Curriculum Innovations: Near-Peer Learning in Neurology Residency Training on Cerebrovascular Disease in a Teaching Hospital in China

Introduction and Problem Statement

During the past decades, tremendous changes have taken place in medicine. There are larger patient volumes, higher expectations, more complicated medical management, and rigorous legal regulations. As a result, residency training worldwide must adapt to the changing landscape of medicine.¹ The nationwide reform of medical education in China is complicated by its vastness, diversity, and unique history. To set national quality standards, China launched the 5+3 system, which comprises 5 years of undergraduate medical education and 3 years of standardized residency training (SRT), similar to US residency training.² SRT requires trainees to practice under supervision in relevant departments (including neurology, neurosurgery, emergency department, internal medicine, and radiology) to gain qualifications for independent practice. On completion of the 3-year training, residents must pass a 2-step test (clinical skills and clinical knowledge) in accredited training bases to ultimately achieve certification.^2,3

Neurology residency training is complicated. Many trainees find neuroanatomy and neurophysiology to be complex. Advances in diagnostic and therapeutic technology have made medical care more complex to practice, learn, and master. Reliance on technology may lead to difficulty in synthesizing and understanding underlying pathophysiology, especially for beginners.¹ Faculty-led training tends to be teacher-centric and lacks student engagement.⁴ Teaching faculty and resources are often insufficient in undeveloped hospitals, which is another major challenge that should be addressed by China's health reform.

Near-peer learning (NPL) is an innovative teaching strategy that was first introduced in the late 1980s by Whitman.^5,6 During NPL, senior learners teach junior colleagues.^7,8 Compared with traditional teaching modalities such as faculty-led learning, residents participating in NPL not only learn “twice” but also learn in a different way. They are more likely to adopt a step-by-step approach and think from a beginner's perspective. Psychological safety can be established with an atmosphere that may be perceived as less stressful and facilitate student engagement and increased participation. Therefore, NPL could not only promote more efficient knowledge acquisition but also enhance teaching competency. Well-trained SRT residents could constitute teaching faculty for future medical work forces, such as general practitioners.^2,6,8 These advantages of NPL make it a potentially plausible part of the current standardized neurology residency training in China.

In this pilot study, we applied NPL to train neurology residents in cerebrovascular disease, one of the most common and challenging disorders in neurology. Cerebrovascular disease is essential for doctors in non-neurological specialties as well. We hypothesized that NPL could promote knowledge acquisition and enhance teaching competency in residency training in China.

Objectives

By the end of the NPL intervention, both tutors and tutees would be able to (1) demonstrate knowledge of cerebrovascular anatomy, (2) understand cerebrovascular physiology, and (3) use neuroimaging and physiology to evaluate cerebrovascular pathology. In addition, tutors would gain teaching experience.

Methods and Curriculum Description

Results and Assessment Data

Discussion and Lessons Learned

In this study, we report our experience with implementing NPL in neurology residency training in a teaching hospital in China. Knowledge of the presentation and management of patients with cerebrovascular disease improved and was the greatest for first-time participants in NPL. Feedback on the educational value of NPL was favorable, with participants indicating NPL intervention to be enjoyable and helpful in gaining knowledge. These data suggest that NPL is a feasible instructional method and help residents acquire foundational knowledge of cerebrovascular diseases and provide the senior residents with teaching opportunities.

Improvements in examination scores and favorable learner feedbacks in this study suggest that NPL could assist residents in comprehending foundational knowledge of cerebrovascular diseases. Similar to previous studies, growing evidence had been established to support its implementation within medical curricula.^4,14,-,16 The integrated theoretical model of peer learning proposed by Topping suggest that the effectiveness of peer learning lies in the processes of “organization and engagement, cognitive conflict, scaffolding and error management, communication, and affect.”¹⁷ Each of these was incorporated into our NPL intervention. Organization and engagement included several features of learning interactions that occurred in our course such as time engaged with tasks as well as collaboration between the tutor and the tutee. The learning process reported by tutees and tutors involved cognitive conflicts and challenges. Near-peers can help learners manage misconceptions and errors by thinking from a beginner's perspective. This creates an environment of psychological safety within the learning environment and could allow students to learn from errors more effectively. When tutors are trying to explain a concept to tutees, they have to grasp the concept comprehensively and improve their communication skills. In addition, participants felt psychologically safe and were more proactive in learning among peers. These processes promote both the tutors and tutees to learn in an NPL environment.

It was interesting that the first-year residents and first-time participants obtained the most remarkable improvements in the examination score. However, the improvements did not persist but were on a plateau. For one thing, this might indicate long-term knowledge retention after NPL, in line with previous literature.¹⁴ For another, it also implied that it might be unnecessary to require second-year residents participate in NPL again. That could save much time and avoid burn out for residents.

Previous studies demonstrate that tutors might obtain more improvements than tutees.¹⁸ However, this is not the case in our study. The underlying reasons might be the following: (1) These results might be underpowered because of small sample size and (2) the precourse examination was arranged 30 minutes before the first session when the tutors had already prepared the teaching materials. It is reasonable to assume that greater improvements in tutors might be achieved if the precourse examination was conducted before course preparation. Such arrangements were infeasible because of restrictions during the coronavirus disease 2019 pandemic in the past 3 years. Limited numbers of face-to-face classes were allowed.

We also gained several insights from feedback. First, foundational knowledge is more suitable for the near-peers to comprehend and teach. Nearly all participants reported satisfaction toward the arrangement of foundational knowledge of cerebrovascular disease. Near-peers were able to lead these lectures and case discussions. For more advanced knowledge such as reperfusion therapy in ischemic stroke and stroke in young adults, misconceptions can occur and confuse the tutees. Second, the NPL intervention is enjoyable for both tutors and tutees. We observed more relaxed atmosphere and engagement in NPL. Participants even asked for longer course length and more case-based discussions. Third, instructors reported that their burden was relieved during the NPL intervention when foundational knowledge was delivered by senior residents. This implies that NPL could be a win-win solution in areas with insufficient faculties.

In future iterations, several revisions could be made to address these recognized challenges with NPL. First, as for the teaching contents, more difficult materials, such as the principles and interpretation of TCD, might demand more time and illustration. Second, more case-based discussions on ischemic and hemorrhagic stroke could be applied. This would enhance residents' confidence and independency in clinical practice. Third, to relieve the burden of tutors when preparing for the course, recommended materials and teaching skills should be provided. Fourth, participation of second-year residents would not be required because their improvements in the postcourse/precourse examination score were not remarkable.

The strengths of NPL in this study included: (1) It was integrated into the neurology residency training on the foundational knowledge of cerebrovascular diseases. The anatomy of cerebral blood vessels and neuroimaging were difficult to memorize and easily forgotten. NPL might promote learner autonomy and engagement, leading to long-term knowledge retention. (2) The guidance of instructors specialized in cerebrovascular diseases with years of clinical practice and teaching experience assured the teaching quality. (3) Precourse/postcourse examinations as well as postsession and postprogram feedbacks were applied to assess the effectiveness and to allow for further revisions.

There are some limitations in this study. First, there was no comparator group in which the teaching was performed by faculty; therefore, the effectiveness of NPL compared with faculty-led teaching might be unknown. However, the number of neurology residents in our training base was too small even after we enrolled all residents in the program (18–21 people per year). Therefore, we applied the historical comparison among residents. Future studies might include more training centers to strengthen the efficacy of NPL in neurology residency training. Second, the reliability and difficulty level of home-grown examinations were uncertain. To lessen the bias, the questions were chosen from our neurology examination database with similar difficulty levels. They were further revised and approved by instructors. Third, the effectiveness of NPL in enhancing teaching competency was not sufficiently evaluated in this study. The evaluation of teaching ability was multifaceted and might manifest as a long-term effect. We obtained postprogram feedbacks from tutors 1–3 years after teaching. Future studies could involve assessments from tutors, colleagues, fellows, and instructors. Fourth, some residents participated in NPL more than once, which might affect the precourse examination scores.

Our study suggested that NPL might be feasible and enabled residents to gain foundational knowledge of cerebrovascular diseases. It also provided the senior residents with teaching opportunities. With some revisions, we intend to continue this NPL integrated residency training program annually. Future studies might explore its utilization in other residency programs in China.