Near-peer Tutoring Compared With a Standard Faculty-led Course for Undergraduate Training in Abdominal Ultrasound.
Condition: Ultrasonography; Educational Techniques
Study type: Interventional

Summary: 
      Background:

      Ultrasound has become clinical skill widely used in most medical disciplines. Institutions
      are changing their curricula to implementing basic ultrasound knowledge, often supplementing
      traditional teaching with 'near-peer' tutoring through classes held by advanced peers.
      Near-peer tutoring has been found to be both effective and cost-effective.

      In Switzerland the most popular course in postgraduate training is a resource-intensive
      21-hour basic course for abdominal ultrasound. However, this is expensive, and may not be the
      best way to impart these skills to undergraduates, who need training more adapted to their
      needs.

      Therefore a 21-hour blended-learning ultrasound course, comprising 5 hours of e-learning and
      16 hours of near-peer tutoring has been developped. Students and their near-peer tutors
      autonomously organize individual practical teaching sessions within a 16 weeks time period.

      Methods:

      Medical students from second to fourth year at the Universities of Bern, Fribourg and Zurich
      will be included. Stratified by study site, students will be randomized to one of the two
      interventions. The blended-learning group will receive e-learning and near-peer tutoring over
      16 weeks; the other group will receive 21 hours of teaching, from ultrasound experts, in a
      2.5-day course. All participants will undergo a six-station OSCE directly after the course
      and 6 months later. Students will fill out online questionnaires at baseline, directly after
      the course and 6 months later. The mean scores of both groups will be compared at six months
      after the end of both courses. Secondary outcome measures will be students' ultrasound skills
      immediately after the courses, student satisfaction, multivariate regression exploring
      factors that affect outcome at 6 months and exploratory subgroup analysis.

      Discussion:

      This study is designed to compare the current way of ultrasound education in Switzerland with
      a new blended learning course. It aims to determine whether the blended learning course is as
      good as, or better than the existing 21-hour standard course. If this is found to be the
      case, blended learning could help to expand capacity to offer such courses to undergraduate
      medical students. It would eventually allow undergraduate Swiss medical students to acquire
      ultrasound skills before starting their residencies. This study also aims at improving the
      understanding of how to achieve effective student-centred learning supported by near-peer
      tutoring.
    

Detailed description: 
      Background:

      Over the last decades, ultrasound (US) examination has become commonly used in many medical
      specialties, including internal medicine and primary care. Young doctors often perform simple
      ultrasound investigations as residents in internal medicine or primary care especially in
      emergency care. Currently, 30% of Swiss primary care practices are equipped with an
      ultrasound machine.

      The Swiss Society for Ultrasound in Medicine (SGUM/SSUM) is the accreditation body for
      ultrasound education in Switzerland. Doctors must obtain a certificate from the SGUM before
      they can bill ultrasound examinations for insurance payments. However, ultrasound courses are
      time-intensive (63 hours total, plus a final examination), and are offered in the
      postgraduate phase, when doctors often have few resources and little time. This may explain
      why only about half of General Practitioners who use ultrasound have the SGUM certificate.
      For the half without the certificate, not only can they not bill their ultrasound examination
      to an insurance company, but also the quality of the examination is less assured, as they
      have not demonstrated their competence in US skills in the SGUM examination. This may lead to
      insecurity for the patient and for the performing doctor. There is also a risk that this
      results in unnecessary examinations.

      The SGUM certificate is achieved by passing three courses (basic/advanced/final; 21 hours
      each) as well as a summative final examination. Between courses, trainees must perform a
      certain number of US examinations on real patients, under direct and distant supervision.
      These courses are now being opened to undergraduates, and the 2017 revision of the Swiss
      learning objectives for medical studies (PROFILES) added basic US skills as mandatory
      learning goal.

      In the past years US training courses at Swiss medical universities were mostly optional, and
      were quickly overbooked. This shortage of courses could be addressed by using near-peer
      tutors, which are increasingly used in faculty-organized US classes. Near-peer tutors are
      "trainees one or more years senior to trainees on the same level of medical education
      spectrum". Five randomized-controlled trials of ultrasound training have compared near-peer
      tutoring with faculty-led teaching and assessed students' practical ultrasound skills as a
      primary outcome measure. Four of these found peer-tutoring to be non-inferior and one found
      that students in the near-peer-tutoring group slightly underperformed.

      Near-peer tutoring in undergraduate US training offers many potential advantages over
      traditional faculty-based teaching:

        -  Since mostly reciprocal US is being done by the participating medical students, perfect
           conditions for learning basic sonographic anatomy can be found. Medical students, in
           contrast to patients, are mostly slender, healthy and mobile.

        -  In near-peer tutoring settings, students are more likely to ask questions and
           participate actively. In addition, having ultrasound skills can help students feel more
           secure in their basic clinical examination skills.

        -  Near-peer tutoring relieves pressure on the university by alleviating the increasing
           teaching demand and by being cost-effective.

        -  There is evidence that students who work as tutors constantly improve their own skills.

      In Autumn 2017, the Institute of Primary Health Care (BIHAM) at the University of Bern set up
      a working group of 24 US experts from all Swiss universities and of representatives of SGUM
      sections. The group decided on the "Swiss standard" for basic abdominal ultrasound
      examination after discussing it at two consensus-building meetings. In Spring 2018,
      videotapes of SGUM experts demonstrating the ultrasound examination of the various abdominal
      organs, based on that consensus, were recorded. These videos were integrated into interactive
      e-learning modules. They have been available to all Swiss medical students since the
      beginning of 2019.

      In parallel, a formal system of training and continuous education for near-peer tutors was
      put in place by a collaboration of motivated students and faculty staff. Near-peer tutors
      receive at least 6 days of US training, including teaching on didactic techniques, and
      afterwards be registered as so-called 'junior-tutors' by SGUM. They must offer at least four
      hours of US class per semester, but can choose the times and dates. Tutors will be reimbursed
      for their teaching through course fees paid by course participants.

      Methods:

      The standard "Basic course in abdominal ultrasound", delivered over 2.5 consecutive days,
      contains 5 hours of theory and 16 hours of practical training. In contrast, our
      blended-learning course is more student-centred, in that it expects students to take the
      initiative to learn the theory from (A) the e-learning developed by the working group, and
      (B) 16 hours of near-peer tutoring in groups of two to four, at times that are mutually
      agreeable for tutors and students, without faculty involvement.

      The e-learning is made up of five modules starting by an introductory e-learning module on
      technical basics in ultrasound, followed by four practical modules comprising the abdominal
      organs. For each of the four practical modules, students start by working through the
      e-learning module, followed by four hours of individual near-peer tutoring sessions.

      Students decide the pace of their 16 hours of training, typically over a four-month period.
      When a student completes all five e-learning modules and has gathered 16 signatures from the
      peer-tutored classes, they can apply to take a summative final examination. If they pass the
      Objective Structured Clinical Examination (OSCE) validated by Hofer et al. (2011) and adapted
      to Swiss needs, they are accredited by SGUM, according to Swiss national accreditation
      guidelines, for the "Basic course in abdominal ultrasound" - the first of the three
      ultrasound courses within the SGUM curriculum.

      The OSCE will be assessed twice for every participant. Once at the end of the course and once
      6 months after the end of the course. The second OSCE will be the primary outcome, since it
      evaluates long-term retention of acquired US knowledge. Every student will be tested by six
      different examiners in each OSCE. Differences in difficulty of the four series of OSCE
      stations as well as difficulty of every station will be taken into account in the statistical
      analysis.

      The blended-learning course offers several other advantages by implementing modern didactics:
      by distributing teaching sessions over 16 weeks instead of just 2.5 consecutive days,
      students benefit from "spaced repetition" which improves long term retention. In our
      programme, students can decide which session to choose next, and tutors and students arrange
      the teaching sessions according to their availability and needs, so learning is
      student-centred. These factors differentiate our study from the near-peer tutoring in
      ultrasound education reported in some studies, in which tutors engage in scheduled courses
      organized by university faculty.

      Between randomization and the end of the training (t = 16 weeks), students will be instructed
      not to undergo any additional training (e-learning, practical sessions or other) other than
      those provided within the intervention. Additional training will be recorded directly after
      the end of the training by questionnaire and by going through e-learning logs. During the
      6-month follow-up period, students in both groups will be equally encouraged to continue
      self-organised training and both will be granted access to ultrasound machines.

      Adjusting to local curricula we will primarily recruit students in semester 7 in Bern (total
      medical student intake per year = 220) and in semester 6 in Zurich (240) and Fribourg (120).
      At each site, we will present the programme during a plenary session, assisted by our local
      co-investigators.

      To avoid systematic differences in additional training during the follow-up period, the
      following rules will put in place:

        -  Students will only be told their test results from the first test after the end of the
           study

        -  Test performance in the follow-up test will have no effect on the accreditation

      To reduce loss to follow-up, we will:

        -  Require all students who apply for the programme to sign a separate form confirming
           their availability and intention to complete the course and the examinations

        -  Reimburse participants 50.- CHF after they have taken the second OSCE.

        -  Reimburse travel costs for the second OSCE

        -  Hand out the test result and the course certificate only after the second OSCE

      Students' motivation for ultrasound training is very high. The optional courses at Swiss
      universities are typically overbooked within minutes and many students are disappointed that
      they are unable to take part. Our study will give students the opportunity to get a
      certificate accredited by the SGUM for a course fee of 200.- CHF, regardless of the
      intervention they are assigned to. Postgraduate training for the same degree costs around
      1200.- CHF.

      We will use centralized computed randomization in blocks of 4 to allocate each of the
      participants to one of the two study arms, with allocation in a 1:1 ratio, stratified by
      study site. The reason for block randomisation is the requirement of the control group to
      comprise of exactly 24 or 28 students due to the maximum group size of 4 students per tutor.
      The randomization will be performed by a blinded external partner (Clinical Trials Unit in
      Bern).

      Outcome assessors will be experienced sonographers who have not taught course participants of
      either group.

      To ensure high interrater-reliability, faculty training for all assessors will be held
      immediately before the OSCE. In the first part of this training, the assessors discuss key
      aspects of the rating using videotaped examples of OSCE stations to achieve a common
      standard. At the end of the training, assessors will rate another video example, where the
      interrater-reliability will be assessed.

      OSCE assessors will be blinded to group allocation. The assessments will be at the same time
      for each group. We will instruct students not to reveal their group allocation to the OSCE
      assessors.

      Sample size calculation has been done as follows: Based on a pilot with 20 students we expect
      a mean score of 33/50 points per station with a standard deviation (SD) of 4 points. The
      study was powered for non-inferiority using a margin of a -1.5 points for the difference in
      mean OSCE scores between the intervention and control group in the practical exam at 6 months
      (primary outcome). 1.5 points difference would correspond to an effect size of 0.375 standard
      deviations (SD), which we would still consider as non-inferior. We calculated the sample size
      with the assumption that the intervention group will perform somewhat better (+0.5 in mean
      score) than the control group based on test results from previous pilots. We chose a 1-sided
      alpha-error of 0.05 and a power of 90% (138 participants). Allowing for a 9% dropout rate we
      decided to include 152 students.

      Discussion:

      If the new blended-learning format is shown to be at least as good as the existing standard
      course, we could quickly expand our capacity to offer such courses to undergraduate medical
      students, replacing resource-intensive faculty-led courses with peer-assisted learning
      programmes. This will eventually allow all undergraduate students to acquire ultrasound
      skills that will help them in their residencies. The national accreditation body fully
      supports this near-peer-tutoring-based course both financially and through full accreditation
      of a pilot project and has committed to continue its support if we find that this teaching
      format produces results that are just as good as, or better than, the usual faculty-led
      courses. Learning more about the advantages conferred by student-centred learning through
      near-peer teaching will enable us to design better peer-assisted learning programmes and to
      design new, similar programmes in other areas.
    

Intervention name(s): Blended learning; Standard course
Intervention type(s): Other; Other
Intervention description(s): In the intervention group, students will be given access to an e-learning platform that contains five e-learning modules. They will attend individual small group tutoring sessions, with a maximum of 4 students per group. They will be able to book these sessions at a dedicated web platform. They will have 16 weeks in which to complete the 5 e-learning modules and 16 hours of practical training. Progress will be monitored and supported by regular follow-up messages and calls by the study team. Students must hand in the logbook with tutors' signatures when they enter the exam. All students within the blended learning group that completed 5 hours of e-learning as well as 16 hours of peer-tutoring and passed a predefined total score in the test directly after the intervention will receive a course certificate. Students not fulfilling all of these criteria will have the possibility to complete the program and/or re-do the test after the end of the study.; In the standard course or control group, students will participate in a 2.5-day course in abdominal ultrasound, comprising 5 hours of lectures and 16 hours of ultrasound training in small groups, with a maximum of 4 students per group. The course will be held in an ultrasound training centre in Bern. All students within the standard course group that participated in the whole 2.5 day course and passed a predefined total score in the test directly after the intervention will receive a course certificate. Students not fulfilling all of these criteria will have the possibility to complete the program and/or re-do the test after the end of the study.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: We will include 152 medical students at the Universities of Bern, Fribourg and Zurich. Stratified by study site, students will be randomized to one of the two interventions. The blended-learning group will receive e-learning and near-peer tutoring over 16 weeks; the other group will receive 21 hours of teaching, from ultrasound experts, in a 2.5-day course.
Masking: Single (Outcomes Assessor)
Primary purpose: Other