCT on
[14]
[15]
[16] [17]
[18]
[19] [20]
[21]
7
students’ long-term ability to perform procedural clinical skills. PloS one 2013;8:e76354. Weyrich P, Celebi N, Schrauth M, Moltner A, Lammerding-Koppel M, Nikendei C. Peer-assisted versus faculty staff-led skills laboratory training: a randomised controlled trial. Medical education 2009;43:113–20. Hudson JN, Tonkin AL. Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients. Medical education 2008;42:901–8. Tolsgaard MG, Gustafsson A, Rasmussen MB, Hoiby P, Muller CG, Ringsted C. Student teachers can be as good as associate professors in teaching clinical skills. Medical teacher 2007;29:553–7. Heni M, Lammerding-Koppel M, Celebi N, Shiozawa T, Riessen R, Nikendei C, Weyrich P. Focused didactic training for skills lab student tutors - which techniques are considered helpful? GMS Zeitschrift fur medizinische Ausbildung 2012;29. Doc41. Blohm M, Krautter M, Lauter J, Huber J, Weyrich P, Herzog W, Junger J, Nikendei C. Voluntary undergraduate technical skills training course to prepare students for clerkship assignment: tutees’ and tutors’ perspectives. BMC medical education 2014;14:71. Ringel N, Burmann BM, Fellmer-Drueg E, Roos M, Herzog W, Nikendei C, Wischmann T, Weiss C, Eicher C, Engeser P, Schultz JH, Junger J. [Integrated Peer Teaching of Communication and Clinical Skills How to Train Student Tutors?]. Psychotherapie, Psychosomatik, medizinische Psychologie 2015;65: 288–95. Schnabel KP BP, Breuer G, Fichtner A, Karsten G, Kujumdshiev S, Schmidts M, Stosch C. Konsensusstatement ‘‘Praktische Fertigkeiten im Medizinstudium’’ – ein Positionspapier des GMA-Ausschusses für praktische Fertigkeiten. GMS Zeitschrift fur medizinische Ausbildung 2011;28:12. M.M.F.d.B.D.e. V., Nationaler Kompetenzbasierter Lernzielkatalog Medizin (NKLM) (2015). Buss B, Krautter M, Moltner A, Weyrich P, Werner A, Junger J, Nikendei C. Can the ’assessment drives learning’ effect be detected in clinical skills training?– implications for curriculum design and resource planning. GMS Zeitschrift fur medizinische Ausbildung 2012;29. Doc70. Roos M KM, Kirschfink M, Koch E, Jünger J, Strittmatter-Hausbold V, Steiner T. Developing medical educators - a mixed method evaluation of teaching education program. Med Educ Online 2014;27. Biggs J., T. C., Teaching for Quality Learning at University: What the students does., Open University Press/McGraw Hill, Maidenhead:, 2007. Lockspeiser TM OSP, Teherani A, Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ Theory Pract 2008;13:12. Yu TC WN, Singh PP, Lemanu DP, Hawken SJ, Hill AG. Medical students-asteachers: a systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract 2011;2:16.
Please cite this article in press as: Lauter J, et al. Tutor-led teaching of procedural skills in the skills lab: Complexity, relevance and teaching competence from the medical teacher, tutor and student perspective. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.03.005
