A Near-Peer Surgical Teaching Programme for Junior Doctors

Shoaib Fahad Hussain Buckinghamshire Healthcare NHS Trust Teri Hsiao Hsui Toi Norfolk and Norwich University Hospitals NHS Foundation Trust Edward Peter Laurent Southend University Hospital, Mid and South Essex NHS Foundation Trust Shaikh Sanjid Seraj Basildon and Thurrock University Hospital, Mid and South Essex NHS Foundation Trust, Nether Mayne Samer-ul-Haque (  samer@doctors.org.uk ) Basildon and Thurrock University Hospital, Mid and South Essex NHS Foundation Trust


Background
The clinical environment in the UK's National Health Service (NHS) is changing rapidly due to the challenges posed by increasing service demands, staff shortages and budget cuts; with junior doctor training becoming an unfortunate casualty (1). Surgical departments are now having to mitigate service demands with their statutory duty to provide high-quality education and training mandated by the General Medical Council (GMC) and the Joint Committee on Surgical Training (JCST) (2,3).
Doctors are expected to ful l the roles of a clinician and an educator as re ected in the GMC guidance, and several commentators have expressed concerns that the shift in working patterns and reduced contact hours may have impacted the quality of training and even affected the experience and competence of new consultants (4)(5)(6)(7).
In an overstretched NHS, opportunities for consultant-led teaching on ward rounds or in the operating theatre have become scarcer as the demand for service provision continues to rise. Furthermore, European Working Time Directives (EWTD) that capped the working week to 48 hours, as well as the 2016 NHS junior doctors' contract has resulted in ' rm' to shift-based working practices for compliance (8,9).
While this is a welcome improvement to the historical 100-hour working week, shift-based working has reduced the continuity of care for patients and continuity of supervision for junior doctors (4). Surgical teams can change daily, with the consequent reduction in contact hours resulting in trainers being less familiar with individual training needs and the opportunity to develop a mentor-mentee relationship in what has traditionally been a craft-based specialty (10). This has contributed to the di culty in trainees nding enough time for on-the-job teaching, slowly rendering the adage of 'see one, do one, teach one' obsolete.
To circumvent these issues, many surgical departments have adopted consultant-led didactic lecturestyle teaching sessions with 'bleep-free' protected time for trainees, or informal ad hoc bedside teaching. However, as detailed above, service pressures may preclude consultants from providing consistent teaching. Generic teaching provided by Foundation Schools are also often of limited hours and due to clinical duties, Foundation doctors may miss learning opportunities and struggle to meet requirements to pass their Annual Review of Competency Progression (ARCP).

Near-peer teaching
Near-peer teaching is a relatively new teaching strategy where students or junior doctors are taught by peers who are a few years ahead in their training (11). It has emerged as an increasingly popular method to enhance teaching for trainees and reduce a constant dependence on senior clinicians and consultants.
There remains a paucity of articles in the literature evaluating the long-term impact of near-peer teaching programmes. The present study evaluates the impact of a 12-week rolling surgical teaching programme in a District General Hospital which was designed with the input of senior faculty, specialist registrars, Foundation doctors and core surgical trainees over a 16-month period. Junior doctors [1] delivered teaching on a broad range of surgical topics with guidance and supervision from surgical registrars or associate specialists.
We hypothesised that this near-peer surgical teaching programme will (a) improve junior doctors' con dence in a broad range of core surgical topics, (b) develop their communication and presentation skills, and (c) demonstrate long-term sustainability as different doctors rotate through the specialty. We also brie y discuss how this programme can be adapted in view of the COVID-19 pandemic. [1] We use the term 'junior doctors' to refer to both Foundation doctors and Core Surgical Trainees

Methods
Programme structure and curriculum design The programme consisted of weekly 1-hour sessions over a rolling 12-week period to cover each 4-month Foundation rotation. Topics were selected by the lead consultant with input from each cohort of registrars and junior doctors and were aimed at covering the management of common surgical presentations ( Table 1). The programme was also prominently displayed on weekly rotas disseminated to all surgical wards to emphasise that these were protected and 'bleep-free' teaching sessions. The unwell surgical patient All junior doctors at Basildon Hospital were invited to attend but most participants were Foundation doctors rotating in General Surgery, Vascular Surgery or Urology. A surgical registrar or associate specialist was allocated to supervise each session and facilitate discussion. Teaching sessions followed a small group tutorial format with a single junior doctor giving a slide-based presentation followed by a discussion among participants.

Recruitment, organisation and continuity
Junior doctors were recruited to teach via an online webform which was disseminated by email and were asked to rank their topic and presentation slot preferences prior to the start of their rotations.
Continuity of the programme was ensured through a three-tiered process ( Figure 1); the lead consultant overseeing the programme, a lead registrar who coordinated teaching during their 6-8-month rotation and 1 or 2 lead junior doctors who recruited peers and organised individual sessions over their 4-6-month rotations. Lead registrars and junior doctors took part in a structured handover at the end of the rotation with the next group of teaching leads to facilitate a smooth transition.

Feedback and data collection
Online feedback forms were designed using Google Forms and responses were collated on the Google Drive™ platform using a dedicated Google account. Feedback on session content, presenter and supervisor was collected electronically after each session as a surrogate for attendance and anonymised. Separate feedback on the overall programme was also collected and anonymised after each 4-month rotation to monitor and evaluate the programme's e cacy.
We used 5-point scales ranging from 1 (e.g. 'poor' or 'strongly disagree') to 5 (e.g. 'excellent' or 'strongly agree') as well as free-text comments to assess individual session and overall programme metrics.
Individual session feedback forms asked respondents to rate the overall quality, relevance and usefulness of the topic, the presenter and supervisor's knowledge and coverage of the topic and the supervisor's role in facilitating discussion. We also asked respondents to self-assess their knowledge of the topic before and after the presentation. Free-text comments were aimed at providing constructive feedback and suggestions for improvement for the presenter.
End-of-rotation programme feedback forms asked respondents to rate the overall programme using a 10point scale. A 5-point scale was used to assess the quality and knowledge of presenters and supervisors as a group, the relevance of the surgical teaching curriculum and its impact on their perceived clinical performance. We also asked junior doctors who taught during the programme to rate its impact on their clinical education and professional skills.
Data regarding attendance, venue and interruptions due to clinical duties were also collected in order to continually improve on extrinsic factors affecting quality of the programme. Data was analysed using Microsoft ® Excel and the paired t-test was used to calculate statistical signi cance.

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Between March 2019 to April 2020 a total of 42 junior doctors consisting of 34 Foundation Year 1 doctors, 7 Foundation Year 2 doctors and 1 Core Surgical Trainee responded to the end-of-rotation programme feedback survey (Table 2), encompassing Foundation rotations from December 2018 to April 2020. Global feedback on the programme was excellent. Respondents rated the overall programme very highly (8.83/10, SD 1.08) with additional comments stating that it was 'well organised' and 'highly recommended'.
Respondents indicated that the topics were relevant, with comments suggesting that the selected topics were 'useful' and 'very helpful' in their day-to-day clinical practice. Presentation quality, supervisor knowledge and engagement were also highly rated by respondents. 95.2% (n=40) of respondents had attended more than 3 sessions and 71.4 % (n=30) had participated in teaching sessions as well as attended them.
A total of 107 responses were recorded for individual feedback forms during the study period. Overall, respondents rated their knowledge and familiarity with the topic before sessions as 3.72/5, SD 0.92 and 4.50/5, SD 0.56 following each session (P<0.0001).
Of the 30 respondents who had taught at sessions, 93.3% (n=28) agreed that the programme had helped them improve their skills as a clinical educator. 88.1% (n=37) of all respondents agreed it had a positive impact on their perceived clinical performance as a junior doctor.
Additional feedback for the programme showed participants were greatly appreciative of the teaching leads and registrars for their effort and for organising the sessions. Many comments pointed out that this 'boosted their teaching hours' for their e-portfolios, a pre-requisite for successfully passing their ARCPs, and that they were especially valuable as their daily role provided 'minimal learning opportunities'.

Discussion
The results of our study demonstrate that this programme signi cantly improved participants' con dence in a broad range of core surgical topics which also translated to day-to-day perceived clinical performance. Presenters and supervisors received excellent feedback, with free-text comments highlighting the importance of the post-presentation discussion in clarifying key concepts, local guidelines or to explore the topic in greater detail. This indicates that our use of small group tutorial-style sessions with a discussion moderated by a surgical registrar or associate specialist was effective in maintaining interest and facilitating group learning. This has also had the collateral effect of raising awareness of local diagnostic and management pathways for newly rotating junior doctors.
Junior doctors who taught during their rotations overwhelmingly reported that the programme improved their skills as a clinical educator which is a core competency of the Foundation Programme (12). Free-text comments from participants also suggested that these sessions augmented their teaching attendance hours, a minimum number of which must be recorded on their e-portfolios to pass their ARCP, indicating that the programme had helped ll potential gaps in the generic Foundation teaching programme.
One of the early challenges of the programme was to maintain teaching quality and secure senior supervision. The use of a three-tiered leadership framework enabled junior doctors and surgical registrars take greater ownership of their clinical education, improved engagement as participants became more invested in supporting their peers and has ensured continuity.
During this programme's 16-month study period, there were four handovers among lead junior doctors, two handovers among lead registrars and one overseeing consultant. The natural overlap in rotations for registrars, core surgical trainees and Foundation doctors has meant that there was always an individual engaged with the project, enabling staggered handovers, protecting continuity of the programme and preventing any sessions from falling through. All 12 sessions have been successfully delivered in each rotation and the programme is still ongoing in webinar format during the COVID-19 crisis.
The use of a Google Drive™ has been instrumental in facilitating an easy and effective handover. This drive included; a list of teaching topics, session registers and sign-up sheets, individual session feedback forms, overall programme feedback forms and certi cate templates on completion of teaching sessions. Handover occurs when teaching leads for the next rotation have been identi ed and ensures that the next 12-week rolling programme can begin on time. We also incorporated a buffer period of 4-5 weeks in the 4month rotation to account for delays in start times between rotations, bank holidays, clinical emergencies and sickness. This exibility allowed additional sessions to be organised, if required, before the end of the rotation.
Participant ratings for the programme as well as supervisors and presenters remained consistently high throughout the study period, with 4 different groups of Foundation doctors having now engaged with the programme. This suggests that the use of electronic resources coupled with structured, staggered handovers has helped sustain the programme and maintain its effectiveness.
Several studies have shown that the outcome of near-peer programmes is as effective as consultant-and faculty-led teaching and are potentially more popular among trainees, possibly due to proximity in age and experience (13)(14)(15)(16)(17). Designing and participating in such programmes also provides trainees with teaching opportunities, enhances their knowledge of the subject and develops their communication, presentation and leadership skills. This may also have the added bene t of engaging trainees to take a greater interest in the specialty, particularly in the context of Foundation training where doctors have not sub-specialised. In the long term, the formal incorporation of these programmes can also improve overall trainee satisfaction with their rotation. This programme was also highly cost-effective; all participants taught or attended voluntarily, sessions were held at the hospital's main lecture theatre and no additional funding or equipment was required.
We are encouraged by these positive results but are also cognisant of the limitations of this study. Over 70% of respondents had taught during the programme which may have introduced an element of bias in their evaluation of the programme. To reduce bias, we anonymised all feedback and actively encouraged suggestions for improvement which were followed through in successive iterations. Furthermore, our evaluation of post-session clinical knowledge and con dence is based on a subjective self-assessment. The use of pre-and post-session multiple choice questions (MCQs) could be used in future iterations of the programme as an objective measure of participants' knowledge.
Adapting the programme for COVID-19 The COVID-19 pandemic introduced new challenges to the programme including the cancellation of all face-to-face teaching, increased work demands and rota changes resulting in fewer junior doctors in hospital at any given time. We have responded by using an online video conferencing platform to adapt this into a virtual teaching programme using the same teaching structure. We also advertised the programme on social media platforms to make it more accessible to doctors and medical students whose centres did not provide an alternative to face-to-face teaching. Participants now only require an internet connection and a computer or mobile device to access teaching anywhere, and sessions can easily be recorded for future use or for those unable to attend. We have also been able to expand our target audience from junior doctors rotating in the surgical specialties to medical students, interim Foundation Year 1 doctors and junior doctors from other specialties. This virtual platform remains in its infancy and was born out of necessity; future research is needed to compare the e cacy of a virtual approach with the face-to-face small group programme described above.

Conclusions
Our results show that this long-term near-peer teaching programme was an effective, cost-e cient and sustainable medical education strategy which was very well received by multiple cohorts of junior doctors. A structured handover, the use of appropriate electronic resources and senior guidance and supervision were crucial in ensuring the programme's continuity and securing the engagement of all stakeholders. This programme's format can easily be implemented in other departments and settings and has been adapted into a virtual programme during the COVID-19 crisis.
Near-peer teaching programmes have the potential to augment junior doctors' teaching, leadership and organisational skills, reduce the pressure for consultant-led teaching, ll potential gaps in generic teaching programmes and provide a mechanism for workplace-based assessments with appropriate supervision. In the context of Foundation training which imparts generic education and skills, the inclusion of specialist surgical teaching enhanced junior trainees' understanding of common surgical conditions and may have helped foster greater interest in the specialty. We therefore advocate using nearpeer teaching as an adjunct in the education and training of Foundation doctors and Core Surgical Trainees.

AVAILABILITY OF DATA AND MATERIALS
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.