Prior Presentations

This work has not been presented previously.

Background

Peer-assisted learning (PAL), a pedagogical model where near-peers serve as the instructors, has been implemented formally in undergraduate medical education (UME) in many countries [1]. PAL has been studied in a variety of settings [2,3,4,5,6] and consistently shown to enrich the educational experience of both the peer instructors and learners, and to contribute to the formation of future physician educators [7]. Peer instructors may better cater the educational experience to the learner, allowing them to understand difficult content areas and sociocultural aspects of the student experience [2, 6, 8]. Additionally, students and peer instructors tend to be more socially connected, leading to open discourse and comfort asking clarifying questions [9, 10]. Most literature on PAL focuses on students in the role of supplementary, short-term instructors. We report on a 9-week UME physical exam (PE) course with upper-level student peers as the primary instructors and faculty members as co-instructors. Through evaluation of the impact of this PAL hybrid course design on learners and peer instructors, we aimed to deepen our understanding of the benefits and limitations of PAL.

Activity

In 2021, in response to the challenges of faculty recruitment during the COVID-19 pandemic, we re-designed our introductory PE course. Traditionally, faculty would teach PE to the same small group of students weekly throughout the 9-week course. In the course re-design, henceforth referred to as the PAL hybrid design, each small group of student learners had an upper-level student peer instructor as primary instructor and a faculty member as co-instructor. Upper-level students who passed their first-year physical exam course and completed their core clinical rotations were invited to participate as peer instructors for the PE course via a recruitment email. Anyone who expressed interested was incorporated into the course and matched with a small group of student learners.

Course Overview

The PE course for first-year medical students ran from January to March of 2021 and covered core PE maneuvers for the components of the exam listed in Table 1. Peer instructors met in-person weekly for 75 min with the same two groups of four student learners. Later in the week, student groups also met over Zoom with their faculty co-instructor, separate from the peer instructors. Peer instructors emailed faculty co-instructors after each session to provide an update on the material covered, learner progress, and maneuvers that would benefit from further explanation based on their direct observers of learner performance. Peer instructors received mandatory weekly in-person mentorship from course leadership to discuss PE and teaching techniques.

Table 1 Course overview of content covered in each educational session
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Course Evaluation

We evaluated the PAL hybrid design using quantitative and qualitative methods. At the end of the course (March 2021), all student learners were asked to rate how well the course organization facilitated learning using a Likert scale (1 [not conducive at all] to 5 [very conducive]). Additionally, we adopted a qualitative approach to understand how the hybrid teaching approach impacted learners and peer instructors. From May to June 2021, we interviewed a sample of student learners and peer instructors about their PAL experience (Fig. 1) by randomly inviting one student learner from each group and all peer instructors to participate. The 30-min interviews were conducted one-on-one via secure Yale Zoom accounts by medical student researchers (MAS, AMW) using a semi-structured interview guide (Supplementary Appendix). Interviews were transcribed prior to review and analysis. The faculty investigator (JHD) was blinded to the interviewees. Transcripts were sequentially coded independently by the three authors and then compared to create a code book. The code book was applied to subsequent interview transcripts in an iterative process with new codes added as they emerged. Codes were then reviewed to identify themes related to how the PAL hybrid design impacted learning and teaching.

Fig. 1
figure 1

Flow chart of participant selection. All peer instructors for the eleven groups and one randomly selected student representative from each group were invited to participate in the interview. If a student learner refused to participate or did not respond, another student from the same group was randomly invited. If that student learner refused to participate or did not respond, one final student from the same group was randomly invited

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Ethical Considerations

This study was exempt from review by the Yale University IRB. All participants consented to participate.

Results

Seventy-three of 104 (70.2%) learners responded to the end of course survey. Seventy-two (99.0%) found the course organization to be conducive (43.0%) or very conducive (56.0%) to their learning. In 2020, when the course was solely taught by faculty, 91.0% of students found the course organization to be conducive (38.0%) or very conducive (53%) to their learning.

We interviewed eight of eleven (72.7%) peer instructors and a student representative from ten of the eleven (90.9%) peer instructor groups. All peer instructors described their experience as positive. Three out of eight (37.5%) described prior interest in medical education, and an additional four, for a total of seven out of eight (87.5%), described interest in medical education after participating in the course. Eight student learners (80%) described the overall PAL hybrid design as positive, one (10%) as neutral, and one (10%) as negative. Three (30%) described an interest in medical education prior to the course and five (50%) reported a definite interest in medical education following the course. Seven (70%) responded that they would apply to be a peer instructor in the future.

Thematic Analysis

We identified the following themes which further our understanding of the impact of the PAL hybrid design on student learners and peer instructors (Table 2): the value of social connectedness, the pros and cons of academic proximity, and the importance of a longitudinal teaching experience coupled with faculty mentorship. Representative quotations are highlighted below and in Table 2.

Table 2 The impact of PAL on peer-instructors and student-learners
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The Value of Social Connectedness

Both student learners and peer instructors highlighted the added value of social connectedness through the PAL experience. A peer instructor comment, “I was pleasantly surprised that my group stayed to ask about things outside of the course. That made me realize how valuable it can be to have student–teacher interactions.” More explicitly in the words of a learner, “It was a mentor–mentee relationship, but it was informal. They could relate with what you were going through in your personal or student life.”

The Pros and Cons of Academic Proximity

Student learners felt the academic proximity to their peer instructors facilitated the learning experience by creating a safe learning climate. “Lowering that level of formality made it easier to feel okay making mistakes and asking questions. If there was a physician in the room, even if they were approachable and made it comfortable, there is always a hierarchy.” However, it was also perceived by learners to negatively impact the learning experience in two ways. The first, by making the learning climate excessively comfortable it lowered the drive to prepare each week: “If I’m being honest, I didn’t prepare for the sessions, as much as I should have.” The second, by the perception that peer instructors’ effectiveness was negatively impacted by their limited clinical experience: “If we ran into problems, peer instructors lacked experience to troubleshoot or comment on the clinical importance of maneuvers.”

The Importance of a Longitudinal Teaching Experience Coupled with Faculty Mentorship

Peer instructors found both the longitudinal course experience and faculty mentorship to be important formative components of their participation. One instructor reflected, “Seeing your students go from feeling clueless, daunted, and intimidated, then watching them grow over the course of these weeks and being comfortable and getting to a level where they understand much more than they did at the beginning, it’s humbling to be the catalyst for that growth.” And, over time, “I learned how to communicate better, give instructions in a direct way, and not convey unnecessary information.” Peer instructors commented that interacting with faculty mentors each week was critical to honing their exam and teaching skills over the course: “They explained them in a way that makes sense… I appreciate how great of role models the faculty are for medical education and clinical skills.”

Discussion

The PAL hybrid design was well received by learners and many of the themes which emerged from our qualitative evaluation are consistent with the literature supporting the effectiveness of PAL [3, 4, 11]. The longitudinal nature of this course led to key observations into what peer instructors and student learners value from the PAL experience, namely, strengthening of community and the ability to grow together as the instructor-learner unit. The peer instructors attributed much of their positive experiences with PAL to personal growth and the growth they observed in their students. Our evaluation noted symbiotic growth in the student–teacher unit, with the peer instructor competence in physical exam skills and teaching becoming foundational to the positive experiences of the students who valued the tailored instruction and safe learning climate.

We also identified elements of PAL perceived to negatively impact the student learner experience. Peer instructors may create an overly comfortable learning environment, thereby lowering the pressure to prepare and limiting attainment of PE skills. Additionally, there was the perception that peer instructors were limited by their lack of clinical experience. These factors may be partially mitigated through the partnership of peer instructors with faculty co-instructors. Faculty co-instruction can balance the limited clinical experience of peer instructors and elevate the expectations for weekly preparation, thereby assuaging the student fears of receiving an inferior learning experience.

PAL is an effective pedagogical modality with important benefits to peer instructors and student learners. As it is increasingly used in UME, a deeper understanding of its benefits and limitations becomes essential. Through evaluation of this PAL hybrid PE course, we identified factors that positively and negatively impacted the experience of both peer instructors and student learners. Faculty co-instructors partnered with peer instructors may offset some limitations of PAL. Optimizing the balance of the social connectedness and safe learning climate provided by peer instructors with the clinical experience of faculty instructors remains a future consideration for study.