Medical students’ perception of dyad practice

Training in pairs (dyad practice) has been shown to improve efficiency of clinical skills training compared with single practice but little is known about students’ perception of dyad practice. The aim of this study was to explore the reactions and attitudes of medical students who were instructed to work in pairs during clinical skills training. A follow-up pilot survey consisting of four open-ended questions was administered to 24 fourth-year medical students, who completed four hours of dyad practice in managing patient encounters. The responses were analyzed using thematic analysis. The students felt dyad practice improved their self-efficacy through social interaction with peers, provided useful insight through observation, and contributed with shared memory of what to do, when they forgot essential steps of the physical examination of the patient. However, some students were concerned about decreased hands-on practice and many students preferred to continue practising alone after completing the initial training. Dyad practice is well received by students during initial skills training and is associated with several benefits to learning through peer observation, feedback and cognitive support. Whether dyad training is suited for more advanced learners is a subject for future research.


Introduction
The increasing numbers of medical students internationally is a growing concern from a training perspective. These concerns have led to the search for efficient and effective educational strategies that address issues of quality of training, cost, and clinical teacher resources. This may include the use of testing technologies, structured supervision and feedback or strategies to promote self-regulated learning, self-direction and cooperative learning. In an experimental study by Tolsgaard et al., students who trained patient management skills in pairs (dyads) demonstrated significantly higher learning outcomes than students who trained alone (singles) [1]. The students in the dyad group were also significantly more confident after completed training compared with the students who practised alone. Recent studies on simulation-based training confirm these findings by demonstrating non-inferiority of dyad practice compared with single practice in a group of residents [2,3]. These results are remarkable as the dyads received only half the hands-on training time of the singles. Previous research from the field of psychology has suggested that reduced cognitive load, improved confidence, and positive effects of observation are responsible for the beneficial effects of dyad training [4][5][6]. However, there is currently little knowledge of the proposed mechanisms of action and few studies have addressed how medical students perceive working in pairs. The aim of this pilot study was therefore to explore the reactions and attitudes of medical students, who were instructed to work in pairs during clinical skills training.

Methods
This pilot study included follow-up survey data from the intervention group of a previously published randomized controlled trial; the intervention has been described in full detail elsewhere [1]. Twenty-four fourth-year medical students without prior clinical experience underwent a four-hour course on how to manage patient encounters. The primary focus of this course was on patient history taking and on how to perform a standard physical examination. The students then practised for four hours on different case scenarios using standardized patients. The students were instructed to practice together and take turns as the active participant. Discussion was allowed but there were no explicit instructions on how the students should interact during practice. Two weeks after completed training, the students were surveyed on how they perceived training in pairs in terms of advantages and disadvantages of this type of training. The survey items included four open-ended questions: 1) What do you think about training in pairs? 2) Which benefits for learning did dyad training provide? 3) Which limitations to learning does dyad training provide? 4) Describe how you interacted with your training partner.
The survey responses were analyzed by two of the authors (MGT and CR) and categorized according to emerging themes without the use of coding software. Agreement on themes was reached through discussion until consensus. The authors used a constructivist approach to analyze data. The theoretical lenses used by the authors during the data interpretation were shaped by existing dyad literature from the field of psychology [3][4][5][6]. Ethical approval was obtained from the Ethical Committee for the Capital Region, Denmark, prior to undertaking this study.

Results
The response rate was 100 % (24 respondents). The students were generally positive about training in pairs. Responses and themes are shown in Table 1. The students felt dyad practice improved their self-efficacy through the social interaction with peers, provided useful insight through observation, and contributed with shared memory of what to do, when they forgot essential steps of the physical examination of the patient: 'By observing, you free the capacity to think about what to do better' [and] 'it was an advantage to get feedback from each other after each encountermy partner helped me point out the things I forgot.' The students in the present study indicated that a significant part of the benefit of dyad practice was due to peer feedback and improved confidence: 'Having a partner makes you less nervous and more confident during the first patient encounters.' Yet some students indicated that the social dynamics within the dyad could be harmful to learning due to the psychological pressure of being observed by a peer. The most common concern about dyad practice was the reduced amount of hands-on time: 'Less hands-on time worries me!' [and] 'it decreases the amount of direct contact with patients'. While appreciating dyad practice in the initial stages of learning, students expressed concerns about this training format in later stages of learning: 'It was nice to have a partner during the first few patient encounters but that was enough. To become experienced I would have to practice alone at some point'.
The students reported that the interaction with a peer provided them with a structured approach to case-based learning: 'We used each other as checklists' and 'we used each other for systematic case discussion'. Finally, the students reported that dyad practice stimulated deliberate practice strategies: 'We had a relevant discussion of why we did as we did and what to improve' and 'we talked about what we remembered and what we forgot and what to do better the next time'.

Discussion
This study aimed to explore students' reactions to dyad practice and to probe students regarding both positive and negative aspects of this training format. Our results confirm the theoretical underpinnings of dyad practice with regard to shared memory, improved self-efficacy, and positive effects mediated through observation and peer feedback [7]. Although experimental studies conducted within the field of psychology and medical education provide evidence of the effectiveness of dyad practice, this study stresses the need to further explore, which learners may and may not benefit from dyad practice and under what conditions. Research from the field of psychology suggests that collaboration may reduce the risk of cognitive overload due to united memory and shared information processing [8]. These aspects relate well to the results of our study, demonstrating that students perceived considerable social and psychological benefits from dyad training. However, in contrast to the motor skills learning literature suggesting that observation is the most significant factor 'Decreases interaction with patients-not significantly though' 'Risk of being less thorough because you always have someone to remind you of things you forget' 'Sometimes you may be less focused when you are not the one who is active' Medical students' perception of dyad practice 505 responsible for learning during dyad practice [9], the students in the present study indicated that part of the benefit stems from feedback and shared memory with the other peer. While previous studies on dyad practice have focused on motor skills learning, the task being trained in the present study involved knowledge, technical skills, and diagnostic reasoning skills. The discrepancies between our findings and the existing literature may therefore reflect the different tasks being practised, as motor skills learning may rely more on observation than tasks that depend on problem-solving and diagnostic reasoning skills. Although the students reported several benefits from practising in pairs during initial practice, they also expressed concerns regarding dyad practice during later stages of learning. By contrast, Crook & Beier suggested that dyad training may be harmful in early acquisition of declarative knowledge [10] and Shanks et al. recently hypothesized that the benefits from training in pairs stems from using advanced learners, who have the experience needed to provide meaningful feedback to each other during dyad practice [2]. However, more advanced learners may not appreciate working in pairs, as the students in our study called for increasing amounts of individual hands-on time and less time for observation after only four hours of practice. Hence, students may wish to practice alone once the advantages from working in pairs in terms of increased confidence and shared memory no longer outweigh the limitations of reduced hands-on practice.
The high response rate was a major strength of this study. The students who participated in this study were highly motivated volunteers, which may explain the fact that all of them contributed with written evaluations. Furthermore, it is customary in our institution that all courses are followed by written evaluations so this may also explain the high response rate. There are several limitations to this study. The largest one is that we used a survey rather than interviews or observations, which would have enabled a more in-depth analysis of learning mechanisms during dyad practice. However, this was a pilot study that aimed to explore students' perceptions of dyad practice, and the purpose was to generate questions and to probe for reactions rather than to provide an exhaustive explanatory framework for dyad practice. Future research is needed to explore how the quality of peer feedback may affect learning during dyad practice and under which conditions dyad practice is most effective.

Conclusion
Dyad practice is well received by students during initial skills training and is associated with several benefits to learning through peer observation, feedback and cognitive support. Hence, dyad practice is supported by both empirical evidence as well as learning theories and should be considered for future basic clinical skills training. Whether dyad training is suited for more advanced learners is a subject for future research.
Ethical Standard Ethical approval from the Regional Ethical Committee for the Capital Region, Denmark, was granted in terms of an exemption letter.
Funding This study was funded by a grant from the University of Copenhagen.
Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.