Teaching and Learning Forum 2000 [ Proceedings Contents ]

Developing health professionals through the use of reciprocal peer coaching

Richard K. Ladyshewsky
Graduate School of Business
Curtin University of Technology
    Success as a health professional requires a commitment to life long learning. Without this commitment, professionals are unlikely to remain competent in their field. A variety of approaches are typically used by health professionals to keep on top of their field. For example: continuing education, reading of discipline specific text books and journal articles, or further formalised education. These approaches typically emphasise the acquisition of content and skills. Frequently, the professional is left to their own devices to master this material. Reciprocal peer coaching (RPC) is a strategy that can be used to deepen the acquisition of content and skills. This strategy involves two peers of equal status taking turns coaching one another through news or unfamiliar tasks or concepts. The effectiveness of RPC over more traditional methods of learning is the focus of this research presentation.

    The main aim of this study was to evaluate the effects of individuals learning versus RPC on the cognitive, psychomotor and affective components of clinical competence. Novice undergraduate physiotherapy students were the subjects for this quasi-experimental study. In the study, individual subjects were each required to evaluate a patient. This was the control group. Reciprocal peer coaching dyads comprised the experimental group. Each dyad was also required to evaluate a patient. The same patient (a high fidelity simulation) was used for all subjects. Differences in history-taking, physical examination, and clinical reasoning skills were evaluated across the two groups using a variety of measurement instruments. The main findings of the study were that RPC led to significant improvements in performance and clinical reasoning in the experimental group. These results are consistent with the major conclusion in the literature Specifically, that peer assisted learning methods can increase achievement in learners. The implications for professional development programs are considered in this presentation. In particular, how RPC can be used to heighten knowledge, cognition and meta-cognition in professionals.

Teaching and Learning Forum 2000 Home Page


Introduction

An understanding of clinical reasoning (CR) is essential for health professional educators and supervisors if they are to develop strategies which support the acquisition of competence in novice clinicians. Through this understanding comes more efficient and effective educational practice and ideas to improve our learning programs; both within the academic and clinical setting.

Definitions

As the focus of paper centers around the novice practitioner and clinical reasoning, it is useful to define these terms. The novice practitioner is defined as "...one who lacks clinical experience... knowledge, psychomotor and affective skills have been learnt previously, but not in the context in which they must now be applied." p. 39.[1] Clinical reasoning is defined very broadly as the thinking and decision making processes associated with clinical practice.[2-5] This reasoning is influenced by: the personal context of the client; the context of the clinical setting; the personal and professional framework of the clinician; and the context of the health care system .[2-5] Clinical reasoning is comprised of three interactive components: knowledge, cognition and meat-cognition.[2] Cognition relates to the thinking skills of analysis, synthesis and evaluation of data whereas meta-cognition is the awareness of thinking and the ability to assess one's knowledge base. The emphasis on the thinking and decision making processes is an important distinction of clinical reasoning.[6]

The novice practitioner: Clinical reasoning characteristics

Novice reasoning is characterised by a reliance on biomedical and applied science knowledge.[7-11] This knowledge base, however, is poorly organised in comparison to experts.[7, 11-15] This poorly organised knowledge base and the reliance on biomedical propositions has been described as the first stage of medical expertise.[16] Through clinical experience, however, the novice enters the second stage of medical expertise whereby these biomedical propositions are transformed into higher level causal models explaining the basis of observed signs and symptoms. With further experience, these patho-physiological networks are compiled into diagnostic and mental labels that explain the overall phenomena being observed. These labels are called illness scripts and represent stage three of Schmidt's model of medical expertise.[16] These scripts provide rules which enable the practitioner to construct mental models of a family of diseases, a specific disease, a movement disorder, or functional problem.

Novices also recall more surface features of a problem when reasoning and have fewer patterns of clinical conditions stored in their memory.[11, 17] Hence, novices must rely on their biomedical knowledge for reasoning, using textbook cases as their guiding patterns. When cases vary from this simplistic prototype, novices experience difficulty in working through the case as they have not integrated their knowledge into meaningful patterns.[15, 17] When novices begin to see patients, however, their biomedical knowledge and clinical experiences combine which transforms their knowledge into more meaningful clusters of information which facilitates more efficient and accurate reasoning.[10, 18] This is seen in experiments where clinicians, with varying degrees of experience, are asked to describe their CR when given a case.[19, 20] In these instances, novices generally recall more relevant and irrelevant information whereas experts make more inferences from highly relevant cues. This latter feature demonstrates a much deeper understanding of the problem and a more organised knowledge base among experts.

Novices also are seen to have lower levels of procedural knowledge in comparison to experts as much of this knowledge is acquired through experience.[13, 21] This lack of procedural knowledge has an impact on how novices manage a case. Novices also do not have any history of situational contexts in which to apply their knowledge and procedures, therefore, they find it difficult to judge the relevance and importance of certain aspects of a task.[1]

Novices also use hypothetico-deductive forms of reasoning.[22-25] Elstein and associates were one of the first groups of researchers to formally describe this model of reasoning in the health sciences which has four stages: cue acquisition, hypothesis generation, cue interpretation and hypothesis evaluation.[26] They found that Doctors generated a series of hypotheses that directed their inquiry strategies. This model of reasoning has been very influential in guiding the research in CR across the health disciplines and has been corroborated by other research.[25, 27, 28]

Novices, however, when engaged in hypothetico-deductive reasoning, generate quite narrow hypotheses. This is in contrast to experts who generate much broader, contextually deeper hypotheses.[27, 29] This difference stems from the processing of cues. Each cue that is offered by the patient causes the practitioner to generate specific hypotheses. The hypotheses that are generated by the novice are based on biomedical principles and not clinical patterns.[2, 7, 12, 23] Hence, with respect to the number of hypotheses generated, novices appear to be able to generate the same breadth of responses to clinical information as their more experienced counterparts.[25, 30] However, the hypotheses of novices do not contain the richness of information that are seen in experts.[24]

The notion of pattern recognition or forward reasoning is another key component of what separates novice from expert practitioners. Pattern recognition is used by health professionals as part of their reasoning. Grant and colleagues feel that the emergence of pattern recognition emanates from the combination of biomedical knowledge and clinical experience.[33] Experienced clinicians, by virtue of their more organised knowledge base, are able to recognise syndrome patterns more readily. This enables them to process incoming cues much more discriminately than novice practitioners.[33].

Clinical reasoning in the allied health professions

The allied health professions have been critical of the CR literature that has emanated from the medical profession as it ignores the role of the patient in the CR process. This is seen in the following definition of clinical reasoning. Clinical reasoning is defined as:
"a complex intellectual process that surpasses logical thought and is depicted as a process that involves the therapist in a phenomenological approach to make sense of the patient's condition, and evokes the therapist's use of a caring perspective in establishing a collaborative relationship with the patient" p.1033.[31]
The phenomenological approach involves investigating the general approaches and knowledge people use to learn and understand a situation or problem.[32] This phenomenological perspective to CR, with its meaning centered focus of illness and dysfunction, is more recent and is reflected in the breadth of qualitative studies on CR found in the allied health literature.

A variety of forms of CR have been described in the allied health literature.[2,5,13,17,21,45] These supplement the research on CR in medicine and psychology. For example, diagnostic reasoning is aimed at revealing the patient's disability and associated impairments. Procedural reasoning refers to the decision making that occurs in making treatment decisions. Interactive reasoning is the positive and purposeful interaction that occurs between therapist and client. This interaction is used to build rapport and to increase the therapist's understanding of the patient. Predictive reasoning is employed by the therapist to estimate the client's response to management as well as the client's response to the treatment outcome.

Peer assisted learning and clinical reasoning

With this brief overview of the differences in novice and expert CR, what can educators do to facilitate the acquisition of clinical competence in novice practitioners? A strong argument exists for encouraging students to generate early hypotheses in their patient encounters, rather than relying on menu driven formats.[34, 35]. Menu formats, encourage students to collect comprehensive data bases of information without early hypothesis generation.[36] The end result is that students collect reams of data that are unrelated to the specific condition or hypotheses. This only serves to confuse the student. Encouraging students to develop several early hypotheses, independently and in collaboration with their peers, and to organise their data search around these hypotheses, is more appropriate as this is how clinicians solve problems in the real setting.

While menu driven search methods are useful for preventing reasoning errors, as they ensure students don't forget to ask key questions, they should only take a secondary role.[37, 38] Problem directed inquiry, instead of menu driven search methods, can be developed in the academic setting using case studies and problem based learning methods.[39] A problem-based learning focus encourages students, either singularly or collaboratively, to apply the cognitive skills they will need to apply in future setting.[35]

The use of experiential learning methods is another key teaching philosophy that can be used to develop CR skills in novices.[31, 40-43] Several activities that encompass experiential learning include: group discussion; case studies; journals/diaries; role play; work and community placements; simulations; projects; and problem based learning.[44]

In the academic setting, establishing tutorial groups that discuss a variety of cases and use the hypothetico-deductive reasoning approach to work through problems, is one teaching strategy that can be used with the pre-clinical novice. Learning from mistakes and exploring alternative treatment decisions can be the focus of discussions in these groups and may enhance transfer of learning to the clinical setting. This learning format also encourages discussion among peers, clarifies reasoning processes and introduces meta-cognition into the learning experience.

Boud (1988) provides a three stage experiential learning model which can be applied to peer learning partnerships in the clinical setting.[41] The first stage involves 'returning to the experience' so that the learner can recapture as many parts of the experience as possible. The second stage involves 'attending to feelings'. Here, the learner examines what feelings were evoked. A learning partner is particularly useful for these two stages as they encourage the other learning partner to be reflective and to point to specific instances requiring processing. 'Re-evaluating the experience' is the final stage. Here, the new experience is related to prior experiences and new knowledge is re-organised using a variety of cognitive and meta-cognitive strategies.[41]. Again, the presence of a peer can be useful as the dyad can discuss their conclusions and relate them to their biomedical and clinical knowledge bases.

Boud (1988) sees these learning partnerships, and the discussion that emanates from them, as a particularly useful experiential learning strategy in the clinical setting.[41] Students share experiences, clarify expectations of the placement, provide mutual support and ask questions of one another which they might be inhibited from asking their supervisors. The discussion that emanates from these experiences should enable students to create stronger relational structures and pattern recognition frameworks in their knowledge base, leading to better encapsulation of their knowledge and enhanced reasoning potential.

Numerous researchers support the concept of discussion with peers as a strategy for the promotion of CR skills.[6-8, 15, 31, 38, 40, 43, 45] The communication that takes place between peers exposes the learners' thoughts and arguments and allows for discussion and restructuring of knowledge to take place.[15] This forces learners to explicate their reasoning and fosters the development of meta-cognitive skill since it requires students to think about how they think, and to consider how much they know or don't know.[5, 46] Through peer-centred discussion, novices also transform their stage one biomedical propositions into more comprehensive stage two causal networks.[16, 47] The development of rudimentary illness scripts may even be possible through this peer-centred collaboration.[16, 47] This transformation of biomedical knowledge into more clinically applied forms assists the novice in transferring their skills and knowledge to the clinical practice setting.

Specific peer-centred learning strategies can be used to enhance the development of CR skills for both undergraduate and post-graduate health professionals.[39] For example, the use of stimulus questions encourages structured controversy and facilitates learners to explore their hypothesis generation activities. Some example questions that may be posed to learning groups are:

The common denominators for effective peer-assisted learning are: ensuring that the learning activity requires students to problem solve; ensuring that students' thoughts are accessed; feedback (including guidance for further 'study') is provided; and new opportunities to re-apply refined reasoning and knowledge organisation are given.

When novices are required to make their CR explicit, through collaborative group discussion or reciprocal peer coaching exchanges, their reasoning is activated. This activation assists them in their development of clinical competency, facilitates the development of their CR skill and promotes their commitment to lifelong learning.

Conclusion

Notable differences exist in the CR skills of the novice and expert clinician. As a result, educators in both clinical and academic setting need to implement specific educational strategies that facilitate the development of CR skills within the novice practitioner. The use of group discussion and peer-centred learning strategies, such as reciprocal peer coaching, appear to be a useful framework for enhancing clinical reasoning in the novice practitioner.

References

  1. Oldmeadow, L., Developing clinical competence: a mastery pathway. Australian Physiotherapy Journal, 1996. 42(1): p. 37-44.

  2. Higgs, J. and M. Jones, Clinical Reasoning, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth Heinemann Ltd.: Oxford, UK. p. 3-23.

  3. Higgs, J. and A. Titchen, The nature, generation and verification of knowledge. Physiotherapy, 1995. 81(9): p. 521-530.

  4. Higgs, J., Valuing non-propositional knowledge in clinical reasoning: an educational perspective. Australian New Zealand Association of Medical Education Bulletin, 1997. 24(1): p. 7-15.

  5. Jones, M., Clinical Reasoning and Pain. Manual Therapy, 1995. 1: p. 17-24.

  6. Higgs, J., Developing Clinical Reasoning Competencies. Physiotherapy, 1992. 78(8): p. 575-581.

  7. Boshuizen, H. and H. Schmidt, The development of clinical reasoning expertise, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth Heinemann Ltd.: Oxford, UK. p. 24-32.

  8. Boshuizen, H. and H. Schmidt, On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cognitive Science, 1992. 16: p. 153-184.

  9. Newble, D., C. van der Vleuten, and G. Norman, Assessing clinical reasoning, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth Heinemann Ltd.: Oxford, UK. p. 168-178.

  10. Schmidt, H. and H. Boshuizen, On acquiring expertise in medicine. Educational Psychology Review, 1993. 5(3): p. 205-221.

  11. Traband, M. and T. Dunn, Differences in clinical simulation performance: a role for advice-strategies? Respiratory Care, 1988. 33(9): p. 779-785.

  12. Barrows, H. and P. Feltovich, The clinical reasoning process. Medical Education, 1987. 21: p. 86-91.

  13. Jensen, G., et al., Attribute Dimensions that Distinguish Master and Novice Physical Therapy Clinicians in Orthopedic Settings. Physical Therapy, 1992. 72(10): p. 711-722.

  14. Norman, G., et al., Knowledge and clinical problem solving. Medical Education, 1985. 19: p. 344-356.

  15. Regehr, G. and G. Norman, Issues in cognitive psychology: implications for professional education. Academic Medicine, 1996. 71(9): p. 988-1000.

  16. Schmidt, H., G. Norman, and H. Boshuizen, A cognitive perspective on medical expertise: theory and implications. Academic Medicine, 1990. 65(10): p. 611-621.

  17. Jones, M., Clinical Reasoning in Manual Therapy. Physical Therapy, 1992. 72(12): p. 875-884.

  18. Carnevali, D., Self-monitoring of clinical reasoning behaviours: promoting professional growth, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth Heinemann Ltd.: Oxford, UK. p. 179-190.

  19. Groen, G. and V. Patel, The relationship between comprehension and reasoning in medical expertise, in The Nature of Expertise, M. Chi, R. Glaser, and M. Farr, Editors. 1988, Lawrence Erlbaum and Associates: Hillsdale, New Jersey. p. 287-310.

  20. Patel, V. and G. Groen, Differences between medical students and doctors in memory for clinical cases. Medical Education, 1986. 20: p. 3-9.

  21. Jones, M., G. Jenson, and J. Rothstein, Clinical reasoning in physiotherapy, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth Heinemann Ltd.: Oxford, UK. p. 72-87.

  22. Bordage, G. and M. Lemieux, Semantic structures and diagnostic thinking of experts and novices. Academic Medicine, 1991. 66(9): p. S709-S72.

  23. Elstein, A., M. Loupe, and J. Erdmann, An experimental study of diagnostic thinking. Journal of Structural Learning, 1971. 2(4): p. 45-53.

  24. Elstein, A., Clinical Reasoning in Medicine, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth Heinemann Ltd.: Oxford, UK. p. 49-59.

  25. Neufeld, V., et al., Clinical problem solving by medical students: a cross-sectional and longtitudinal analysis. Medical Education, 1981. 15: p. 315-322.

  26. Elstein, A., L. Shulman, and S. Sprafka, Medical Problem Solving: An Analysis of Clinical Reasoning. 1978, Cambridge, Massachussetts: Harvard University Press. 330.

  27. Barrows, H. and K. Bennett, The diagnostic (problem solving) skill of the neurologist. Archives of Neurology, 1972. 26: p. 273-277.

  28. Barrows, H., et al., The clinical reasoning of randomly selected physicians in general medical practice. Clinical and investigative medicine, 1982. 5(1): p. 49-55.

  29. Thomas-Edding, D., Problem-solving in physical therapy: Implications for curriculum development, 1987, University of Toronto.

  30. Grant, J. and P. Marsden, The Structure of Memorized Knowledge in Students and Clinicians: an Explanation for Diagnostic Expertise. Medical Education, 1987. 21: p. 92-98.

  31. Barker-Schwartz, K., Clinical reasoning and new ideas on intelligence: implications for teaching and learning. American Journal of Occupational Therapy, 1991. 45(11): p. 1033-1037.

  32. Patel, V. and J. Arocha, Methods in the study of clinical reasoning, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth-Heinemann Ltd: Oxford. p. 35-48.

  33. Grant, R., M. Jones, and G. Maitland, Clinical decision making in upper quadrant dysfunction, in Physical Therapy of the Cervical and Thoracic Spine, R. Grant, Editor. 1988, Churchill Livingstone: New York. p. 51-80.

  34. Barrows, H. and R. Tamblyn, Problem Based Learning: An Approach to Medical Education. 1980, New York: Springer Publishing Company.

  35. Barrows, H., Inquiry: The pedagogical importance of a skill central to clinical practice. Medical Education, 1990. 24: p. 3-5.

  36. Delitto, A. and L. Snyder-Mackler, The Diagnostic Process: Examples in Orthopedic Physical Therapy. Physical Therapy, 1995. 75(3): p. 203-211.

  37. Gale, J., Some cognitive components of the diagnostic thinking process. British Journal of Educational Psychology, 1982. 52: p. 64-76.

  38. Terry, W. and J. Higgs, Educational Programmes to Develop Clinical Reasoning Skills. Australian Physiotherapy Journal, 1993. 39(1): p. 47-51.

  39. Carr, J., M. Jones, and J. Higgs, Teaching towards clinical reasoning expertise in physiotherapy practice, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth Heinemann Ltd.: Oxford, UK. p. 235-245.

  40. Refshauge, K. and J. Higgs, Teaching clinical reasoning in health science curricula, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth Heinemann Ltd.: Oxford, UK. p. 105-116.

  41. Boud, D., How to help students learn from experience, in The Medical Teacher, K. Cox and C. Ewan, Editors. 1988, Churchill Livingstone: London. p. 68-73.

  42. Brown, J., A. Collins, and P. Duguid, Situated cognition and the culture of learning. Educational Researcher, 1989. 18(1): p. 32-42.

  43. Graham, C., Conceptual learning processes in physical therapy students. Physical Therapy, 1996. 76(8): p. 856-865.

  44. Henry, J., Meaning and practice in experiential learning, in Making Sense of Experiental Learning, S. Warner-Weil and I. McGill, Editors. 1989, Society for Research into Higher Education and the Open University Press: Philadelphia. p. 25-37.

  45. Schell, B. and R. Cervero, Clinical Reasoning in Occupational Therapy: An Integrative Review. American Journal of Occupational Therapy, 1993. 47(7): p. 605-610.

  46. Higgs, J. and A. Titchen, Propositional, professional and personal knowledge in clinical reasoning, in Clinical Reasoning in the Health Professions, J. Higgs and M. Jones, Editors. 1995, Butterworth-Heinemann Ltd: Oxford, UK. p. 129-146.

  47. Carr, J. What do physiotherapists do when doing physiotherapy? and, what do undergraduate students do when learning physiotherapy? in Australian and New Zealand Association for Medical Education Annual Conference. 1992. St. Lucia, Queensland.
Please cite as: Ladyshewksy, R. K. (2000). Developing health professionals through the use of reciprocal peer coaching. In A. Herrmann and M.M. Kulski (Eds), Flexible Futures in Tertiary Teaching. Proceedings of the 9th Annual Teaching Learning Forum, 2-4 February 2000. Perth: Curtin University of Technology. http://lsn.curtin.edu.au/tlf/tlf2000/ladyshewsky.html


[ TL Forum 2000 Proceedings Contents ] [ TL Forums Index ]
HTML: Roger Atkinson, Teaching and Learning Centre, Murdoch University [rjatkinson@bigpond.com]
This URL: http://lsn.curtin.edu.au/tlf/tlf2000/ladyshewsky.html
Last revision: 19 Feb 2002. Curtin University of Technology
Previous URL 19 Dec 1999 to 19 Feb 2002 http://cleo.murdoch.edu.au/confs/tlf/tlf2000/ladyshewsky.html