Original Articles
 

By Dr. William Hogg , Dr. Simon Street , Dr. Jean-francois Kozak , Dr. Dawn Bell
Corresponding Author Dr. William Hogg
Family Medicine, University of Ottawa and C.T. Lamont Primary Health Care Research Centre, BRI, 369Y - 43, rue Bruyere Street - Canada K1N 5C8
Submitting Author Dr. William Hogg
Other Authors Dr. Simon Street
School of General Practice, Oxford Deanery, - United Kingdom

Dr. Jean-francois Kozak
Population and Public Health, Faculty of Medicine, - Canada

Dr. Dawn Bell
(independent), - Canada

MEDICAL EDUCATION

Family medicine, Peer visiting, Medical education, Residents, Qualitative research

Hogg W, Street S, Kozak J, Bell D. Peer Visiting as a Tool to Enhance Teaching and Learning in Post-Graduate Medical Training. WebmedCentral MEDICAL EDUCATION 2013;4(4):WMC004192
doi: 10.9754/journal.wmc.2013.004192

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
No
Submitted on: 17 Apr 2013 06:00:18 PM GMT
Published on: 18 Apr 2013 05:31:12 AM GMT

Abstract


Purpose: The Peer Visiting model is a new model for educational assessment in postgraduate training in Family Medicine. In this paper we describe the model and a qualitative study designed to determine: First, how the model is perceived by the preceptors and their residents and second, whether or not preceptors and residents believe the model enhances teaching and learning.

Methodology: In Phase I focus groups were used to identify the underlying constructs and language used by family physicians and residents in describing the Peer Visiting experience. The constructs identified in Phase I were used in Phase II, which evaluated the perceived effect of the peer visiting program.

Findings: The thematic areas identified were: 1) Interpersonal Relations, 2) Learning Process, and 3) Faculty Development. Participants in Phase II of the study overwhelmingly believed Peer Visiting to be a positive experience. Most felt that the interpersonal relationship between the preceptor and resident was improved by the visit. All preceptors planned to make pedagogical change as a result of the peer visit. After the Peer Visit, residents became more aware of their responsibility to direct their own learning.

Conclusion: Important issues were addressed during the visits. Including the resident as a member of the visiting team is an innovative aspect of this model of peer review, which the participants felt was an essential aspect of the model. Peer visiting holds the potential to improve aspects of the resident’s relationship with their preceptor and their overall resident experience, and to make students more self-directed. 

Introduction


The teacher’s role in the field of medicine has changed from that of authoritative and didactic expert to facilitator of students’ self-directed learning. Today’s graduates from those medical schools that espouse self-directed learning expect to participate actively in assessing and directing their post-graduate training. Today’s teachers need to be innovative and imaginative if they are to meet the challenges of these new expectations1. The Peer Visiting model is a new model for educational assessment that we believe to be appropriate for this pronounced emphasis on self-directed learning. The Peer Visiting model focuses on the potential for learning within a Family Medicine residency.

Background

A peer is a colleague of the same ability and effectiveness with comparable experience. We are defining peer visiting as a review of professional efficacy by a colleague in the same occupation. In Canada, the definition of peer review has been linked with the intervention of a consultant2. Peer review has developed as a force in faculty development, and methods of facilitated feedback have been devised and evaluated3. Brinko’s4 work demonstrated that the addition of a consultant to the process of student feedback can enhance teaching performance. Furthermore, Tiberius2,3 has shown that faculty prefer verbal feedback rather than information from a questionnaire.

In Canada, review by peers comes in different forms, for example: review of audio tapes; co-teaching and debriefing; and reflective questioning for groups of teachers. These activities have various names such as peer coaching, peer tutoring, peer observation, and peer teaching consultation5. The whole range and potential of peer review is comprehensively described by Grol and Lawrence6 whose work was primarily based in the Netherlands. New Zealand also promotes peer visiting as a method of professional development7. However, more and more literature from the U.S. also supports these findings8, 9. In the UK the General Medical Council recommends that assessment should now adapt to the new styles of learning and reduce the emphasis on the uncritical acquisition of facts10. Self-directed learning is now recognized as the centerpiece for the continuing education of the general practitioner11,12. Peer review is an integral part of postgraduate training12-16.

The Peer Visit

The peer visit is an informal, self-initiated, needs-based visit by one preceptor/resident pair to another preceptor/resident pair. Research shows that peer assessment can predict future performance and provide residents with valuable feedback about professionalism17. The visit is an educational exercise, a formative assessment of learning and teaching that focuses on the relationship between teacher and learner. What is unique about the model evaluated in this paper (the peer visit) is the involvement of the resident in the visiting team.

Participants are sent an information package explaining the rationale and format of a peer visit. It is suggested that the preceptor/resident pair being visited and evaluated (the host pair) may prepare for the visit by selecting charts of recent consultations or making video recordings of tutorials. Visits last two hours and take place at the medical centre of the host preceptor/resident pair. Following introductions, an agenda for the interview is agreed upon, the content being dictated by the needs and interests of the residents. Interviews typically explore areas of interaction between preceptor and resident, issues of time and motivation, educational concepts such as learning contracts, and the type of feedback preferred by the resident.

There are ethical issues that should be considered. These include confidentiality, trust, and how to deal with the revelation of unacceptable practices. Resolving these issues will be the responsibility of the visiting preceptor. The format of the visit is as follows: First, all four participants meet together for the main body of the visit (approximately 90 minutes). Next, the two residents and the two preceptors then confer separately in order to bring up any issues not discussed with everyone present (approximately 10 minutes). The visitors then confer briefly while the hosts take a break (approximately 5 minutes). Finally, all four reconvene to discuss any new issues, and the visitors conclude by verbally summarizing the findings (approximately 15 minutes).

A written summary of the feedback is prepared by the visiting pair and forwarded to the host preceptor and host resident approximately two weeks after the visit. The feedback should be constructive and encouraging and be directed to behaviors which can be changed. This summary is written for the benefit of the participants only and must be kept confidential.

In this paper, we present a qualitative study designed to determine first how preceptors and their residents perceive the process of a peer visit: What do they think is happening? Secondly, we wanted to find out whether or not they believe the peer visit enhances teaching and learning in the context of post-graduate study in Family Medicine.

Methods


The present study used a qualitative design that consisted of two parts. Phase I involved the identification of underlying constructs and language used by family physicians and residents in describing the peer visit experience. The constructs identified in Phase I were used in Phase II, the evaluation of the perceived effect of the peer visiting program. Participants in both Phases consisted of preceptors and their residents from the Department of Family Medicine at the University of Ottawa, Ottawa, Canada. The peer visit model had been developed and previously piloted by two of the authors (SS and WH) at The University of Western Ontario, London, Ontario, Canada.

In Phase I, six preceptors and their residents, who were new to the concept of peer visiting, were visited by one visiting professor (Dr. S.S.) who had extensive experience with the peer visiting program. The six preceptors were purposefully recruited so that all the teaching and learning approaches within the Department of Family Medicine in Ottawa were represented. Six peer visits were made by the professor with a different Family Medicine resident accompanying him each time. In this way, within a period of one week, six preceptors and 12 residents were introduced to the concept of peer visits. 

All preceptors in the Family Medicine Department and their first-year residents were invited to participate in Phase II of the study. The preceptors and residents who had been hosts in Phase I became the visitors in Phase II. Four peer visits were arranged. 

Phase I: Identification of Constructs Underlying Peer Visiting

Six weeks after hosting their peer visits, the six preceptors and 12 residents were invited to attend separate focus group sessions, one for preceptors and another for residents. These focus groups were held to explore the participants’ feelings and perceptions about the peer visit process. Semi-structured interview guides were used to conduct the focus groups. The interviewer was purposefully not one of the originators of the peer visiting concept and had never experienced a peer visit. According to a carefully constructed script, co-created by the investigators and the interviewer, the focus groups began with open-ended questions and were guided by the interviewer in a flexible manner. Three preceptors and two residents took part in the focus groups. 

Both focus group sessions lasted one hour and with the help of a facilitator, the following issues were discussed: 1) the impact of the peer visit; 2) the value of the peer visit; 3) preparation for the peer visit, 4) feedback from the peer visit, 5) usefulness of the peer visit. Audiotapes of the sessions were transcribed. Comments from the transcriptions were broken down, and key words and emerging themes identified by the two study investigators who had not been involved in the development of the model. An editing analysis style was used15. The identified constructs were summarized, and a report was sent by mail to the remaining investigators, as well as to all of the participants in Phase I of the study. Recipients were asked to comment on the validity and accuracy of the constructs identified by the content analysis. All of the original participants provided feedback on the identified constructs as well as additional comments on either the structure or process of peer visiting.

Phase II: Evaluation of Peer Visiting

In Phase II, four preceptors and four residents who were hosts in Phase I formed four visiting teams to four new host preceptor/resident pairs. All 16 participants, and additionally one preceptor and one resident who had taken part in an impromptu peer visit, were interviewed by telephone about their experience and perceptions of the peer visit process. Telephone interviewing was adopted as the preferred method of evaluation due to the difficulty experienced in scheduling face-to-face visits. Interview times were pre-arranged with the participants, and lasted a total of 30 minutes. The interviewer followed a structured format exploring the three thematic areas identified in Phase I. Participants were also asked to indicate their overall satisfaction with the peer visit process and to indicate what changes, if any, are needed to make the process more effective and meaningful. 

Extensive field notes were taken during the interviews and subsequently transcribed for analysis by the rest of the research team. All the investigators read the transcriptions, identified key words and emerging themes, and consulted with each other to combine their analysis. The results of this analysis were summarized and were sent to all participants for comments on the accuracy of the findings. 

Results


Phase I

Content analysis of the audiotaped transcripts revealed three major constructs that both preceptors and residents used to describe and evaluate the peer visiting process. The three major themes identified by focus group participants were: Interpersonal Relations, Learning Process, and Faculty Development.

Phase II

The number of participants in Phase II (18 participants) was sufficient to reach saturation. Information from the final interviews did not add any new concepts and confirmed what had previously been reported. Participants in Phase II of the study overwhelmingly believed peer visiting to be a positive experience.  All participants felt relaxed during the visit and commented on the pleasant, non-threatening atmosphere. Almost all of the preceptors said they enjoyed the experience and would participate again. Residents and preceptors both, whether hosts or visitors, found the peer visit very helpful and stimulating.

Interpersonal Relations

Both preceptors and residents appreciated having the opportunity to spend two hours of uninterrupted time to communicate openly about teaching and learning. Preceptors and residents both believed it was essential to have a resident as a member of the visiting team. Both groups also believed a peer visit would be particularly useful to preceptors and residents having trouble communicating. Most preceptors and residents felt afterwards that the relationship had improved as a result of the visit. 

Learning Process

Both preceptors and residents believed peer visiting should be a part of the academic program. All preceptors believed participation should be voluntary, while half the residents thought it should be mandatory. The written feedback was considered helpful, not only as a reminder of what was covered in the peer visit, but also as an aid in preparing to be a visitor. 

Before the visit, hosts were unsure of what to expect, unlike visitors who had already gone through the experience. More than half of the hosts did not feel sufficiently prepared for the visit and made suggestions for improving the information package. Most visitors believed they probably learned most from a visit to a similar practice where information could be easily transferred to their own situations. All, however, stated that they learned something regardless of how different the practices were, and some said they preferred visiting a practice totally different from their own. It was recommended that first year residents be visited six-months–to-one-year into their residency.

Obstacles

Both preceptors and residents identified specific barriers to implementing a peer visiting program: scheduling difficulties; apprehension on the part of hosts; lack of awareness of the program; and negative attitude of potential participants. Despite these problems, all of the preceptors and residents felt that the barriers could be overcome by a number of concrete solutions. These solutions included: Set aside a specific day every year for scheduling all peer visits; offer information sessions to acquaint people with the concept; publicize the program through written and verbal presentations; incorporate peer visiting into the training program; and combat negative attitudes with positive feedback from enthusiastic participants.

Faculty Development

All preceptors reported that they planned to make some changes in their teaching as a result of the peer visit. One preceptor, for example, resolved to make his educational philosophy more explicit (18). Several preceptors undertook to change the way they provided feedback to their students. Most hosts felt confident about becoming visitors. Residents reported that after discussing learning contracts and personal learning styles, they became more aware of their responsibility for directing their own learning.

Discussion


The Peer Visit model provides a positive, stimulating, and non-threatening opportunity to talk about the process of teaching and learning, which is consistent with literature about effective evaluation and feedback19-21. The participants recognized the potential for exploring any topic relevant to their residency and emphasized the importance of both verbal and written feedback. 

Including the resident as a member of the visiting team is an innovative aspect of this model of peer review. The participants all agreed it was an essential aspect of the model. It is encouraging and important that a one-time, two-hour intervention could improve relationships between preceptors and residents. 

In medical education, we aim to teach new knowledge and new skills and to change the attitudes of our residents. Addressing attitudes is by many thought to be the most difficult. The fact that some residents became more aware of their responsibility for their own learning indicates that important issues were addressed during the visit. Additionally, the teachers in this study expressed a resolve to change the way they teach. This result is consistent with the finding in the educational literature that student feedback can enhance teaching performance22.

Consistent with the traditions of action research, the results of this research have directed development of the Peer Visiting model to emphasize the preceptor/resident relationship and self-directed learning. Further study should look for evidence of improved learning following a peer visit.

References


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Source(s) of Funding


This study was funded by The Ottawa Hospital, Ottawa, ON.

Competing Interests


The authors do not have any competing interests.

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