Career--3

MedicalMedical Scientist Scientist Physiotherapist Physiotherapist

Cardiologist Cardiologist Nurse Nurse

Surgeon Surgeon

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lsjm 30 april 2010 volume 01

EDITORIAL

No white space, no brain space?

This year, several medical schools will be piloting yet another change to the Foundation Programme Application process.

Coming out of the recommendations made in the Department of Health’s document The Next Stage Review: A High Quality Workforce[1], the proposed changes will see the current ‘white space’ questions being replaced by ‘situational judgement tests’ written under the watchful eye of an invigilator.

The new method of assessment is an attempt to address concerns raised by the Department of Health review, which states that “new work needs to be undertaken to develop more reliable and valid selection tools for recruitment”.

But by removing what critics have often anecdotally called the ‘creative writing’ element of the Foundation application process, have the medical education chiefs taken a step backwards from their commitment to reflective practice?

White space questions allowed for the expression of reflective thinking about different facets of life – not just the healthcare experience. Offering candidates the opportunity to show that they have a range of interests, and asking them to demonstrate how their outside experience enhances their professional attributes is surely a worthwhile test of reflective learning?

Reflection seems to be the buzz word in healthcare education today, yet in other fields it is not a new idea. From the truisms of Confuscious in BC China to the theories of pre-war educationalist Dewey, self-reflection has been a key part of the learning process.

What does this mean for students today? Porfolios and projects have replaced the hours of rote learning and memorisation of anatomy and pathological processes. Yet, the evolution of medical education has not been so much a straight switch, rather a bolting on of added requirements, resulting in more hoops to jump through and more boxes to tick. Of course anatomy and pathology are not subjects to go without, so with all this additional reflective work to complete, when is there time to actually take stock of your progress, to take a longer, career-focused view - in short, to reflect?

This issue, Dr Harley Liker talks about his role as medical advisor on hit US drama House. Liker is also heavily involved in undergraduate medical education at UCLA and says that bringing a breadth of experience to the table is important for a fledgling doctor.

“I often encourage my medical students, mainly first and second years, to use their free time away from medicine because I think it makes them better rounded. So if you told me they had the opportunity to watch an hour episode of House MD or go see a provocative foreign film, I would say to them go do the latter as it’s going to broaden you. If they enjoy House then that’s great but I would not give it to them as an assignment.”

Given the demands of the Foundation Application process, if extracurricular, non-medical pursuits are to go unrecognised, will medical students end up narrowing their horizons too much?

More than two and a half thousand years ago, Confuscious said: “By three methods we may learn wisdom: first, by reflection, which is noblest; second, by imitation, which is easiest; and third, by experience, which is the most bitter.”

In order to learn by reflection, one needs time. By removing the white spaces and filling them with ever increasing hurdles and hoops, we reduce the opportunity to learn how to practice wisely.

Through our pursuit of reflective portfolios we become better at playing the game. Whether it makes us better doctors remains to be seen.

Illustration: Ella Beese

Sonia Damle Section Editor Careers References 1.

The Next Stage Review: A High Quality Workforce, Department of Health, June 2008

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ARTICLE

Inside the Mind of House MD Gurpreet Kharay Bsc(Hons) Year 5, King’s College London Gupreet.kharay@kcl.ac.uk doi: 10.4201/lsjm.car.006

Consider the humble physician - devoting time and attention to patients in need; maintaining a commitment to life-long learning to keep his or her skills up to date; upholding the Hippocratic oath; and reviewing scripts for a top-rated television drama in the heart of the Hollywood Hills.

Not expecting a doctor’s responsibilities to be so broad? Neither was UCLA physician Harley Liker MD. When Dr Liker entered the profession he was sure that medicine would be a varied and interesting profession; but no one was more surprised than he when he found himself working on the script of the award winning medical drama House MD. Access to and interest in medical matters has never been greater, and the advent of internet search engines such as google and wikipedia means that everyone can be a home-made medic. The international success of shows such as Grey’s Anatomy and House is proof of medicine’s popular appeal. Dr Liker, one of the medical technical advisors on House - the most watched show in the world[1] - agrees that medicine is something that we all can relate to.

Liker was the first medic to be brought on board the Emmy awardwinning show, and explains how he landed the job several years ago: “My son Jake was in preschool with the daughter of House’s creator, David Shore.

David and I would discuss new projects and one time he said ‘I’ve been asked to pitch this idea of creating a television show’. His idea was that he was going create a physician who was going to be edgy and solve mysteries; the term he used with me was ‘I want him to be like Sherlock Holmes’. I think few people know the show is called House as it bears resemblance to the name Holmes.”

At the time, a drama based on medical mysteries had never really been done before.

Shore, had a background in law but needed someone with medical expertise to get the show right. Liker recalls the early stages of getting the show off the ground where he drew on his experience in the profession to come up with the character credentials: “When it came to the characters and their professions I immediately said you’re going to need an oncologist’, so that’s what Wilson - House’s best friend - became. From an dramatic standpoint you want oncology to feature in the show. It’s life threatening and allows for emotional highs and lows and that’s drama.”

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“Also at the time of my discussions with David, the Anthrax scare was not too long ago and there was a lot of concern about bio-terrorism.

I said you need an infectious disease person because people get really sick from all kinds of strange organisms - so that’s what Dr House became. Furthermore you need a neurologist because that allows for dramatic signs such as seizures and directs interest to the brain which fascinates people and so we had Foreman.

“Chase became the pulmonary critical care doctor since there are bound to be really sick inpatients and you need someone with expertise to care for them too.

“Finally we thought rheumatology would work well because rheumatologic diseases can present in odd ways and some can actually be life threatening, like advanced Lupus. So Cameron became the rheumatologist on the team.”

Discussing medical cases amongst fellow physicians and health professionals is one thing but making medicine make sense to those from non-medical backgrounds is a whole other ball game.

And that includes the writing staff. Liker recognized some common misunderstandings stemmed from the medical jargon: “One of the things writers love to say is ‘give him an MRI’ and I tell them doctors don’t give patients an MRI, they order an MRI. Similarly David very early on knew he wanted Dr House to report to someone high up and he called Dr Cuddy the Dean of Medicine. I told him ‘it should be the Chief of Medicine’ but then the average person watching House MD is from a non-medical background so in a way whether it’s the Chief or the Dean it doesn’t matter.”

Liker forgives the writers’ errors, knowing that all but one, David Foster - a fellow physician - do not have the benefit of clinical experience to steer their ideas.

When asked who’s the real star of the show - the medicine or the drama - Liker is quick to explain: “It’s not really a case of one before the other. The show is ultimately about telling stories – hopefully highlighting human characteristics and emotions such as sadness, joy, betrayal that are universal.

So the show is much bigger than just the diseases. The medicine and the cases are the vehicles by which we can illustrate human nature. Then you have the arcs which is where the drama fits into the script. The nice thing about medicine is that it is very accessible and something everyone can relate to you can personalize it. It also makes us think about moral and ethical issues.”

But while the storylines and character development fall within the remit of David Shore and the writing team, Liker’s chief interests lie in the technicalities and medical nuances of the show, and he works hard to maintain accuracy, inviting specialist consultants in various medical fields to advise the show.

“I really leave what’s happening with the characters to the writers.

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One of the recurring characters early on was a pharmaceutical company boss called Edward Vogler. My input was about the nature of the relationship between him and Dr House as I knew the ins and outs of hospital administration and hierarchy. For the most part, how the characters evolve is left 99.5 per cent in the writers’ hands.”

Liker is always on hand to point the writers in the right direction when it comes to ideas for diseases and cases, and he is keen to point out that the choice of condition is driven by dramatic interest rather than commercial ones.

“I was asked by an individual who was wondering whether the pharmaceutical industry had undue influence on the show. In other words where we paid to do product placement? Well, on the show we only use generic names and never the branded ones. We would say ibuprofen rather than use its tradename. So, just so the record is clear, the pharmaceutical industry has zero influence on the writers or the content.”

“This isn’t a show about coughs and colds or something that’s going to be easily diagnosed with the first blood test because there’s

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no mystery, no hook to keep the viewers engaged. I’ve given the writers some interesting websites that help guide them to some rare diseases and every year someone from a different field of medicine comes down to talk with and sit amongst the writers. The brief is simply to tell us about their most interesting and challenging cases.

“The nice thing about House is that there is a medical mystery to be solved and they’re typically complicated enough that a second or third year medic is not going to figure out, and so it can get their minds to think of differential diagnosis which is good.”

“The writers are constantly reading and they are hearing about strange poisonings that were not easy to detect. You want to find diseases that are similar enough to other diseases so it’s easy enough to go down the wrong path. You know the old saying ‘If you hear hoof beats think of horses not zebras’? Well in House we have them hear hoof beats, think of horses but ultimately it turns out to be zebras.”

The high value placed on medical accuracy is obvious, but does the often-idiosyncratic behaviour of the eponymous Dr House stem from similarly factual origins? Does his habitual use of Vicodin and his apparently dismissive attitude to his team and patients alike, have a basis in reality? Liker insists that House is purely fictional and emphasises that he is not aware of any doctors who conduct themselves in the manner Dr House does.

“The notion that I’m not going to see a patient and instead send my residents to see them while I sit and pop Vicodin and play with a tennis ball in my office is the furthest from the truth. There’s no question that I would ever conduct myself the way he conducts himself professionally or I would not have a practice! If you want to put me on the spot here and ask me whether I know of any doctors who get their interns or residents to break into patients’ homes - I most certainly do not...!”

While some of House’s more outlandish character traits may push the boundaries for the sake of entertainment, creator David Shore will often ask the writers to present medical literature that supports the disease they are working on for an episode, to make sure everything is as plausible as possible. If Liker feels the medicine is being pushed too far he will take a stand.

“The conflict for me is when I think that something is not medically possible - you can’t tell me you can take a kidney from a bird, put it in a man and that kidney is going to start working. The unwritten rule is - if it could happen or it’s happened at least once – it could happen on House.”

References: 1.

http://thecelebritycafe.com/features/28886.html

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INTERVIEW

Women in Surgery Prini Mahendran

Year 4, St George’s, University of London m0401028@sgul.ac.uk

Have you ever felt that your gender has ever impeded your career?

Actually I always felt it gave me a slight advantage - if getting noticed is important then being the only woman most of the time was definitely a positive. There were one or two senior consultants who genuinely doubted whether I could manage but I guess I proved them wrong anyway.

09/09/09 Pregnant Pause: Flash Mob

Some argue that groups such as Women in Surgery[4] have promoted positive discrimination by encouraging the appointment of female surgeons over their male counterparts. Is there any truth in this?

The role of Women in Surgery and groups like it is not to promote positive discrimination but to raise the profile of women in surgery. In that I think they have succeeded. I don’t believe that women have been promoted over men because of their gender, and I wouldn’t want that to be the case either. Surgery should be a meritocracy as that is the best way to maintain high standards.

Caption: Ms Karen Daly, a Children’s Orthopaedic Surgeon The existence of women in surgery is a relatively recent event.

It was the mid 1500s when Henry VIII united the Fellowship of Surgeons with the Company of Barbers to form the forerunner of the Royal College of Surgeons of England.[1] At that time, and for the next 300 years, the profession remained a male bastion, penetrated only by those such as Dr James Barry, in fact a woman who managed to pass as a man and have a successful surgical career. It was only after her death in 1865 that her gender was revealed.[2] Thankfully today women do not have to go to such lengths to pursue a career in medicine. In 2007, the majority of students studying pre-clinical medicine are women. [3] But are women given equal opportunities as their male colleagues in the surgical field? In the same year, more than 93 per cent of surgeons at consultant level were men.[3] Why is this still the case?

Consultant Surgeon Karen Daly has bucked the trend.

Qualifying more than 20 years ago, she specialises in Children’s Orthopaedics and Trauma at St George’s Hospital, London.

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Do you think that old boys’ network still exists?

If there is one, then they are way out of touch. It is no longer possible for a patron to get their trainee appointed. In fact we had a discussion not long ago about a trainee who was thought to be very good but had not be able to get a post through interview. My view is that good trainees will get there without us. We have all had set backs and bouncing back afterwards says a lot about someone’s resilience - which is a good attribute in a surgeon.

Do you think it is possible to balance family life and a career as a successful female surgeon?

I suppose you should ask my children that one! I have a full time consultant job and six children but I still feel I have a good work life balance - equally busy at home as I am at work! I know this isn’t necessarily the right thing for everyone. In order to run this sort of life, you do need a lot of stamina and an ability to organise oneself as well as others, as well as good childcare - which isn’t cheap! What is really important is to realise is that there are choices to be made and these are part of the active process that is career planning. There are so many variables that need to be taken into account - but if a woman has what it takes to be a surgeon then she can find a solution that is right for her.

References 1. http://surgicalcareers.rcseng.ac.uk/wins/history 2.

3.

4.

http://www.newscientist.com/article/mg19726462.000-histories- the-male-military-surgeon-who-wasnt.html http://surgicalcareers.rcseng.ac.uk/wins/research-and-stats/statistics http://surgicalcareers.rcseng.ac.uk/wins

lsjm 30 april 2010 volume 01

INTERVIEW

The View from a Bridge- The Chief Health Professions Officer Oluwatosin Haastrup Year 3 Medicine, St George’s, University of London m0700193@sgul.ac.uk

Karen Middleton is Chief Health Professions Officer for the UK Department of Health. As such she advises ministers and Department of Health officials on anything to do with the Allied Health Professions, an umbrella term which encompasses 14 disciplines including art therapists, physiotherapists and paramedics.

[1] Appointed in 2007, she is only the second person to have ever held this relatively new position, and is also tasked with bringing stakeholders such as the Royal Colleges on board with the Department's proposals for Allied Health. She also works to ensure that the policies made at strategic level translate to improve clinical practice.

What was your route to becoming the Government’s Chief Advisor on Allied Health?

I qualified as a chartered Physiotherapist in 1985. I have worked for most of my career in and around London and in 1996, I was seconded on an 18 month user consultation to look at services provided for people with severe physical disability. This was not something I was at all used to and it totally changed my career. I realised that until that point I had probably been meeting my own needs as a clinician and not at all what these people wanted. As a result of this I set up a multidisciplinary service, Disability Options Team which is still running today. From there, I went into managing until 2003 when I came to the Department of Health to advise on Allied Health and started this role in 2007.

How did you come to realise you might not have been meeting patients' needs?

Well, I was successful at what I did but I went out to meet these people in pubs, clubs, homes, hospitals but it suddenly dawned on me that we clinicians think we are providing the best healthcare possible but I wonder how much of it is actually to meet our need to be needed. Do we develop services because they interest us or are they genuinely centred around patients’ need?

The term 'patient-centred care' is used very often these days. If you think about it, a clinician’s purpose is to provide a service to patients so why do we need to invent the phrase ‘patient-centred care’? Most people go into healthcare to serve and yet so many of our services are organised to suit ourselves.

I’ll never forget meeting with a 46 year old lady who was disabled with Multiple Sclerosis. I asked what she would need to improve her quality of life and she simply replied...a window cleaner. “If I am going to sit here almost 24/7,» she said, «the only delight I get is watching people pass by. I would like clean windows and I am unable to clean them myself.”

At the time it only cost £8 a month for this but I had to go from service to service searching for an allowance to fund it. Fortunately,

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these days training is much more focussed on the patient's perspective and so we do not make as many assumptions about what people need.

Your present role involves encouraging different healthcare professions to work in an integrated fashion. How did you find the interdisciplinary approach was perceived when you were training?

When I trained at St. Mary’s Hospital, in London we had no interdisciplinary training and there was much more of a hierarchy, with clear demarcations between healthcare students. Nonetheless, I soon realised some integration was needed - some of the patients we saw had been visited by as many as fifteen professionals a day!

I started to appreciate the value of interdisciplinary working, as opposed to just multidisciplinary work - particularly in the areas where our roles overlapped significantly.

By embracing this overlap in roles, isn't there a danger that the distinction between roles will disappear? And doesn't this increase the risk of mistakes happening if people are uncertain where their responsibilities begin and end?

People worry that I am advocating for a ‘generic health professional’, but I'm not saying that the individuality and specificity of our disciplines should be eroded. In areas where there is a great deal of commonality between the professions, we can and should blur the boundaries to complement one another. For example when we learnt anatomy, you know, we could have done it with the medics.

Why on earth were we all doing it separately? We've already moved away from that a great deal and we will continue in that direction.

If we subscribe to the idea of ‘patient centred care’, as long as the professional is competent, and there are very many competencies that are generic, does it matter which profession does it?

How do you see the current relationship between medics and allied

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INTERVIEW health professionals?

The problem is of course that when you say Medicine, Joe public and indeed the clinicians - think doctors. We had a scenario recently where the Florence Nightingale Institute issued a lot of money for both nurses and Allied Health Professionals, but because of the title, people just didn t read on. And that is the case with the term medicine. But the new generation of health care professionals will change this.

Allied Health Professionals are only just becoming recognisable to members of the public. And while roles such as the Chief Nursing Officer or the Chief Medical Officer have been around for some time, there has only been one Chief Health Professions Officer prior to me.

On every board there will be a Director of Nursing, a Medical Director but not necessarily anyone at that level for Allied Health and that’s been one of my real campaigns. This needs to change, to allow Allied Health Professionals to have input to healthcare in this country at a strategic level.

A Leadership Challenge was run this year for the first time, particularly for Allied Health Professionals. I wanted to raise the profile of Allied Health Professionals as leaders of change, of transformation and improvement and raise their profile at strategic health authority level and give individual Allied Health Professionals the experience of working in management/ leadership positions to demonstrate how their inherent skills as clinicians are transferable to a leadership position. It gave them this very experience and they were amazingly successful.

Do you think people are otherwise unable to see strategic influence as a possibility for Allied Health Professionals?

I think your generation will be different, but people of my generation - where we all learnt separately and were not able to exert influence find it more difficult. I want us to get to a place of equal footing. On the whole, Allied Health Professionals just get on with their jobs. I want them to know that they can influence upwards too.

I care about relationships, about the vulnerable, and I think that is the driver for me. Although I am here for the Allied Health Professionals, I am only interested in the difference it can make to patient care; I am not interested in pushing for the movement of Allied Health Professionals onwards and upwards for their own sake.

Karen Middleton is married with two step children. Her many and varied personal interests include sailing, skiing, biographies and reading about politics, as well as spending time with her friends

Karen Middleton is a patron of the LSJM.

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References 1.

http://www.dh.gov.uk/en/Aboutus/Chiefprofessionalofficers/ Chiefhealthprofessionsofficer/DH_075030

Most people talk about adding years to life for patients, I am interested in the quality we can add to that life, adding life to years.

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”

At 30 years old, my life seemed pretty settled. I was living in a North London flat with my long-term partner. We were pretty short of cash, but that was alright because, after years of secretly regretting not choosing medicine first time round, I had finally quit my job and got into medicine via the Graduate Entry Programme at King’s College, London. Now over a year into the course, and part way into the clinical years, consultants and colleagues had passed on a number of medical mantras.

“Common things are common,” they intoned on a regular basis.

Imagine my surprise then, when I found myself unexpectedly expecting.

I discovered that I was pregnant just over a year ago. Whilst I had always known that I wanted children one day, I hadn’t reckoned on that day arriving so soon. Taking a break so soon after starting clinical placements certainly wasn t part of the plan, but after the initial surprise had worn off, there was no doubt in my mind that I was going ahead with the pregnancy. I did worry about informing the medical school initially, but I really need not have done this was nothing they hadn t seen before and they left it entirely up to me to decide whether I wanted to take a year’s break before resuming my medical career. Although my baby was due just four days after the 3rd year exams, I decided that, if all went went, I could get through those, and then take a year-long hiatus.

As luck would have it, I had quite an easy pregnancy. There were a few times when I rushed in late due to morning sickness, but having informed the medical school and the head of my medical firm about the state of affairs early on, my occasional tardiness was met with nothing but understanding and support.

Of course, as the bump got bigger, it became a nice talking point with patients on the wards and in clinics. On one occasion, a patient who happened to be a retired consultant obstetrician managed to guess exactly how many weeks pregnant I was just by looking at me!

Having been an (albeit welcome) surprise, I was half expecting my baby to continue true to form and arrive early - slap bang in the middle of my exams! Fortunately, my due date came and went without any signs of labour, and I was able to sit my exams.

I even managed to have a few days to catch up on some much needed sleep afterwards. The last few weeks before exams were definitely hard - swollen feet, backache and disturbed sleep, my clinical partner admirably put up with a lot of complaints! In retrospect, studying right up until the end of the pregnancy was probably a nice distraction. It did mean that I didn t do much reading in preparation for the birth - although I am pretty certain that I managed to annoy the obstetrics registrar with my incessant

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PERSPECTIVE

Medicine, Motherhood and Me Asa Shetly

Year 3 Medicine, King’s College, London asa.lundstrom@kcl.ac.uk

09/09/09 Pregnant Pause: Flash Mob

questions (once the epidural took hold, that is)!

My daughter is now five months old and, finally feeling like I’m getting the hang of this parenting thing, my thoughts have turned to what it will be like once I go back to studying. I find myself trawling the internet for information and advice from others who have been in the same boat: what help is available to cover the cost of childcare? How will I ever find time to revise for exams with a baby to look after? What happens if, say, my daughter is ill and I have to miss teaching? How will I ever make it to the hospital for 8am ward rounds? Coming across the blog of a Swedish medical student who manages to combine her studies with pregnancy, looking after a toddler and studying for the USMLEs whilst still finding time to bake bread and make granola was undeniably scary, but thankfully there are plenty of other accounts showing that you don’t have to become Supermum to cope. A fellow KCL student shared her experiences of being a first-time parent and Phase 3 student in the sBMJ in 2003[1], and there are of course plenty of online forums where student parents can receive and provide advice – there is even a separate forum on New Media Medicine dedicated to parents at medical school[2].

Also, what happens after medical school? How will I cope with the on-calls of foundation training with a three-year old at home?

What if I want to have another baby? And what happens after foundation training – how do you combine specialty training with family life? As Annette Johnstone, an LTFT (less than full time trainee) SPR in radiology at Leeds Teaching Hospitals NHS Trust and mother of three boys under five has learnt, it is doable, albeit not always easy: ‘After having my children I really appreciate all the things I used to take for granted getting up and leaving the house at the very last minute, being able to go in for MDT meetings at 8am or staying behind for teaching or to sort out a patient. Now, I am much more organised although you have to be prepared to deal with the unpredictables that come with kids, like the nursery closing at 3 because of snow. You sometimes feel the world is against you!

A great resource on what to expect when combining motherhood with being a doctor is So you want to be a medical mum?[3], with advice on maternity leave, full time vs part time training and plenty of quotes from professionals from different specialties (and there is also a short chapter on having a baby as an undergraduate). Annette has chosen to train part time: ‘Having kids, you need to get the work/life balance right. I currently work 60% as an LTFT which means prolonging training, but I’ll never get this time back with the kids so I enjoy trips to the farm, swimming, parks and picnics while my full-time colleagues are racing through their training’. For me, well, time will have to tell.

Not having decided on a career change until the grand old age of 29, part time training could mean that I am still sitting exams well into my forties depending on which training route I go down, but then again, I don’t want to miss out on too much of my daughter’s childhood.

All things taken into account, how do I feel about it all now, five months down the road of parenthood? Well, considering that some days I’m not even organised enough to leave the flat, I do worry that the task of combining studying with parenting will prove too much. Still, I will certainly try my best and I am confident that the medical school will continue to be as understanding and supportive as they have been so far. Yes, there is the possibility that I will miss important teaching when my daughter is ill and yes, it might be that I never make consultant – but as I sit here by my computer as my baby daughter snoozes next to me in her cot, I mainly feel very, very lucky.

References 1.

2.

3.

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studentBMJ 2003;11:87-130 April ISSN 0966-6494 http://www.thestudentroom.co.uk; http://www.newmediamedicine.com/ forum/parents-medical-school/ Hill, E. (2008). Oxford University Press.

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Manchester Students make the case for Peer-Managed-Peer Assisted Learning Ambrose Boles & Ben Amies Year 4 Medicine, University of Manchester ambrose.boles@postgrad.manchester.ac.uk doi: 10.4201/lsjm.car.007

The practice of peer-assisted Learning (PAL) can be traced back to the philosophers of Ancient Greece1. At its heart is the idea that students benefit from being taught by - and teaching - each other. For this reason, it is often informally used by medical undergraduates2 and other healthcare students. A recent international medical education conference described PAL as an “exciting and developing area in medical education”3.

Since 1993, PAL has enjoyed increased popularity, following the General Medical Council’s recommendation that medical graduates should have “appropriate teaching skills”2,4. At present at least 11 of 31 medical schools in the UK run a PAL programme as part of their core curriculum5. PAL is often used to complement existing medical curricula2, with benefits for both tutors and tutees widely described in the literature. It has been shown to deliver teaching comparable to that of an expert6,7, as well as offering some added unique benefits.

PAL sessions are more friendly and informal than expert-led teaching. Tutees regularly report that they find it easier to ask questions in this setting, without fear of judgement for lack of understanding8,9. There may also be additional benefits associated with the comparable curricular level between tutor and tutee. It has been found that tutees feel PAL is delivered at a more appropriate cognitive level than sometimes experienced with the more traditional teacher/student model of education6,9. Furthermore,

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the greater sense of camaraderie between tutor and tutee is believed to benefit learning10. Peer-tutors can also be excellent role models for younger students11.

It’s not only the tutees that benefit from this scheme. There are also benefits for peer-tutors. PAL provides a rare opportunity for students to develop valuable teaching skills, which are essential for future practice as a doctor4,6. In addition, teaching helps peer-tutors consolidate their own learning and increase their confidence2,12.

PAL programmes can be organised by the medical school (facultymanaged) or by students (student-managed). The majority are the former, offering students interested in becoming PAL tutors the chance to take modules on how to deliver small group teaching.8 The latter, such as the one run at the University of Manchester11, are organised and delivered almost entirely by student-tutors, with only some input from expert clinicians. Although both faculty-managed and student-managed PAL programmes share similar benefits9, there is evidence to suggest that student-managed programmes have additional benefits.

It has been proposed that one of the main benefits of studentmanaged PAL is that it gives students a greater sense of ownership over the PAL programme8,11. This results in peer-tutors taking greater responsibility for ensuring that their teaching is of a high standard, and promotes self-appraisal, which is essential for modern medical practice4,13. Furthermore,

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Another key advantage of student management of the programme is the opportunity for peer-tutors to develop organisational and team working skills. There is also significant interest from tutees in becoming future peer-tutors9. This allows the management of the programme to be passed down from year to year, thus making it self-perpetuating. Furthermore, by its nature student-managed PAL exerts little strain on existing teaching resources14.

A possible criticism of student-managed programmes is that peertutors do not have sufficient formal training in small group teaching to be able to effectively deliver small group teaching. This is supported by the finding that formal peer-tutor training improves tutee learning outcomes15,8. In the Manchester PAL programme, experienced peer-tutors informally train and advise new peertutors in techniques for delivering small group teaching. In order to further improve peer-tutor teaching skills, this process could be formalised. In addition, we have implemented an audit tool to help us assure the quality of our teaching.

In our experience, a student-managed PAL programme can be successfully run with results comparable to existing PAL literature9.

In addition, student-managed PAL has extra benefits over facultymanaged PAL programmes. These benefits include the promotion of student ownership of the programme, encouragement of peertutor self-appraisal, development of organisational and teamworking skills, and self-perpetuation of the programme. For these reasons, it seems that existing faculty-managed PAL programmes could benefit from devolving more management responsibilities to students.

Ambrose Boles is involved in running the PAL programme at Salford Royal Hospital, which is now in its sixth year. Ben Amies is intercalating in Medical Education and is involved in setting up a new PAL programme at the University Hospital of South Manchester. Both authors would like to acknowledge the hard work and dedication of their fellow peer-tutors, and in particular that of James A Giles.

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For full references see thelsjm.co.uk.

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