Senior medical students have been utilized in first- and second-year medical students' education as preceptors,1,2 standardized patients in history and physical examination courses,3,4 group leaders in clinical science courses,5 and teaching assistants. Using fourth-year medical students as teachers has been successful in a number of these settings.1 That approach has been purported not only to help meet the increasing demand for motivated teachers in the first year, but also to serve as a useful educational tool for fourth-year students as they prepare for careers that may involve teaching as housestaff and faculty.1,5 We report here a new and more extensive pilot program in which a senior medical student both designed and taught an original selective course for first-year medical students. The organization of this course was innovative, and the central role that the fourth-year student took in planning and implementing was unique.
THE COURSE
Preparation and Goals
At Washington University School of Medicine, the fourth-year curriculum is entirely elective. Students are encouraged to schedule electives that will round out their medical student training and allow for in-depth study of special interests. During the 2000–2001 academic year, one fourth-year student (SAJ), with a strong interest in academic medicine, teaching, and medical education, spent elective time developing and teaching an original selective in the first-year curriculum.
The fourth-year student wrote a proposal both for his own fourth-year elective and for the first-year selective during the summer prior to the course. The proposal was reviewed and approved by the associate dean of medical student education (AJW), who served as an advisor during the entire project. The selective, entitled “Clinical Evidence-based Medicine,” was offered as one of 50 first-year selectives to a maximum of ten students. All first-year students take a minimum of four 10-16-hour selectives (two basic science, one humanities, and one general selective), which cover a broad array of topics and are designed to complement the core curriculum. The first-year core curriculum includes anatomy, physiology/histology, integrated cell biology/biochemistry, genetics, immunology, microbes and pathogenesis, and neuroscience courses, each of which has a mix of lecture and small-group teaching and clinical correlates. The first year Practice of Medicine course includes an introduction to history and physical examination with hospital-based preceptor visits and quarterly half-day visits to a community-based physician office; a biostatistics section with an introduction to evidence-based medicine; and discussions of ethics and population health.
The educational goals for the fourth-year student included: (1) to gain experience teaching medical students in both classroom and hospital-based settings; and (2) to explore creative methods to convey information to medical students in a classroom teaching setting while encouraging these students to become independent and active learners. The fourth-year student spent approximately four to six weeks total during the summer and fall developing the course and then devoted one month of his fourth-year elective time to teaching the course and receiving credit for this independent study project.
The fourth-year student met regularly with the faculty advisor before, during, and after the course to discuss all aspects of the selective, including lesson plans, teaching styles, evaluation, and feedback. Individual session evaluation included feedback from the advisor based on personal evaluation, student feedback from brief written surveys, and self-critiques by the fourth-year student. For self-critiques, the fourth-year student composed a two-to-three-page summary of each session in which he reflected on the effectiveness of chosen teaching methods. The feedback from all three sources was completed prior to the next teaching session to allow for refinement of teaching based on the feedback.
The specific learning objectives for the first-year students participating in this 16-hour Clinical Evidence-based Medicine selective were: (1) to learn a clinical approach to disorders presented in core courses they had studied, emphasizing diagnosis, the clinical exam, and therapeutics; (2) to introduce first-year students to the application of evidence-based medicine and how it affects decision making in clinical practice; and (3) to excite students who are interested in clinical medicine through tangible, patient-based experiences. This selective sought to reinforce and integrate the concepts introduced in core courses in a practical, disease-oriented approach.
Content, Structure, and Approach
The course consisted of eight two-hour sessions, each of which focused on a clinical medicine problem. The topics included hypertension, diabetes, myocardial infarction, congestive heart failure, stroke, breast cancer, acute leukemia, and coma. Given the clinical focus of this elective, there was concern that the level of material would be presented in a manner that was too advanced for the first-year students; therefore, the fourth-year instructor reviewed syllabi from and directly observed current first-year courses in order to have the appropriate frame of reference from which to design the course content. In addition, the topics in the course correlated with material the first-year students were learning during the same time period in the clinical skills and physiology courses.
During the first hour of each session, the fourth-year student used a variety of interactive teaching methods to engage the students, including discussions, lectures using computer-based presentations, and smaller-group breakout sessions. The content included a clinical overview of each session's topic, focusing on classic signs and symptoms, diagnosis, and principles of treatment. The instructor ensured that each of the first-year students actively participated in every session and, according to the students' responses to surveys, this approach increased their enthusiasm for the material. Teaching also included clinical questioning from the instructor in a manner similar to that which the students would encounter on the wards during their clinical clerkships.
In the second hour, the class moved to the hospital, where selected patients were used to illustrate elements of the physical examination specific to the topic of the session. Since the topics correlated roughly with the first-year clinical skills course, this activity reinforced newly-acquired physical examination techniques. Each student also was responsible for a single ten-minute presentation in which an evidence-based answer to a clinical question relating to the previous week's topic would be explored. In preparation for this presentation, each student met outside the class with the fourth-year instructor for a tutorial to frame a relevant question and identify computer-based and library resources to find answers to evidence-based questions. The first-year student then conducted independent research and presented the results to the group during the next session. This approach, which allowed these first-year students to explore common medical problems with a focus on diagnostics, treatment strategies, and elements of the physical examination, complemented the rest of the first-year curriculum. In addition, the aspects of the course that focused on clinical questioning and evidence-based research provided practical skills that are important for the clinical clerkship years.
Evaluation
Since having a fourth-year student teach a selective at the school of medicine and having a course whose content and organization had been developed by the student were novel, we were careful to elicit detailed feedback from the first-year students before the course, after each session, and at the end of the course in written surveys and less formal group discussions. The evaluations from each session were overwhelmingly positive, with students rating each session highly in a number of areas, including appropriateness of topic and level of material, effectiveness of teaching, and level of personal participation in the session. The students were given opportunities in all surveys and group-feedback sessions to make additional narrative comments. The fourth-year student used these surveys, along with feedback from the faculty advisor and self-evaluations, to improve the course week to week, which was ultimately reflected in the quality of feedback received over time.
The end-of-course survey asked the students to evaluate the course in a number of areas, including appropriateness of material, teaching style, effectiveness of introducing computer resources to explore evidence-based medicine topics, quality of patient sessions, and an overall evaluation. The survey results again were strongly positive, with an average overall rating for the course of 9.7 based on a ten-point scale. Included among the students' comments were that “learning from someone our age was really great” and “this course should be integrated into the [non-selective] curriculum.”
The feedback indicated that these students interacted with the fourth-year instructor quite well, perhaps due to his position as an “advanced peer” who was able to interact more in a peer-to-peer basis rather than in a traditional teacher—student relationship. The students commented in their evaluations that they felt extremely comfortable in this setting, actively participating in discussions and clinical questioning. We might speculate that some of these opinions stemmed from the lack of the intimidation that sometimes accompanies interactions between early first-year medical students and full-time faculty in lectures or small-group settings. This class was taught, as are all courses in the first year, on a pass/fail basis, which also may have contributed to the relaxed atmosphere of the class. Exposing these students to clinical questioning and discussions in the first year should have benefitted them when they encountered this style as the primary teaching method in the third year.
VALUE OF SUCH COURSES
The idea of a clinically-focused course for first-year students that complements existing first-year courses and integrates elements of evidence-based medicine and physical examination skills in a classroom and hospital setting could be (independent of having a fourth-year student as the instructor) permanently inserted into the first-year curriculum. This course benefitted the first-year students by introducing very early in the curriculum an integrative clinical approach to problems, which, outside this selective, currently is introduced in the second year and developed in the third year. The evidence-based medicine focus of this course also added to the existing curriculum, as practical application of evidence-based medicine in the core curriculum is a focus of the clinical years. Additionally, physical examination skills using patients and actors are currently taught to all students in the first year, and linking these skills to discussions of specific clinical problems and demonstration with patients stands as a unique experience in the first-year curriculum.
This course might continue to be taught as a selective in the future or, alternatively, it could be placed as an adjunct to the existing courses. The total curricular hours—16—were quite modest. While students would have liked more sessions, they indicated that if time were a significant limiting factor, they would have found a course half this length to be of high value.
Allowing a fourth-year student to function as a curriculum developer and teacher in the first year stands as a novel and important approach with multiple benefits for the senior student. The fourth-year student used a variety of teaching methods throughout the course, the design of which came mainly from reflecting on effective teaching methods he had experienced in his undergraduate and medical education, as well as from personal teaching experience. This exercise enabled the fourth-year student to critically examine effective teaching methods and develop teaching tools that he will be able to use throughout his career. The fourth-year student felt that the most useful feedback provided by the faculty advisor came from her direct observation and critique of each of the sessions, which could then be compared with both his own self-assessment and direct student feedback. This represents an important teaching skill that is often not acquired by medical students in current medical school curricula. Participation in this pilot program has the potential to make this fourth-year student a better teacher as an attending physician and as a housestaff member, and it also may have the added benefit of allowing the student to develop more active and effective learning techniques.
Through his role as a teacher and curriculum developer, the fourth-year student also gained insight into issues surrounding curricular management and development in the preclinical years, saw improvement in his ability to solicit and give effective feedback, and increased his own communication and presentation skills.
The fourth-year student also used this course as an opportunity to explore various teaching styles and to improve specific skills that he felt would be useful both for a planned career in academic medicine and for teaching medical students on the wards as a house officer. Students at our medical school have developed and implemented educational programs for middle-school children. Peer teaching of medical students by medical students is also a part of our teaching assistant and tutoring programs. Very recently, Red Cross—certified students have begun teaching CPR to other medical students. However, nowhere else in our curriculum are medical students given the opportunity to teach and develop clinical medical curriculum for our junior students. This is a skill that many house officers and fellows are expected to have but often have not had an opportunity to develop. One could envision a course such as this, which involved approximately one to two months of planning outside the fourth-year curriculum in addition to one month of elective time, taking time away from other clinical rotations that could benefit the senior student. However, given the numerous educational benefits discussed, the senior student felt that this was an extremely valuable use of fourth-year elective time, and he and the faculty advisor were satisfied that his educational goals were met.
This pilot program could be of interest to faculty, administrators, and fourth-year medical students at other institutions, especially those schools that feature prominent elective components in their fourth-year curricula. There are a number of potential variations on this project that could be implemented. Obviously, one limitation of the senior elective we describe here is that it requires a highly motivated senior student who is willing to devote a significant amount of time before (one to two months) and during (one month) the course. A course of this scope and time commitment probably could be taught only by a handful of extremely motivated students in each senior class. However, variations on this project could be developed that would allow for participation by a wider range of senior students.
One possible alternative that would require a lesser time commitment by senior students would be to allow them to teach already-existing selectives to first-year students rather than requiring original course design as in this project. A less independent role could therefore be envisioned for the senior student, who would teach only part of the selective course in conjunction with a full-time faculty member. If more senior students wished to be involved in such projects than the first-year curriculum could allow, a group of students could alternate teaching sessions in a course supervised by a faculty member, again reducing the need for a single motivated senior student.
In contrast to the success of our course, we could envision a similarly designed project failing for a number of reasons, including a lack of effective teaching or motivation by the fourth-year student, either an inadequate or an overbearing level of participation by the faculty advisor, or an inability of first-year students in the course to accept the fourth-year student in a positive “peer—teacher” relationship. It also was important that the course content was of interest to first-year students and the fourth-year instructor, and consistent with overall curricular goals of the selective program.
At our institution, the idea for such a course taught by a fourth-year student has subsequently been permanently incorporated into the first-year selective catalog. Interested fourth-year students with original course ideas will be able to apply, with assistance from an appropriate faculty advisor, to teach similar courses in years to come. It would likely be difficult for a senior student in the future to teach an identical course to first-year students, as the research and preparation for each session were uniquely developed by the senior student in this project. However, one could envision senior students in the future developing courses that continue to emphasize basic tenets of this course, including clinically-focused topics, evidence-based medicine, and refinement of physical examination skills, while modifying the topics discussed and teaching methods to suit their academic and teaching interests.
This pilot program concentrated on clinically-focused topics, evidence-based medicine, and physical examination skills, with a senior medical student having total responsibility for developing and teaching the course. The responses of the first- and fourth-year students involved suggest that having fourth-year students teach such selectives not only could be beneficial for the senior medical student but might also serve as an untapped resource at our medical school for high-quality, creative teaching in the first-year curriculum.
ADDENDUM
The project described in this report occurred in academic year 2000–01. In academic year 2001–02, another fourth-year student pursued a similar elective experience. Although she considered replicating the SAJ experience, she chose to develop a first-year selective, “Developing Presentation Skills,” with the same faculty advisor. This selective also was well received by the students. This additional project suggests that curricular development is of interest to and manageable by motivated students. It also suggests that allowing fourth-year students to select curricular content about which they are enthusiastic may be important. Direct observation and feedback by the faculty advisor is the greatest benefit to the fourth-year student. The faculty advisor devoted around 20 hours to each project, which is a significant amount of time, but less than that required for full development and teaching of a ten-hour selective.
REFERENCES
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