Integrated clinical case discussions - a fully student-organized peer-teaching program on internal medicine

Abstract

Background: In response to students´ poor ratings of emergency remote lectures in internal medicine, a team of undergraduate medical students initiated a series of voluntary peer-moderated clinical case discussions. This study aims to describe the student-led effort to develop peer-moderated clinical case discussions focused on training cognitive clinical skill for first and second-year clinical students.

Methods: Following the Kern Cycle a didactic concept is conceived by matching cognitive learning theory to the competence levels of the German Medical Training Framework. A 50-item survey is developed based on previous evaluation tools and administered after each tutorial. Educational environment, cognitive congruence, and learning outcomes are assessed using pre-post-self-reports in a single-institution study.

Results: Over the course of two semesters 19 tutors conducted 48 tutorials. There were 794 attendances in total (273 in the first semester and 521 in the second). The response rate was 32%. The didactic concept proved successful in attaining all learning objectives. Students rated the educational environment, cognitive congruence, and tutorials overall as "very good" and significantly better than the corresponding lecture. Students reported a 70%-increase in positive feelings about being tutored by peers after the session.

Conclusion: Peer-assisted learning can improve students´ subjective satisfaction levels and successfully foster clinical reasoning skills. This highlights successful student contributions to the development of curricula.

Keywords: Clinical Skills; Instructional Design; Peer-to-Peer; Problem-based/Clinical Case Discussion; Undergraduate Medical Education.

Fig. 1

Workflow for the preparation of one ICCD session. Three parties are involved in the preparation and implementation of an ICCD session: an administrative unit consisting of the organizing undergraduate students (*) and the TUM Medical Education Center (†) (bottom row), tutors (middle row) and clinical supervisors (top row). Their respective tasks are indicated at the relative time points for the preparation of one ICCD. The allotted time frame for each task per one ICCD session is included in round brackets. For their first meeting tutors and supervisors are provided with a checklist (‡), i.e. to i) define content-focal points, ii) select an appropriate clinical case iii) define a clinical skill essential for the successful completion of the case, and to iv) provide the tutor with important clinical findings (e.g. laboratory findings, images)

Fig. 2

Typical outline of an ICCD session. We modified Linsenmeyer´s approach to stimulating interaction between students (Linsenmeyer, 2021). One ICCD session propagates along the x-axis from left to right. Several layers along the y-axis indicate the roles a tutor assumes at each time point, the teaching techniques they employ (examples provided below), and the level of interaction this is likely to be incentivize between tutees. A: Each session starts with a knowledge probe intended to activate students´ prior knowledge by asking five multiple-choice questions that participants must solve individually and anonymously. As indicated by the green triangle at the bottom of the figure this requires only a minimum level of interaction between students. B: Subsequently, tutors introduce the session´s clinical case and moderate a plenum discussion in which participants collectively take a patient´s history, determine an appropriate diagnostic algorithm, and list differential diagnoses. This gradually raises the level of interaction (upward slope of the triangle). C: In the next stage participants are assigned to break-out groups of two to four students in which they practice interpreting patient-specific clinical findings, lab results or different image modalities. Tutors switch from group to group to help if needed. D: Finally, the breakout groups meet back in the plenum and discuss their findings and differential diagnoses under the tutor´s moderation. We rated this as the most demanding level of interaction as it requires students to present in front of a larger group. At this point, tutors are oscillating between facilitating the discussion as different groups present their findings and providing direct instruction when explaining the meaning behind lab results/images, etc. Under the tutor’s guidance differential diagnoses are eliminated and the final diagnosis emerges. E: Lastly the tutor outlines treatment options. Due to time constraints, this was predominantly done in direct instruction

Fig. 3

Evaluation of ICCD vs. lecture. A Kiviat diagram representing students´ mean subjective assessment after attending lectures alone (round dots) and after attending both lectures and ICCD (long dashes) in categories knowledge, skill, attitude, and overall grade each represented on one of the axes of the diagram. Students were asked to rate their gain in each of the categories for both tutorial and the respective lecture on a five-point Likert scale with 1 denoting the greatest and 5 the lowest degree of satisfaction. Questionnaires were administered immediately after each tutorial. Tutorials took place one week after the general lecture. All differences are significant (p < .01). Effect size was calculated using Cramer´s V