Enhancing Medical Students’ confidence and performance in Integrated Structured Clinical Examinations (ISCE) through a novel near-peer, mixed model approach during the COVID-19 pandemic

doi:10.21203/rs.3.rs-1975793/v1

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Enhancing Medical Students’ confidence and performance in Integrated Structured Clinical Examinations (ISCE) through a novel near-peer, mixed model approach during the COVID-19 pandemic

https://doi.org/10.21203/rs.3.rs-1975793/v1

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published 23 Feb, 2023

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Background

Due to the reduced clinical exposure because of the COVID-19 pandemic, we developed a mentorship scheme to help medical students with their Integrated Structured Clinical Examinations (ISCEs) by providing a combination of near-peer mentorship together with lecture-based teaching on a weekly basis for a 12-week period. Students attended a specialty-focused lecture every Tuesday followed by a small group teaching session organised by their tutor.

Methods

Students' perceptions of ISCEs (confidence, anxiety, and overall performance) were evaluated using 5-point Likert scales while their knowledge of the specialty was assessed using 10 single best answer questions which were distributed via Google® forms at the start and end of each week. In addition, we assessed tutor perceptions of our virtual “OSCEazy” programme.

Results

72 tutees were enrolled in the programme (mean age: 24.4, female: 77.8%). 88.9% of the participants had not attended any online ISCE teaching prior to this. They preferred in-person ISCE teaching as compared to virtual sessions [median 4.5 (IQR 4-5) vs 3 (IQR 3-4), p<0.0001), respectively]. There was a significant overall increase in knowledge when comparing pre-session and post-session performance [mean 53.7% vs 70.7%, p<0.0001)]. There was a significant increase in student confidence [Confidence: median 3 (IQR:3-4) vs 4 (IQR 3-4), p<0.0001] while no change was seen in the anxiety and perception of their overall performance in an ISCE. [Anxiety: median 3 (IQR 2-4) vs 3 (IQR 3-4), p=0.37, Performance: median 3 (IQR 3-4) vs median 3 (IQR 3-4), p<0.0001]. The tutors reported an increase in their confidence in teaching ISCEs online [median 3 (IQR 2-3.25) vs median 4 (IQR 4-5), p<0.0001)].

Conclusion

Online near-peer teaching increases the confidence of both tutees and tutors involved while enhancing the tutees’ knowledge of the specialty. Thus, medical schools should incorporate near-peer teaching in their curriculum to enhance the student learning experience.

Near-Peer

Mixed modal

Medical Education

Clinical Assessment

OSCEs

The COVID-19 pandemic has made a huge impact on the delivery of medical education. To teach clinical medicine, medical school curricula often allocate medical students to hospitals to provide clinical exposure (1). However, due to the risk of contracting, spreading, and facing the impacts of COVID-19, medical schools in the United Kingdom have had to discontinue or cancel clinical placements for a sustained period (2, 3). To combat this, many students lend themselves to other forms of learning such as online or virtual learning platforms. However, medicine invariably requires elements of practical learning, not only for essential procedural skills, but also to develop consultation skills such as the art of eliciting a comprehensive history (4). The latter is typically gained through repetition throughout medical school by spending time shadowing clinicians and by regular patient-student interactions (5, 6). However, the COVID-19 pandemic has forced medical schools and student organisations to employ online teaching methods to deliver medical education on a consistent basis in an attempt to replace clinical placements temporarily.

In recent decades preceding the COVID-19 era, there has been a significant change in the delivery of medical education, from a model of didactic, lecture-based teaching, to one of problem-based, facilitated small group teaching (7). This is due to the recognition that traditional didactic techniques limit student interaction and often present too large a volume of information for students to reasonably be able to understand and retain (8, 9). In contrast, small group methods foster camaraderie among participants and group learning (10, 11). Nevertheless, the logistical requirements for organising multiple small groups are significant when compared to that of a single lecturer giving a talk to a single cohort. The COVID-19 pandemic has brought virtual platforms such as Zoom^TM to the fore, meaning that didactic knowledge can be shared without geographical constraints. Furthermore, a recent systematic review has shown that there is no clear evidence to suggest that offline (in-person) learning is superior to online learning (12). Simultaneously, studies have demonstrated the value of teaching delivered by individuals who are only slightly more senior than the learners (so-called ‘near-peers’), demonstrating positive outcomes in certain contexts, including that of clinical examinations (13, 14, 15, 16). Therefore, we aimed to integrate virtual learning, near-peer teaching, lecture-based teaching, and small group teaching to provide an effective 4-week course for second year medical students. Herein, we report the results of our mixed-modality teaching course from the perspective of tutors and tutees, and its effects on clinical confidence and performance in the end-of-year Integrated Structured Clinical Examination (ISCE) examination.

Study Design

This longitudinal evaluative interventional study was performed via the national medical student led organisation, OSCEazy. Study participants were second-year medical students, and all teaching sessions were delivered by third-year medical students. Tutees and tutors were selected by invitations disseminated via email and group messages to the entire cohort of second- and third-year medical students respectively. Teaching sessions were delivered once-weekly over a twelve-week period on the following medical specialties: Cardiology, Respiratory Medicine, Gastroenterology, and Neurology. Each virtual session was delivered across the online platform Zoom^TM and comprised of a one-hour virtual lecture followed by a small group session. The small group session (‘one-to-two programme’) involved one third-year student and two second-year students, covering a simulated ISCE scenario relating to the preceding lecture (Figure 1). In order to assess the effects of the intervention, we obtained responses to surveys circulated prior to (pre-session questionnaire) and following (post-session questionnaire) the sessions on a weekly basis for four weeks, evaluating two domains: (i) the change in students’ perceptions of the ISCE format (confidence, examination anxiety and perception of personal performance); and (ii) the change in performance on knowledge-based questions relevant to that week’s specialty.

Questionnaire Design and Dissemination

Questionnaires were distributed as described above using anonymised Google® Forms. Perceptions of ISCE assessment were evaluated using five-point Likert scales. Clinical knowledge was assessed using ten standardised single best answer questions with 5 options, written by lecturers and peer-reviewed by a minimum of 3 other tutors. Sample questions from one pre-session and post session questionnaire have been attached in the Appendix.

Ethical considerations

This study constituted an evaluation of a voluntary novel teaching format. Approval was sought from the Cardiff University School of Medicine Research Ethics Committee who confirmed that formal approval was not required. Questionnaires contained relevant information about the study and stated that completion of the survey assumed consent for use of anonymised data in future presentation and publication.

Statistical Analysis

Summary statistics were reported as appropriate for baseline characteristics. Shapiro-Wilk test was used to test for the normality of data distribution, where a threshold of > 0.05 was considered to indicate normal distribution. Where more than one questionnaire was distributed for pre and post evaluations, the non-parametric unpaired Wilcoxon rank sum test with continuity correction was utilised (questions for tutees across the programme) however, when this was based on one questionnaire (tutors’ questionnaire), a paired analysis was utilised of the same test.

Binary proportion comparisons of pre and post knowledge scores was determined using a McNemar’s Chi-squared test. For all statistical analyses, a p-value threshold of <0.05 was considered to indicate statistical significance. All statistical analyses were performed in R.

Study population

72 out of 330 (21.8%) second-year students were enrolled on the one-to-two programme. The mean age of the tutees was 24.4 years, with 77.8% being female. 89% of the tutees stated they had not attended any form of virtual ISCE/OSCE teaching prior to the present programme.

Questionnaire analysis: tutee responses

Analysis of the initial tutee perceptions showed that they felt more confident being taught ISCE content in-person as opposed to in a virtual format [median 4.5 (IQR:4-5) vs 3 (IQR:3-4) respectively, p<0.0001)] (Table 1).

Table 1: Table showing the perception of confidence of tutees in receiving ISCE teaching virtually and in-person

Median (IQR)

p-value

Confidence of tutees in receiving ISCE teaching through a virtual format

3.0 (3 - 4)

< 0.0001

Confidence of tutees in receiving ISCE teaching in-person

4.5 (4 – 5)

Tutee performance in knowledge-based questions improved significantly with the teaching intervention. In analysing the percentage of correct answers in the pre-session questionnaire compared to the post-session questionnaire, there was a significant increase in the mean percentage correct (mean difference 17.0%, p<0.001) (Table 2).

Table 2: Table showing the mean value of correct responses to the knowledge assessments completed before and after each teaching session

Correct answers (mean)

p-value

Knowledge assessment in pre-questionnaires

53.7%

< 0.0001

Knowledge assessment in post-questionnaires

70.7%

The confidence of tutees with respect to sitting their upcoming ISCE improved over the course of the programme. However, despite this improvement in confidence, there was no significant change in the anxiety tutees felt towards the ISCE (pre-median 3 (IQR:2-4) vs post-median 3 (IQR:3-4), p=0.37). Similarly, there was no change in the tutees’ perception of how well they will do (overall performance) in their ISCE over the course of the programme (Table 3).

Table 3: Table showing the confidence, anxiety, and perception of ISCE performance of tutees at the start and end of the teaching programme

	Pre-Questionnaire (median (IQR))	Post- Questionnaire (median (IQR))	p-value
Confidence of tutees in performing well in their ISCE before and after the programme	3.0 (3 – 4)	4.0 (3 – 4)	< 0.0001
Anxiety of tutees towards their ISCE before and after the programme	3.0 (2 – 4)	3.0 (3 – 4)	0.37
Perception of tutees’ overall performance in their ISCE before and after the programme	3.0 (3 – 4)	3.0 (3 – 4)	< 0.0001

Questionnaire analysis: tutor responses

Among the 36 out of 300 (12%) third-year tutors who volunteered to delivered the teaching programme, an increase in confidence in delivering ISCE teaching virtually over the course of the programme was evident [median 3 (IQR:2-3.25) vs 4 (IQR:4-5), p<0.0001)]. Similarly, tutors reported an increase in their confidence in delivering such teaching in-person [median 3 (IQR:2-4) vs 4 (IQR:3-4), p<0.0001)] (Table 4).

Table 4: Table showing the tutor perceptions towards the delivery of ISCE teaching

Pre- Questionnaire (median (IQR))

Post- Questionnaire (median (IQR))

p-value

Confidence of tutors in delivering ISCE teaching through a virtual format at the start and end the programme

3.0 (2 – 3.25)

4.0 (3 – 5)

< 0.0001

Confidence of tutors in delivering ISCE teaching in-person at the start and end of the programme

3.0 (2 – 4)

4.0 (3 – 4)

< 0.0001

The COVID-19 pandemic has represented an unprecedented challenge to medical educators and medical students alike. The shift to online/distance learning during the early phases of the pandemic meant that there was a significant loss of face-to-face clinical learning opportunities for early years medical students. We identified an opportunity to deliver a structured, weekly virtual teaching programme aimed specifically at improving students’ preparedness for the examination utilising a near-peer learning model. To our knowledge, this is the first near-peer mixed-modality clinical teaching programme described and evaluated. We have shown that this model is effective not only in improving students’ knowledge (Table 2), but also improving their confidence going into the real-world examination (Table 3). Moreover, highly positive feedback was received from the third year near-peer tutors, identifying significant improvement in their confidence in delivering such teaching (Table 4) (17).

Near-peer teaching is not new to medical education. This teaching model leverages the principles of cognitive and social congruence between the student and near-peer teacher. Cognitive congruence refers to the similar knowledge base shared by near-peer tutors with their tutees, resulting in tutors understanding the likely gaps in their knowledge/skills and being able to deliver the content at an appropriate level (10,18). By comparison, social congruence occurs due to the common or similar social role shared by tutor and tutee (10). The social and cognitive congruence between near-peer tutors and tutees fosters a pleasant, serene and motivational work environment (6, 19, 13). It allows for supportive learning with ease in understanding concepts, tutees feeling able to ask for clarification when required, as well as providing constructive feedback to the tutor (19). Near-peer education has been shown to improve students’ motivation for study, problem-solving, organisational and time management skills (14). These skills are said to be less well addressed by senior-led teaching as faculty are separated from tutees in terms of both experience and relatability. Conversely, near-peer-educators recall their examination experiences and guide their tutees with respect to the specifics of the examination and the preparation required. The near-peer tutors, based on personal experiences, are therefore able to segregate essential and trivial information, hence imparting specific knowledge to their tutees (10, 15). This concept is underpinned by work by Ten Cate et al. and Whitman et al. who suggest that peer-educators have a ‘conscious competence’ of a recently completed examination as compared to senior faculty who possess an ‘unconscious competence’, resulting in them being less skilled in providing highly specific advice and conveying concepts which novices struggle to understand (15, 16, 20).

Interestingly, our results indicate that the overall academic performance and confidence of the tutees increased throughout the programme while there was no significant change observed in their anxiety and the perception of their performance in an ISCE. It has been shown previously that confidence and anxiety are unrelated to a student’s eventual examination performance (7). However, others have shown that in the context of clinical examinations, practice in the form of formative assessments improves examination outcomes (8). Anxiety is conventionally divided into ‘trait’ and ‘state’ forms. State anxiety is defined as the temporary reaction to an adverse event while trait anxiety is a more perpetual prolonged form of anxiety associated with one’s personality. We could hypothesise that students in our study are experiencing trait anxiety due to the continuous barrage of medical education provided to them coupled with the overbearing constant worry of approaching ISCEs and other examinations (9).

The Yerkes-Dodson law suggests that a small degree of state anxiety enhances performance. However, greater anxiety/stress levels would be more likely to adversely affect student performance in an ISCE (21). The participants in this study demonstrated an improvement in knowledge as well as confidence. Therefore, their anxiety appears to be of a ‘trait’ type given the unchanged nature of anxiety levels despite objective improvement in preparedness. This might be a result of the continuous academic pressures associated with medical school, the wider societal uncertainties associated with the pandemic, or indeed an amalgamation of factors.

Tutors’ perceptions

Medicine in general relies on a hierarchical transfer of knowledge (10, 18, 15, 20). This consistent transfer requires competent professionals that are willing and have the skills, capacity, and motivation to teach their juniors. Our study adds to the body of literature suggesting that tutors who have just experienced examinations are the most valuable for junior students, in certain contexts. This value arises from relatability as well as a first-hand experience of the upcoming examination providing ease of communication and cognitive congruence (22).

In order to successfully teach a topic, a tutor must have sufficient depth of understanding for the intended session. Tutors therefore need to prepare adequately to be able to support juniors through their learning journey. This involves in-depth content preparation and planning of delivery method in order to convey the information in an understandable manner, as well as being able to answer any questions posed by the tutee (15).

Our cohort of tutors found that their confidence in teaching ISCEs online improved through the duration of the course. Furthermore, they felt that their confidence in teaching ISCEs in-person increased because of participating in this virtual programme. Sawyer et al. suggest that teaching improves grades in the tutors’ own coursework (23). Such analyses are beyond the scope of the present study, but Whitman et al. similarly suggest that ‘to teach is to learn twice’ which links with our postulation that tutors gain an academic advantage through the process of imparting knowledge to their juniors (16). Thus, our near-peer teaching programme is of benefit not only to the tutees, but to the tutors as well.

Limitations

This study has several limitations. Firstly, our analysis method of using bi-weekly surveys targeting similar domains may have induced an element of ‘feedback fatigue’ among participants, potentially skewing responses in some way (11).

There is also potential for heterogeneity in the experience of tutees depending on which tutor was facilitating their one-to-two sessions. This might relate to differing personalities, teaching styles and/or delivery of content by individual tutors that is beyond our control.

This was a single-centre study with a relatively small cohort (tutees: n = 72; tutors: n = 36). Hence, data might not be able to be generalised. Moreover, 77.8% of our tutee cohort were female, thus the levels of anxiety seen in our study might be different in a more balanced group, given known gender-specific differences in levels of test anxiety (24).

Delivering education online remains a novel and convenient method of disseminating knowledge to large cohorts, especially in the context of the COVID-19 pandemic. In our study, we demonstrate that near-peer, multi-modality teaching has increased knowledge among tutees and confidence among both tutors and tutees. However, as the COVID-19 pandemic restrictions are eased, we cannot continue to rely on an online platform to deliver ISCE/OSCE teaching. Ideally, medical education would undergo a smooth transition to a new multi-modal approach which leverages the positives of both in-person teaching combined with online clinical teaching, providing students with the best of both worlds. Equally, the anxiety that students face through their academic year could be mitigated by conducting longitudinal and regular lower stakes ISCEs that assess the domains required by the General Medical Council (GMC) (25). The integration of such virtual interactions into the medical curricula would allow for students to be well equipped for the future where elements of patient care are likely to move onto contactless platforms (26).

Ethics

The need for ethical approval was waived by the Cardiff University School of Medicine Research Ethics Committee for this study. Participants were also shared a Participant Information Sheet (PIS) attached in Supplementary materials during their orientation session and the link to this was present on every questionnaire they filled. All data collected was completely anonymous with no identifiable data present. Completion of the form indicated informed consent for the use of the data for future publications as each form contained the below mentioned disclaimer. All participants were over the age of 18.

All our questionnaires distributed had the following statement: “Taking part is completely voluntary. By filling this questionnaire you are giving your consent to participate in this study and for use of your anonymised data for future publication. Any responses you provide are anonymous. Participating in this survey indicates that you are consenting to the handling of data in accordance with Article 6(1)(a) General Data Protection Regulation (GDPR) principles in the UK.”

Consent for publication

All authors consent the latest manuscript for publication in BMC Medical Education.

Availability of data and material

The datasets generated and/or analysed during the current study are available in the ‘Raw Data’ repository, in Supplementary Materials.

Competing interests

The authors report no competing or conflicting interests

Funding

The Authors report no sources of funding

Authors contributions

R.B. (Ravanth Baskaran) conceptualised, administered surveys, did data analysis and wrote the main manuscript, S.M. (Srinjay Mukhopadhyay), M.P.G., and N.D. administered survey and wrote the manuscript, S.G. conceptualised, wrote and did data analysis, R.B. (Richard Bennett) conceptualised the tutor's perspective, V.N. prepared the appendix, S.S. and P.S. assisted and reviewed the manuscript, R.S., H.B. and S.M. (Susruta Manivannan) reviewed and edited the paper as senior authors and M.Z. conceptualised, reviewed, resolved conflicts, edited and oversaw the whole project. All authors reviewed the manuscript and have agreed upon submission.

Acknowledgement

We would like to thank the OSCEazy team for the support through this. We would also like to thank Miray Kirollos and Allen Matthew on their contributions to the creation of the pre-and post-session quizzes.

Data and Consent

All data was collected and stored according to General Data Protection Regulation (GDPR) guidelines. All methods were carried out in accordance with the relevant guidelines and regulations. All participants were made aware and informed of the study. All participants provided informed consent.

Declaration of Interest

The authors report no conflicts of interest.

de Cates P, Owen K, Macdougall CF. Warwick Medical School: A four dimensional curriculum. Med Teach. 2018 May 4;40(5):488–94.
Ahmed H, Allaf M, Elghazaly H. COVID-19 and medical education. Lancet Infect Dis. 2020 Jul 1;20(7):777–8.
Wilcha RJ. Effectiveness of Virtual Medical Teaching During the COVID-19 Crisis: Systematic Review. JMIR Med Educ. 2020 Nov 18;6(2):e20963.
Cairney-Hill J, Edwards AE, Jaafar N, Gunganah K, Macavei VM, Khanji MY. Challenges and opportunities for undergraduate clinical teaching during and beyond the COVID-19 pandemic. J R Soc Med. 2021 Mar 1;114(3):113–6.
Gormley G. Summative OSCEs in undergraduate medical education. Ulster Med J. 2011 Sep;80(3):127–32.
Burgess A, Dornan T, Clarke AJ, Menezes A, Mellis C. Peer tutoring in a medical school: perceptions of tutors and tutees. BMC Med Educ. 2016 Mar 8;16(1):85.
Ferreira É de MR, Pinto RZ, Arantes PMM, Vieira ÉLM, Teixeira AL, Ferreira FR, et al. Stress, anxiety, self-efficacy, and the meanings that physical therapy students attribute to their experience with an objective structured clinical examination. BMC Med Educ. 2020 Sep 10;20(1):296.
Chisnall B, Vince T, Hall S, Tribe R. Evaluation of outcomes of a formative objective structured clinical examination for second-year UK medical students. Int J Med Educ. 2015 Jun 21;6:76–83.
Saviola F, Pappaianni E, Monti A, Grecucci A, Jovicich J, De Pisapia N. Trait and state anxiety are mapped differently in the human brain. Sci Rep. 2020 Jul 6;10(1):11112.
Andrew Jay E, Starkman SJ, Pawlina W, Lachman N. Developing medical students as teachers: an anatomy-based student-as-teacher program with emphasis on core teaching competencies. Anat Sci Educ. 2013 Dec;6(6):385–92.
Naeger DM, Jen A, Ahearn B, Webb EM. Effectively Acquiring and Using Feedback. J Am Coll Radiol. 2015 Dec;12(12):1320–3.
Pei L, Wu H. Does online learning work better than offline learning in undergraduate medical education? A systematic review and meta-analysis. Med Educ Online. 2019 Jan 1;24(1):1666538.
Chou CL, Masters DE, Chang A, Kruidering M, Hauer KE. Effects of longitudinal small-group learning on delivery and receipt of communication skills feedback. Med Educ. 2013;47(11):1073–9.
Khaw C, Raw L. The outcomes and acceptability of near-peer teaching among medical students in clinical skills. Int J Med Educ. 2016 Jun 12;7:189–95.
de Menezes S, Premnath D. Near-peer education: a novel teaching program. Int J Med Educ. 2016 May 30;7:160–7.
Whitman NA, Fife JD. Peer Teaching: To Teach Is To Learn Twice. ASHE-ERIC Higher Education Report No. 4, 1988 [Internet]. ASHE-ERIC Higher Education Reports, The George Washington University, One Dupont Circle, Suite 630, Dept; 1988 [cited 2021 Aug 28]. Available from: https://eric.ed.gov/?id=ED305016
Mukhopadhyay S, Baskaran R, Gamage MP, Dalavaye N, Ng WSV, Srinivasan S, et al. Assessing the Publicity and Reach of Peer-Led Online Medical Teaching: A Single-Event Evaluation. Adv Med Educ Pract. 2022 Jul 30;13:781–8.
Du X, Kebreya M, Bishop P. A faculty-facilitated near-peer teaching programme: An effective way of teaching undergraduate medical students. Med Teach. 2014 Mar 1;36(3):273–4.
Ten Cate O, Durning S. Dimensions and psychology of peer teaching in medical education. Med Teach. 2007 Jan 1;29(6):546–52.
Ten Cate O, Durning S. Peer teaching in medical education: twelve reasons to move from theory to practice. Med Teach. 2007 Jan 1;29(6):591–9.
Boe EE, Church RM. Punishment; Issues and Experiments. Ardent Media; 1968. 346 p.
Naeger DM, Conrad M, Nguyen J, Kohi MP, Webb EM. Students Teaching Students: Evaluation of a “Near-Peer” Teaching Experience. Acad Radiol. 2013 Sep 1;20(9):1177–82.
Sawyer SJ, Sylvestre PB, Girard RA, Snow MH. Effects of supplemental instruction on mean test scores and failure rates in medical school courses. Acad Med. 1996 Dec 1;71(12):1357–9.
von der Embse N, Jester D, Roy D, Post J. Test anxiety effects, predictors, and correlates: A 30-year meta-analytic review. J Affect Disord. 2018 Feb;227:483–93.
Ganesananthan S, Li C, Donnir A, Anthony A, Woo T, Zielinska AP, et al. <p> Changing Student Perception of an Online Integrated Structured Clinical Examination During the COVID-19 Pandemic. Adv Med Educ Pract. 2021 Aug 12;12:887–94.
Marshall M, Howe A, Howsam G, Mulholland M, Leach J. COVID-19: a danger and an opportunity for the future of general practice. Br J Gen Pract J R Coll Gen Pract. 2020 Jun;70(695):270–1.

No competing interests reported.

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Enhancing Medical Students’ confidence and performance in Integrated Structured Clinical Examinations (ISCE) through a novel near-peer, mixed model approach during the COVID-19 pandemic

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