Nested peer tutoring in clinical reasoning


  • Ingeborg Zijdenbos,

  • Gerlof Valk,

  • Olle Ten Cate

ThJ. ten Cate, Center for Research and Development in Education, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. Tel: 00 31 88 755 7010; Fax: 00 31 88 755 3409; E-mail:

Context and setting Since 2000, University Medical Centre (UMC) Utrecht’s vertically integrated medical curriculum has included a mandatory, case-based clinical reasoning (CBCR) course for Year 2 students. In nine 2-hour sessions, held over 7 months, clinical cases are discussed in depth in groups of 12 students. Previously, two or three students from the group (‘peer teachers’) have led the tutorials in turn; a consultant clinician has been present to guide only when necessary. Cases include written clinical vignettes and series of questions and tasks. They follow the natural clinical course, from the initial clinical presentation up to therapy policy. Peer teachers receive additional information on the case, such as answers to history questions, physical examination findings and diagnostic information, so that they can provide this at appropriate points during the sessions.

Since 2004, all Year 6 medical students have been required to take a 1-week mandatory course in teacher training, which includes one hands-on real teaching experience. From September 2008, Year 6 student-consultants have replaced all Year 2 CBCR clinical student-consultants.

Why the idea was necessary It is difficult to find enough highly motivated, broadly oriented clinical teachers, who are sufficiently prepared to lead a diverse range of sessions. Evaluation ratings have declined in recent years. A suitable teaching experience was sought for Year 6 students, who, incidentally, had run CBCR sessions very successfully.

What was done Schedules for students in Years 2 and 6 were rearranged to make them compatible. Year 6 students receive a prior training to ensure optimal didactic and content preparation. To counter a lack of between-session continuity for Year 2 students, and also as part of the teacher training course, all Year 6 student-consultants complete a written report on group and individual functioning and special points of attention after each session, to be passed on to the next student-consultants.

The CBCR course is not only run by peers from the groups, but now also tutored by near-peers, a model which can be designated as ‘nested’ peer teaching. The coordination and responsibility resides with a three-person team: a recently graduated doctor; an internist, and a medical educationalist.

Evaluation of results and impact Evaluations with both Year 2 and Year 6 students revealed that student-consultants were enthusiastic about their role as tutors. They felt adequately prepared and qualified to facilitate the CBCR classes. Year 2 students, evaluated halfway through the year, also showed enthusiasm about peer teaching by Year 6 students. They found the student-teachers to be highly motivated and well prepared, and a majority felt better stimulated in terms of clinical reasoning and perceived a higher level of commitment than they had in clinical teachers who had taught them before. Furthermore, they indicated that student-consultants adjust their teaching better to match the level of Year 2 students; 43% preferred student-consultants as facilitators; 18% preferred clinicians, and 29% indicated no preference.

In conclusion, senior medical students seem to be adequate and encouraging facilitators for clinical reasoning courses for junior students.