Issue 29 / 5 August 2013

INCREASED opportunities for peer-assisted learning in Australian medical schools and teaching hospitals are on the agenda, according to leaders in medical education.

The authors of Perspective article in the MJA have described early results of an extracurricular peer-assisted learning (PAL) program initiated at the University of WA as positive. (1)

The authors wrote that teaching was an essential skill for junior doctors, as it improved their interactions with patients and their efficacy as mentors for medical students.

“We believe Australian medical schools should strongly consider implementing a comprehensive, vertically integrated student teaching program employing PAL”, they wrote.

Evidence from European and US medical schools suggested PAL programs taught students how to “teach and give feedback” as well as giving them the chance to “practise and consolidate” their own skills, the authors wrote.

Professor Alistair Burt, the recently appointed dean of medicine at the University of Adelaide, told MJA InSight that a similar program to the University of WA was under consideration at his university.

“We believe [PAL] should be a really important element of a modern medical curriculum”, Professor Burt said.

“We see it as an important attribute of our graduates that they see themselves as teachers. At the moment we don’t have a formal training program but we have it in our sights as we renew our curriculum in the very near future.”

The University of Adelaide already offers a 9-week elective unit in the final year of its 6-year MBBS degree, in which students receive structured teaching training and the opportunity to teach second- and third-year students.

“In the last 2 years that it has been offered it has been taken up by 31% and 30% of students respectively, and the evaluation of that course has been very positive”, Professor Burt said.

“There are challenges — this kind of program needs committed medical educators to champion it, and you have to make sure the induction is solid and robust. There would be nothing worse than doing it piecemeal and getting it wrong.”

Dr Will Milford, chair of the AMA’s Council of Doctors in Training (CDIT), said his group “thoroughly supported” PAL programs, adding that major hospitals should share the responsibility with medical schools of giving junior doctors adequate training in teaching.

“There’s no question that a large amount of teaching is delivered by junior doctors, most of it on the job and informally, and that continues right through our medical training”, Dr Milford told MJA InSight.

“There is a large demand from the hospitals on the junior doctors to do this teaching but we’ve found that many juniors feel they don’t get much support from the hospitals.”

A 2012 survey by the CDIT of more than 1000 junior doctors across Australia highlighted the problem of a lack of training in teaching in hospitals. More than half (51%) of the respondents believed their hospital did not have processes in place to develop the teaching skills of junior doctors who were providing training, for example, to medical students. Forty-six per cent of respondents were unsure whether their hospital had processes in place to develop the teaching skills of more senior doctors who provided training to junior doctors. (2)

“It’s never too early to start teaching people to do this and that’s why PAL programs in medical schools are important, but hospitals need to support it as well”, Dr Milford said.

“Some hospitals are starting to introduce educational registrar positions, which allow the registrars to receive training in teaching as well as be involved in teaching programs within the hospital.”

Professor Peter Smith, president of the Medical Deans of Australia and New Zealand, and dean of the University of NSW Medical School, said PAL programs would need “very clear guidelines”.

“There would have to be very careful assessment of both the process and the outcomes”, he told MJA InSight. “We’d be generally supportive, however.”

1. MJA 2013; 199 (3): 164-165
2. AMA 2013; 2012 AMA junior doctor training, education and supervision survey


Are peer-assisted learning programs appropriate in Australian medical education?
  • Yes - with strong guidelines (67%, 51 Votes)
  • Yes (25%, 19 Votes)
  • No (8%, 6 Votes)

Total Voters: 76

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15 thoughts on “Push for peer-assisted learning

  1. Preeti shanbag says:

    I work in India and  am  nervous regarding the excessive reliance on resident doctors (mainly post-graduates) for the teaching of undergraduate students.Senior doctors are increasingly abdicating their responsibilities of teaching juniors on the flimsiest pretext. Junior doctors need to be groomed to become teachers and require to be closely monitored in their role as teachers.This requires a lot of time, thought and dedication on the part of seniors.Medical education like any professional education is associated with a hidden curriculum and hence good role models are necessary.

  2. Chris Andrews says:

    I believe it is correctly said that MCQs favour the “bright but cavilier” student.

    Not the most knowledgeable.

    My experience with College MCQs was that the answers regarded as correct varied with the references read.



  3. Graham Row says:

    I agree with my friend Brian Seinewiratne who makes the important distinction between treating patients (clinical medicine), and teaching medicine.  Dr Max also highlights the essential element in this discussion.  He describes his good fortune in having a good clinical role model.  As an amateur handyman, I learned a great deal about carpentry, bricklaying, tiling, etc.  not by formal education in a trade school but by closely observing and noting the skilled worker’s “tricks of the trade”.  Reflecting on my own clinical training (that continued for some forty years or more), is that one can learn as much from critical observation of a poor role model about how not to do things as one learns from a good role model.  An aspiring clinician who lacks the ability to distinguish between the two clearly lacks the aptitude required of a clinician. If a medical student has these essential skills, a “business” ward round is a valuable learning experience, observing  the “tricks of the trade”  enhanced by a rich display of human interactions, emotions, and body language. Who was it who said of their life in medicine, “I spent six years learning the facts, Two years learning what was practical and relevant, and  a lifetime learning about human nature”?

  4. Greg Hockings says:

    I agree with the criticisms of MCQs. It is quite  possible to give an incorrect answer to an MCQ despite (or perhaps because of) having an extensive and accurate knowledge of the topic, and conversely to come up with the correct answer through flawed reasoning or limited knowledge.  Try writing a short essay about the diagnostic work-up of a patient with suspected Cushing’s syndrome, as opposed to “which of the following should be the next step in the work-up?”.

    As a profession we should be very aware that MCQs may be a major component of the recertification process currently being proposed by AHPRA and the national Medical Board. I wonder who will set the questions, and whether the “correct” answers can be challenged.

    In my opinion, senior medical students should be focused on their own learning, not spending time teaching junior colleagues. There appears to me to be a wide variation in the skills, knowledge and work ethics of interns, compared to 30 years ago when nearly every graduate was ready to rapidly gain proficiency as an intern.

    The best teachers of medicine are clinicians, not full-time professional educators who do not treat patients, or in some cases do not even have a medical degree.  It is not particularly difficult to determine which clinicians are also good teachers and role models.

    Teaching clinical medicine demands time, effort and planning by the teacher.  Australian universities have turned medical courses into cash cows, with considerable numbers of full-fee paying students (mostly from overseas) and great reliance on busy clinicians doing much of the clinical teaching on an honorary basis.  I don’t believe that this situation can continue much longer.

  5. Chris Andrews says:

    The last comment was interesting if I may have a second go.

    My experience with the “competent for anything” medical view came partly from my experiences with MCQs from a specialist college. They were shockingly set,  were shocking questions, and that section of the exams was my reason, solely , in failing the overall exam for that  college – yet they prided themselves on outstanding examining. Education for MCQs and the rest of the exam was – go  consult your peers. The peers comment was generally, “Hell, what a stupid question. I haven’t a clue what the college wants”. 

    The superb education skills of this college then extended. I asked for remedial interview. The response: “No. We don’t do that. We couldn’t. We destroy all the exam papers before announcing the results.”

    I am a member of two other professions, (engineering and law) and can confidently say that no other profession in which I have been involved would  dream of treating their aspirants in this way. Yet the medical profession regards itself as expert in everything. Any graduate can teach, examine and research.

    I hold a PhD. The medical profession is the only one which regards research training as unnecessary after a primary degree, or specialist diploma (euphemistically referred to as a degree). Research requires proper training – embodied in the PhD.

    Where is this leading …. that junior doctors and registrars are unqualified to do what medical schools ought to be doing themselves. And too busy.

  6. Dr Brian Senewiratne says:

    There is confusion between treating patients and teaching medicine. They are not the same. Teaching requires different skills, expertise and training. It is a failure to appreciate this fundamental fact that has resulted in a crisis in teaching – which there is..

    As a former Professor of Medicine I know this for a fact. I have attended lectures given by my colleagues hich have destroyed whatever interest I had in the subject.

    The same holds for ward teaching. This floating into the ward, doing a round with your resident and registrar, with a collection of medical students tagging on, is no more than a religious performance. That is not teaching, that is doing a ‘business’ round.

    Ward-teaching is an entirely different ball-game. You get to one patient, get the student to present the problem and what he intends to do about it and why.

     Are there solutions? Yes, but those who are responsible must first realise that good-quality teaching is a very specialised art and one that requires training and monitoring. If the person at the top is a poor teacher himself, he will not know the difference between good and poor teaching. Sadly that is the situation today.

     MCQs are another dreadful problem. It has a disastrous effect in communication. No one has ever come to see me with “Doctor, which of the following things about me are untrue?” MCQ’s enable University staff to do their research or roam the world, but the damage done to students is enormous.   

    I wrote a paper on this “Are MCQ’s destroying clinical medicine?” I argued that they were. Not surprisingly, no journal would publish it. It is in the waste-bin. Sadly.

  7. Monash University Publisher Packages says:

    We have seen systematically compromising university educational standard and giving the responsibilities to educate our brightest by themselves. Many who are in hospital teaching will agree that they are not uniform across all hospitals nor systematic. We all learn from our peers at work and learning is continual process but fundamental of university teaching should not be compromised to minimise cost . I strongly support Dr Max. 

  8. Ignacio Mora-Magaña says:

    In medical education field things like this. happen since many years ago, but in other areas too. It is not a law that a good proffesional makes a good teacher, better yet it is uncommon. In Medical education, we took an specialist, a very in his own area, and we put in his(her) hands a chalk and in front of thirty medical student after told them: This is the best teacher in this subject, but,  when did we prepare hin(her) as a teacher? Inn other hand,  this is a work and as it, deserve a pay.

  9. Dr K says:

    I agree. As a junior doctor myself the biggest problem I can see is lack of quality control amongst my junior and registrar colleagues and medical students and the teaching interactions between them. I think medical schools have gone too soft on constructive feedback – you have to be really bad to fail but other than failing there doesnt seem to be a lot of honest feedback from people who see you work. And consequently these people are teaching juniors potentially the wrong things unchecked. Perhaps a more formalised framework including teaching how to give constructive feedback could help.

  10. Max Kamien says:

    This sort of teaching has been going on for eons. When I was a student at University of Adelaide in the 1950s third year students were introduced to the hospital wards and taught the elements of clinical examination by an allocated final year medical student. My mentor was kind, conscientious and a natural teacher. He was also courteous to patients and aware of their need to be made comfortable. He was a great role model.

    Fifty years on and having been an assessor at various medical schools, I have seen the downside of senior students being paid to teach junior ones. Many show little courtesy to patients and a total unawareness of the need to make them comfortable. So there needs to be a quality control on students teaching other students.

    Having just been a patient in a learning hospital I have a number of painful thrombophlebitides in each arm. The resident medical officers clearly lacked the skill and finesse to put in an IV line. After her fifth miss one otherwise charming intern said,”You think I’m not much good at this. But actually I’m very good”.

    Sadly medical education has always been a hit or miss affair made worse by the burgeoning number of medical students. There needs to be a much greater value and emphasis placed on teach the teacher education for students, registrars and consultants . Some quality control of the results would also not go amiss.

  11. Christine Qian says:

    I completely agree with CJA and Anonymous. If universities want doctors to do the teaching for them, they need to hire them as part-time/casual university employees with separate and dedicated time for student teaching  – not just add another task on top of their full-time work.

  12. Therese Jenkins says:

    Feedback from our students’ clinical placements indicate  variable competency demonstrated by more senior students and doctors. Until better systems for establishing baseline competency in clinical skills and teaching are developed, peer assisted teaching programs should be closely monitored.Thankfully,the ‘see one, do one, teach one’ days are gone.

  13. Dr Conor Calder-Potts says:

    A very negative comment by CJA. Who else do you propose do the training? Junior doctors training medical students and registrars training junior doctors has always been the norm. A senior consultant or disconnected university lecturer has no idea how the day-to-day running of hospital ward occurs. It is a great idea to formalise this training process. 

  14. Department of Health Victoria Clinicians Health Channel says:

    every day in hospitals both junior and senior medical staff are stretched to the limit by overwhelming patient work loads, yet the Universities and academics want us to give more and more time to teaching.  Get real !

  15. Chris Andrews says:

    Another opportunity for Medical Schools to hive off teaching to the least qualiified. And fancy thinking that a few weeks training will make someone an educator. Medicos have long been steeped in the notion that graduation, especially with a specialist fellowship, turns someone into a competent proceduralist, consultant, educator, researcher, examiner, and everything. An insular profession unaware of the real competencies properly recognised outside the insularity.


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