Objective
Medical students spend significant portions of their time in the operating room, with many learning skills through trial and error. Peer-assisted learning is a useful teaching and learning method. Our hypothesis is that students will perform basic skills in the operating room environment more often when taught by their peers.
Study Design
Sixty third-year medical students participated in an operating room introduction course. Learners were randomized into 2 cohorts: 1 led by obstetrics and gynecology residents, 1 led by fourth-year medical students. Assessment was performed using an objective, structured clinical exercise.
Results
Peer-assisted learners performed more steps correctly during the objective exercise compared with resident-assisted learners (16.1 vs 14.4 of 22 total steps assessed, P < .01).
Conclusion
Peer-assisted learning may be a useful teaching method for simulation training. Third-year medical students may benefit from this low threat and informal environment.
Medical students spend significant portions of their time in the operating room, particularly during their general surgery and obstetrics and gynecology clerkships. Although surgical clerkships have brief orientations to various technical skills, many students learn to scrub, gown and glove, and suture by trial and error. Many core technical skills are not adequately taught, which can affect confidence levels of fourth-year medical students and new interns. As medical students enter surgical clerkships, including obstetrics and gynecology, many are interested in learning these technical skills, particularly skills that might be performed by nonsurgeons.
Educators have created several programs in general surgery and obstetrics and gynecology to expose clinical and preclinical students to surgical and technical skills, demonstrating that an introduction to basic skills increases self-assessed levels of comfort and confidence toward surgery. Similarly, simulation with an obstetric delivery trainer resulted in students feeling confident they could deliver a baby independently compared with students receiving only lectures.
Whereas simulation and surgical training is being integrated into preclinical and clerkship education, more data are needed on the type of teacher utilized. Peer-assisted learning (PAL) is a useful teaching and learning method, which is increasingly reported on in the medical literature. PAL was a successful adjunct to a standard curriculum for musculoskeletal system training. Peer learning has a benefit of being more informal and allowing learners to raise areas of concern without feeling foolish. Learners generally like being taught by students and find the interaction easier and material placed in context for their level.
Multiple studies have compared PAL with faculty-led learning, finding equal effectiveness using objective outcomes. One study suggests that PAL may lead to poor outcomes, as compared with independent study. The level of advancement may be a critical element of skill instruction. Although resident physicians are increasingly involved in the day-to-day teaching of clinical and technical skills, no study has compared their teaching with PAL. The aim of this study was to evaluate the learners’ performance in an objective, simulated operating room experience, comparing peer instructors vs resident instructors.
Materials and Methods
This study was granted an educational exemption by our institutional review board. During the first half of the 2008-2009 academic year, third-year medical students on the obstetrics and gynecology clerkship participated in an operating room introduction course, held on the first day during the orientation. The course consisted of a 1 hour didactic, highlighting operating room etiquette and traffic patterns. Points included the importance of introductions to staff, pulling one’s gown and gloves, and identification of sterile fields and technique. This was followed by a 30 minute hands-on session in a simulated operating room.
Clerkship rosters are received at the beginning of each academic year. Learners were randomized, using blocked permutation and 1:1 allocation, to 1 of 2 groups: 1 led by obstetrics and gynecology residents, resident-assisted learning group (RAL); and 1 led by fourth-year medical students, the PAL group. Allocation was concealed for each clerkship group until the orientation. Participating fourth-year students were enrolled in an elective teaching course, offered by our medical school. Residents and peer teachers received a 30 minute orientation to the exercise the day of teaching, emphasizing the steps and objectives of the exercise.
Learners were subdivided into smaller working groups of 4-5 students, led by either residents or peer teachers. Both groups worked through the steps of the mock procedure as described below. Learners were provided the opportunity to work on individual steps, ask questions, and simulate the entire procedure.
The simulated operating room exercise included entering the operating room and beginning a surgical procedure, specifically an abdominal hysterectomy. Using a simulated patient (human patient simulator; METI, Sarasota, FL), learners were taught to identify the patient, mark the surgical site, and apply sequential compression devices to the lower extremities. Proper positioning in dorsal lithotomy was demonstrated, taking care to protect the limbs for neural safety. Learners performed a preoperative pelvic examination on a pelvic simulator (clinical female pelvic trainer; Limbs and Things, Savannah, GA). Students scrubbed, gowned, and gloved in a sterile fashion to complete the exercise.
Assessment occurred on the day following the orientation. It entailed using an objective, structured clinical exercise performed in the simulated operating room. Learners were provided a clinical scenario, during which they were entering the operating room for an abdominal hysterectomy and asked to demonstrate the steps needed to properly enter the operating room and prepare the patient for the procedure. A faculty member, blinded to the teaching group, assessed the clinical skills performed as either correct or incorrect on a checklist. A total score was generated from the number of steps properly performed.
All statistical analyses were performed using SPSS version 16.0 (Statistical Package for Social Sciences, Chicago, IL). In addition to descriptive analyses, we compared groups and categorical data using χ 2 analysis. The Student t test was utilized for comparison of group means for normalized data. All results were considered significant for P < .05.
Results
Sixty-five third-year medical students rotating through our clerkship participated in the surgical orientation workshops and were randomized, according to the Figure . Five did not complete the final assessment: one in the peer group and 4 in the resident group. Thirty-two students were evaluated in the peer group and 28 in the resident group. Table 1 shows the clinical experience of each group. The PAL group performed more steps correctly during the objective exercise compared with the RAL group (16.1 vs 14.4 of 22 total steps assessed, P < .01). When controlling for prior surgical experience, the PAL group still performed more steps correctly, although the difference was not statistically significant (15.5 vs 14.4, P = .85).
| Clinical experience | Resident led, n (%) n = 28 | Peer led, n (%) n = 32 | P value |
|---|---|---|---|
| Prior surgical experience | 5 (18) | 9 (28) | .348 |
| Number of prior rotations | |||
| 0 | 7 (25) | 7 (22) | |
| 1 | 13 (46) | 17 (53) | |
| 2 | 8 (29) | 8 (25) | .875 |
| Clerkship Site Selection | |||
| Community | 6 (21) | 11 (34) | |
| Academic | 22 (79) | 21 (66) | .198 |
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