For most medical students, the clinical learning environment features relatively brief episodes of patient contact with limited opportunities for observation, lack of structure, little continuity, and insufficient integration among specialties.1–4 Research has shown that learning during the clerkships occurs in isolation and that students’ well-being, empathy, and patient-centered behaviors diminish over the course of clerkships.5–7 Schools introduced educational continuity in clerkships to foster connections between discrete and disjointed learning experiences in three ways thus far described: continuity of care (caring for patients longitudinally), of curriculum (sequencing clinical experiences with increasing difficulty), and of supervision (longitudinal clinical teaching).2–4,8 When compared with their counterparts in traditional block clerkships, students in clerkship programs with continuity have demonstrated equivalent or higher academic achievement, more patient-centered skills, and higher-order clinical skills.9,10
As these concepts permeate clerkships, another form of continuity in clerkships is emerging: continuity with peers. Peer continuity places a stable cohort of students in frequent (e.g., weekly) meetings, often to process and debrief events on clerkships. Evidence in the psychological literature suggests that a sense of group belonging is important for both physical and psychological well-being.11,12 A recent study examining how students use informal peer learning suggests that students develop trust in each other over time, supporting the concept of peer continuity.13 Some programs have intentionally used peer continuity as the basis for their formation.14,15 Others have fortuitously or serendipitously discovered the strength of these meetings.4,8,9 Literature on this form of continuity shows that peers provide a much-needed support network and enhanced learning environment that in turn mitigates the negative impact of the hidden curriculum and lost learning opportunities.9,16,17 Though peer continuity has been implemented with success and relatively minimal cost compared with other curricular innovations,14 few institutions have capitalized upon this vital resource.
We assert that peer continuity should become a formalized educational structure in the clerkships, for it offers a powerful way to foster students’ integration in the workplace, provide social support, and help students overcome learning challenges. To increase clarity, we will take an unconventional approach by first summarizing research supporting peer continuity in preclerkship and clerkship-based medical education, next invoking educational theories that underpin those findings, and finally outlining the critical practical components required for a successful peer continuity structure.
Preclerkship Peer Continuity
In preclerkship education, literature on learning communities represents the main thrust of our current knowledge. Learning communities refer to groups of students who build shared purpose, interests, and learning experiences over time.16 Although the sizes of these communities vary widely between schools, a fundamental hallmark is continuity of relationship with peers. Through learning communities, schools have addressed numerous student needs, including well-being, perception of the learning environment, clinical skills instruction, professionalism, advising, and mentoring, in more intimate structures than addressing entire classes of students en masse.16–18 Yet, many schools that have adopted learning communities struggle with the loss of the community once students enter clerkships.18 Because of the significant benefits accrued to students, leaders of learning communities have advocated for continued student involvement into clerkships.16
Studies of preclerkship students outside the context of learning communities have also noted significant potential influences of social networks on educational outcomes. Woolf et al19 discovered that in addition to the student groups that schools construct for curricular purposes, students formed networks and friendships based on gender and ethnicity. These networks often became an additional forum for informal learning, encompassing not only explicit learning of content but also work habits. Moreover, students in the same social networks had similar grades on examinations.19 Low peer social support and psychological distress correlated with poor academic self-perception, whereas promoting peer social relationships in medical school mitigated distress and poor academic performance.20,21 Taken together, these studies underscore the powerful influence that spontaneously formed social networks exert on learning, well-being, and academic performance.
Social cognitive theory explains the positive effect of these social networks. Bandura proposed that learning occurs in a social context through dynamic, ongoing interactions between the environment, person, and behavior.22,23 The environment consists of the social and physical milieu. Personal factors include the learner’s cognition, affective influences, and biological states (e.g., fatigue). Behavioral capability includes the knowledge and skills required to perform a given behavior. Learners have agency to direct their own learning and, through interaction with their environment, change their behavior.22 The learning that occurs through learning communities and social networks in the preclerkship years reflects the interaction between the behavioral capability and learner agency that is core to social cognitive theory.
Peer Continuity in Clerkships
Though preclerkship settings frequently deploy peer-assisted learning,24,25 investigators have only recently begun to examine same-level peer-assisted learning in clerkships. Because of irregular and typically long hours during clerkships that distribute students broadly amongst disparate clinical sites, students tend to lose regular connections with each other. Yet, students often vicariously learn from actively watching other students and build trust in each others’ judgments over time.13 Recently, Tai et al26 reviewed the benefits of same-level peer-assisted learning in clerkships, including improved retention of knowledge, increased application of skills and knowledge, and active participation in learning activities. Hence, some institutions have incorporated elements of peer assessment of clinical knowledge and professionalism in their clerkships.27,28
Schools that have developed clerkship models with continuity, including longitudinal integrated clerkships,3,4,10 have described positive benefits associated with peer group interactions, including support of workplace learning, social support, and clinical and professional learning. Studies of structured clerkship programs at the University of California, San Francisco (UCSF) showed that students appreciated the increased workplace-based support from peer continuity groups.4,10,14,29 These support mechanisms facilitated students’ transformation from peripherally involved observers to authentic contributors to clinical care. Processes by which students navigated clerkship structures were often invisible to faculty.29 Students in peer continuity groups frequently advised each other about workplace norms and expectations, content learning, and logistics.30 Regular opportunities to reflect with each other, either in formal sessions with faculty or ad hoc with peers, allowed students to access learning resources, communicate more effectively with team members, transition between clerkships, and understand implicit rules of rotations.29 Moreover, Mazotti et al31 found that students felt that working with a group of peers over time was, unexpectedly, one of the most valuable features of a longitudinal integrated clerkship.
The theory of communities of clinical practice (CoCPs) provides a framework for these results. CoCPs are groups of individuals (e.g., inpatient teams) focused on patient care that a learner joins to learn the practice of medicine.32 Learning occurs through interaction and collaboration in the clinical setting. Medical students begin by practicing legitimately on the periphery of a particular CoCP and move toward full participation as they gain knowledge and skills and negotiate their own place within that community. In medical education, legitimate peripheral participation is determined partially by the characteristics of the CoCP and by the characteristics of the student.32 In clerkships, peer continuity catalyzes workplace skill development that propels students into CoCPs.9,29
Social support also represents a strong benefit of peer continuity groups. Students who experienced regular facilitated interactions with their peers in clerkships noted increased opportunities to develop relationships with fellow students.29 In our VALOR (VA Longitudinal Rotations) structured clerkship, weekly meetings of students provide opportunities to share common challenges, thereby contributing to individual and group resilience.14 Students became essential sources of personal support, particularly during transition periods of elevated anxiety.9,30 Duke et al15 showed that students in clerkship-based peer continuity groups continuing from the preclerkship era valued peer support with “familiar faces” and the ability to share stories and cope with stressful situations. Notably, these students did not experience the erosion of empathy previously described in third-year medical students.15,33 Students without peer continuity had difficulty finding peer groups; occasionally, these students developed an informal peer group on a given clerkship and reported desires to see their peers more often during the clerkship year.29
Finally, peer continuity leads to important academic support, including clinical learning and development of communication skills. Peers learned from each other about patient cases that their colleagues had seen and derived strategies about managing challenging cases they themselves had not seen.29 Students solicited and received updates on patients they shared with each other, enhancing their learning about clinical management.9,14 Further, students reuniting with peers from their preclerkship clinical skills course for a clinical skills examination rehearsal were more likely to give constructive feedback on communication skills than students with no such prior relationship.34 Therefore, consistent with the observation that preclerkship peer groups can influence exam performance, longitudinal relationships among peers also benefit fundamental clinical skills development.9
An additional theory, social comparison theory, can help explain the support found in peer continuity groups.35 Social comparison theory posits that learners often think about others in relation to themselves and develop strategies for coping and learning in different kinds of workplace social situations. Residents often wonder if they fit in and depend on each other by sharing experiences, developing relationships with others who are helpful, and engaging in self-study.36 Early clerkship students also undergo a similar questioning process and wonder whether their performance is commensurate with established norms.37 Peer continuity facilitates social comparisons in ongoing relationships with peers, takes advantage of the heightened judgment that peers develop for each other,26 and gives students a venue to talk about performance in the context of workplace-based, social, and academic support.
Recommendations for Facilitated Peer Continuity in Clerkships
Through the perspectives of the theories and literature presented and with our own personal experiences in administering and evaluating longitudinal clerkships at UCSF, including VALOR, we present recommendations for structuring clerkships to incorporate peer continuity. We focus specifically on some of the logistics that arise when putting the above theories into practice.
Formation, structure, and format
Peer groups range from 6 to 16 students4,9,14 and meet approximately weekly for 6 to 12 months. These peer groups occur separate from and in addition to the typical teams onto which students rotate during their clerkships. Therefore, students can compare their experiences on different teams and often derive vicarious learning from this diversity. Resonant with social cognitive theory, protecting a consistent and regular space and time for students in clerkships holds strong importance. Students greatly value time with peer groups because of the support during clerkship challenges, the forum for facilitated reflection, and opportunities to appreciate patient experiences across the continuum of care.14 “Intersessions” between clerkships may play a similar role2 but occur too infrequently to allow students to develop rich learning connections with each other. In the current era of enhanced virtual communication, peer continuity need not occur only in the context of longitudinal clerkships. Formal, ongoing peer interactions can occur within a given clerkship or across clerkships through regular in-person or virtual learning communities.15
Similar to forming any small group, peer cohorts must set early ground rules for group process and participation.38 These cohorts represent mini-CoCPs, composed only of students who evolve toward legitimate participation in larger CoCPs as a group. Whether fully preassigned15 or allowing for some student choice in group composition,14 specific attention to creating relationships among group members and developing a formalized group structure reinforces that the group is as important as other core clerkship experiences. We have found that convening students during the formation phase in a relaxed and informal setting, sometimes in faculty homes, helps to establish initial relationships. These gatherings allow students to share their background and experiences and become familiar with each other initially, in turn facilitating approachable and comfortable interactions that develop further in formalized peer cohort meetings.
Peer cohort meetings can encompass formal didactic topics, clinical skills development sessions, and built-in time for reflection on patient experiences, well-being, professional development, and discussions on career choices. Facilitated reflections help students prioritize their learning and understanding of professional identity formation. Students report that the “safe space” provides a forum for being heard.14
Faculty supervision during peer continuity meetings is critical; ideally, one (or more) faculty with no evaluative role should lead the peer cohort meetings. Existing research stresses the availability of supervision. Learners not only believe that supervisor presence benefits learning13 but may also develop bad habits and form “illusions of competence.”39,40 If not appropriately guided, members of groups with strong self-identity can adopt group norms of unhealthy behaviors.41–43 Faculty presence can also facilitate mentoring relationships with students.15
Faculty facilitators must reinforce group norms when appropriate, judiciously add their perspective, and dissuade students from developing norms that do not adhere to typical professional standards. Three methods of faculty supervision can enhance learning outcomes for self-guided learning, and these must also be incorporated into peer continuity experiences: appropriately challenging learners when their learning stagnates, structuring training conditions to optimize long-term learning, and identifying and responding to times when learners depend on supportive supervision for success.39 Faculty should refrain from using traditional unilateral didactic presentations. Instead, we emphasize facilitated discussion and reflection within the group to ensure that students receive guidance or resources. Specific facilitator skills that are critical for these meetings include familiarity with the students’ experiences on clerkships, a strong listening ear, a less directive approach that encourages students to reflect and delve into their experiences, and a willingness to demonstrate vulnerability through sharing memories of struggles during their own clerkship experiences. These skills are required to guide cognitive and behavioral development and the process of developing awareness of professional norms in peer continuity groups.
Finally, because developing a “safe space” is critical to the students’ development, we recommend that faculty facilitators of peer continuity groups play a minimal to absent assessment role for students. We have found that students in clerkships feel the weight of almost constant surveillance and assessment by clinical supervisors. A brief retreat for sessions that are wholly supportive without threat of reporting can produce deeper reflection and vulnerability by students.14
Because skilled faculty facilitation is so important, potential barriers to implementing peer continuity as we have described include adequate faculty development to run these sessions effectively. Faculty release time to devote to weekly hourlong sessions with the students is also required, plus time for preparation, debriefing, and potential meetings with individual students as necessary.
In our peer continuity groups, we have encountered two additional challenges. First, undue departure of a student due to personal circumstances or academic difficulty can cause strain on a group. Students undergo a range of feelings related to grief, including sadness, survivor guilt, and relief, for which expert facilitation again is essential. Second, working with just one other peer can raise the specter of competition.35 In clerkship education, social comparison can be rampant and exacerbated by competition for grades. The presence of competition can remain undisclosed and thereby impede the progress of peer group formation. Yet our previous findings suggest that peer continuity meetings helped to reduce the valence of competition by creating opportunities for continuity study groups.14 In addition, clerkship students also note that they sometimes learn more about workplace-based practices and tasks in a competitive environment.29 Competition therefore represents a double-edged sword to be investigated more deeply in further studies. Rather than ignoring the issue of competition, we have found value in our peer continuity groups to name instances where it appears in student discourses, and to work through the students’ understanding of its advantages and disadvantages.
Potential applications and future directions
Several potential educational interventions involving peer continuity appear within reach. First, professional identity formation explicitly includes socialization, where students learn from disparate experiences with peers to synthesize explicit and implicit norms of their workplace.44–46 Yet students often rely on solo reflection to help make sense of their identity. Formal peer continuity settings could provide forums for peer interactions, where students can navigate these experiences together.47 Second, clerkship students often experience significant cognitive and emotional dissonance when one feels impelled to act contrary to one’s own moral beliefs.48,49 A similar dynamic occurs when students witness errors occurring in clinical practice.50 Periodic peer-based reality checks could provide an opportunity for identifying and making sense of these paradoxes. Third, considerable interest has developed around the high prevalence of mistreatment and harassment of students in clerkship years.51–53 Students express hope for ways to debrief the powerful emotions that can arise and to enhance their integrity and well-being.51 It follows that faculty-led peer continuity groups could provide these microcultures of empowerment, facilitating emotional processing and opportunities to ally with faculty facilitators.54
Future studies should clarify specific mechanisms by which environmental and cultural factors on clerkships influence the social learning that occurs in peer continuity. In addition, it will be interesting to determine whether facilitated peer continuity affects social comparison. With the finding that students in peer continuity maintain an empathic stance,15 another next step would be to determine whether peer continuity-based social support in fact leads to decreased burnout and increased resilience. Additionally, further investigation into the interactions, key components, and relative effects of each of the underlying theories on the effectiveness of peer continuity in learning could clarify the benefit of this approach. This could include determining how peer relationships and support evolve over the course of the clerkship year, the optimal frequency of peer interaction, and the range of clinical educational activities that would benefit from peer continuity opportunities. Finally, determining the relative influence of the various types of continuity (of site, of patients, of faculty supervision, of curriculum, and now of peer groups) seems prudent, as no school could consider implementing all of them simultaneously.
Medical education is fundamentally a social process, as students learn from patients, colleagues, residents, and faculty. Fostering explicit, continuous connections among medical student peers represents an overlooked area of learning during clerkships and holds powerful potential to mitigate some of the known difficulties of clerkship education. We advocate that opportunities for peer continuity should become a built-in, formalized educational structure in clerkships. Key successful experiences in peer continuity include attention to the formation and structure of peer cohorts, the format of the group meetings, and training of faculty facilitators. With these fundamental structures in place, continuity with the peer cohort can mitigate some of the negative effects on learners typically experienced during the clerkships. A successful peer continuity experience promotes the academic and social learning that students need so crucially during their clerkship education.
Acknowledgments: The authors are indebted to Carrie Chen, Patricia O’Sullivan, and Ann Poncelet for their indispensable and detailed review of prior drafts of this work.
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