Peer-assisted learning

Introduction

There has been a considerable increase in the number of medical schools incorporating various kinds of peer teaching, peer assessment and medical teacher-training into their undergraduate curricula in recent years. There has also been a noticeable increase in the number of teacher-training courses, qualifications and formalized teaching opportunities available to junior medical staff. These are reflected in the growing literature and supporting evidence for teaching and learning approaches that we will collectively refer to here as ‘peer-assisted learning’ (PAL). This chapter outlines the principles of PAL, the potential applications in medical education with examples from the literature, issues to consider when planning and developing new PAL initiatives and the relationship between PAL and so-called ‘collaborative learning’.

Training-grade doctors and medical students have a long history of supporting and assisting the learning of their peers and colleagues. Examples in the literature can be traced as far back as Aristotle. However, this has tended to be informal, opportunistic and largely undocumented. The origins of the phrase ‘See one, do one, teach one’ are obscure, but the legacy lives on, although generally now with much more consideration of patient safety and quality assurance. Consultants and other experienced healthcare professionals have long been expected to take on teaching responsibilities, and this is increasingly reflected in professional standards for practice and contractual agreements. Only relatively recently, however, have medical undergraduates and junior doctors been required to learn about teaching and gain some practical teaching experience as part of their formal curriculum. Most learning outcome and competency frameworks for undergraduate and postgraduate medical training now include statements about learning to teach, and medical job applications at all levels enquire about teaching experience and training. PAL approaches represent practical and effective ways for medical students and postgraduate trainees to gain experience in teaching, to undertake focused teacher-training, and to receive constructive feedback on their teaching skills.

“One who has just acquired a subject is best fitted to teach it.”

Quintillian (c. 80 AD)

PAL can be defined as ‘People from similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching’ (Topping 1996). Using this definition, ‘peers’ share certain characteristics but are not necessarily from the same course or year of study, and may include students and trainees from different healthcare disciplines. Peers are not professional teachers or ‘experts’ in their subject areas, and should not be significantly different in status or qualification. The term ‘near-peers’ is sometimes used if there is a significant difference between otherwise similar groups, for example, junior doctors teaching senior medical students. The term PAL is a broad umbrella term, covering a wide range of teaching and learning situations. Because it has been developed in different ways across a spectrum of educational fields, the terminology is diverse and sometimes conflicting. PAL approaches are sometimes referred to as peer teaching or tutoring; near-peer teaching; peer-supported learning; peer-assisted study; peer assessment; cooperative or collaborative learning; peer group learning; students helping students; student tutoring or facilitation; student mentoring; study advisory schemes; teaching assistant schemes; supplemental instruction; parrainage and proctoring. Terminology is not standardized, and some of these terms are also used to describe learning and teaching situations which are not PAL. A confusing variety of terms have also been used to describe PAL participants, activities and learning and teaching situations depending upon local preference and context. For clarity in this chapter and elsewhere, we attempt to standardize terminology so that in any organized PAL ‘project’, ‘tutors’ assist the learning of ‘tutees’ through a variety of PAL ‘interactions’ or ‘sessions’. It is recognized, however, that in some instances, as in the production of PAL learning resources, there may be no direct interaction between tutors and tutees. In ‘reciprocal PAL’ each participant may at different times be tutor and tutee.

Theoretical basis for PAL

Most PAL participants report the experience to be enjoyable and beneficial in a variety of ways. Feedback suggests that the nature of the interaction and relationship between PAL tutor and tutee may be qualitatively different than that between student or trainee and ‘expert’ teaching staff. Many educational, psychological, social and organizational theories have been proposed to explain the success and appeal of PAL. Topping and Ehly (2001) offer an accessible introduction to this literature, highlighting cognitive, communication, affective, social and organizational factors.

Cognitive factors: Challenge and support

PAL typically involves tutors and tutees being challenged in their understanding, beliefs and assumptions: leading to ‘cognitive conflict’, which Piaget and others consider crucial to learning. Topping and Ehly note that tutors derive less academic benefit from PAL if there is low cognitive challenge, although they suggest that the cognitive demands of monitoring learner performance and of detecting, diagnosing and correcting tutee errors in PAL are typically high (Topping & Ehly 2001). PAL tutors are closer to the academic level of tutees than ‘expert’ staff and so may be better able to understand their difficulties, sometimes referred to as ‘cognitive congruence’ (Ten Cate & Durning 2007). For tutees, supported or ‘scaffolded’ learning within Vygotsky’s ‘zone of proximal development’ (the distance between what a learner can achieve independently and what he or she can achieve with more experienced assistance) through interaction with more experienced peers is thought to be very significant (Topping 1996). In a classic study, Bargh and Schul demonstrated that learning content in order to teach it results in better understanding and recall than learning the same content for a test (Bargh & Schul 1980). Such goal-orientated information processing, content learning and structuring are thought to offer significant cognitive benefits to PAL tutors (Ten Cate & Durning 2007).

Communication factors

All participants, whether tutor or tutee, may be called upon to recall, explain and structure their understanding of content, perhaps for the first time. Verbalization is considered to be of key importance to the success of PAL, with both tutors and tutees gaining significant benefit from listening, explaining, questioning, clarifying, simplifying, summarizing and hypothesizing during PAL interactions (Topping 1996).

“How do I know what I think until I see what I say?”

E. M. Forester

Affective and social factors

Tutor enthusiasm and competence are likely to motivate tutees and lead to role-modelling. Because of their similarity, PAL participants are likely to establish a relaxed relationship with their peers. Ten Cate and Durning (2007) outline current thought on the impact of this ‘social congruence’ in motivating and reducing anxiety in tutees and of PAL as a vehicle for transmitting the ‘hidden curriculum’. They also discuss affective aspects of PAL for tutors including Maslow’s need for esteem, role theory and self-determination theory. This suggests that by ‘acting’ as a relative expert, tutors are likely to feel, and then become, more like an expert in terms of competency, autonomy, esteem and motivation.

“The authority of those who teach is often an obstacle to those who want to learn.”

Cicero

Organizational factors and the PAL process

PAL is often voluntary and supplemental to core programme learning activities. As such, it may result in increased time and engagement with content for tutors and tutees and may add variety and interest to their studies. In some cases tutors also receive additional teaching from staff as preparation for PAL interactions. Group sizes are often small, resulting in more individualized and immediate feedback for tutees than may be possible from staff. Intrinsic rewards from participating in PAL are thought to have a significant effect on tutor attitudes and motivation, as may extrinsic rewards such as payment, privilege and evidence of participation for their CV and job applications.

All the above factors feed into the PAL process in which participants may extend, modify and rebuild their knowledge and skills; develop shared understanding; rehearse and consolidate core skills; generalize specific concepts; and give and receive feedback and reinforcement. This may lead to increased self-awareness, metacognition and self-confidence in both tutors and tutees.

Evidence for PAL

The medical and healthcare education literature now contains a substantial body of project evaluations, discursive papers and research on PAL (Ross & Cameron 2007). Together with evidence from school and post-compulsory education in other disciplines (Topping 1996), there is much evidence to support and guide the use of PAL. It must be remembered, however, that PAL is not one single approach. Although there is evidence for the utility, acceptability and effectiveness of PAL with certain types of content in particular situations, it will not be appropriate in all situations. There is evidence that PAL can have disadvantages and unintended consequences, particularly if used indiscriminately or inappropriately. For example, it would probably be detrimental to PAL tutees for a tutor to give a didactic lecture on a topic about which they knew little, or teach them how to diagnose or manage complex cases. It may, however, be very effective to have a PAL tutor facilitate a discussion and question-generating session on such topics, lead a problem-based learning tutorial or teach specific well-defined clinical skills (such as shoulder ultrasound in Knobe et al 2010). Commonly cited advantages of PAL for tutors, tutees and the host institution, and potential disadvantages, are discussed below.

“PAL strategies are very well researched, with a substantive evidential basis for effectiveness in terms of raising achievement, fostering social and emotional gains, and often also developing transferable interpersonal skills.”