Effectiveness of peer-assisted teaching of medical English skills to non-native English-speaking medical students

Background Peer-assisted learning has been shown to be constructive in numerous aspects of undergraduate medical education. The purpose of this study was to evaluate the effectiveness of peer-assisted teaching of medical English skills to non-native English-speaking students. Methods A medical English conversation course was conducted at Damascus University by a group of students. Targeted participants were intermediate level fellow students from the same program. A longitudinal study was carried out between 1 st to 31 st March 2019 to assess changes in self-assessment of English language skills among course participants. Pre- and post-course appraisal involved a review of previous experience with medical English language, a self-assessment of five English language skills, and an objective measurement of medical English knowledge. In addition, participants were requested to respond to a set of statements related to the importance and the usefulness of peer-assisted teaching of medical English skills. Paired-sample Student t-test was used to compare pre- and post-course appraisal results. Results 42 students attended the course and completed pre- and post-course appraisals in full. Data analyses showed a statistically significant increase in participants’ confidence in speaking medical English in public ( p<0.001) and using English in various medical settings (presenting and discussing cases, writing clinical reports, interviewing patients and reading English medical texts). Objective measurements of medical English knowledge confirmed a significant increase in participants’ knowledge of methods of administration of therapeutics, knowledge of human body parts in English and familiarity with English medical abbreviations. Most participants agreed that peer-education was effective in teaching medical English skills to non-native English-speaking students and in increasing their confidence when using English in real-life medical scenarios. Conclusions The present study highlights the effectiveness of peer-assisted teaching of medical English skills to non-native English-speaking medical students. Further validation is required and should compare the effectiveness of traditional versus peer-assisted teaching approaches.


Introduction
English continues to be the language of choice for medical teaching, conferences, and publishing.Graduates of overseas medical schools that teach medicine in native languages and wish to practice medicine in English-speaking countries are confronted with the multi-faceted challenge of having to interact with local patients using customary colloquial jargons, and to interconnect with peers with accurate medical vocabulary as well [1][2][3] .Moreover, a multitude of English linguistic skills ought to be acquired in order to be able to obtain up-to-date knowledge, perform state of the art treatments and communicate with an increasing number of international colleagues, the most demanding of which may be writing and presentation skills which are also necessary for success and progression in academic medicine [4][5][6][7] .Several strategies have been proposed to help non-native English-speakers improve their English language skills, such as engaging in verbal exercises, one-to-one sessions with faculty members, academic writing support workshops and the development of interactive computer-simulation materials [8][9][10][11] .
Peer-assisted learning (also known as 'peer-education') is the method of exchanging knowledge between people who are at a similar stage in their academic education 12 .Teachers and students in this setting share similar knowledge base, learning experiences, and social roles.This helps selecting the most appropriate teaching means and promotes student leadership 13,14 and has been shown to be constructive in numerous aspects of undergraduate medical education 15 .
The aim of this project was to evaluate the effectiveness of peer-assisted teaching of medical English skills to non-native English-speaking students from the Clinical Sciences program at the Faculty of Medicine, Damascus University.An earlier version of this study can be found on ResearchSquare 16 .

Ethical statement
The study protocol was approved by the Research and Ethics Committee at the Faculty of Medicine, Damascus University (ref 3/Med/2019).Before course commencement, informed consent to participate and for publishing this study were signed by all course participants who were all above the age of 16 years.Participants' data was protected by removing all identifying information before data is transferred and reviewed, and by implementing robust data security standards.The Medical English Conversation course was also approved by the undergraduate dean prior to implementation.

Study design
This was a longitudinal study using a within-subjects design to assess changes in self-assessment of English language skills among course participants.

Study setting
This research project was carried out at the Faculty of Medicine, Damascus University, which runs a six-years' undergraduate program in Medicine.This program is divided into three years tutoring in basic sciences (biology, chemistry, physics, psychology, and sociology) followed by three years training in clinical sciences, upon completion of which a Doctor of Medicine degree is awarded.
A group of final year medical students from the Clinical Sciences program designed and conducted a dedicated Medical English Conversation course.This was based upon prior experience with peer education courses at the Faculty of Medicine, with input from an experienced English-speaking faculty member (MBI).Targeted participants were fellow fifth and sixth year medical students from the Clinical Sciences program. 12 topics were selected to make up the course curriculum, which are:

Amendments from Version 1
We have revised the manuscript as follows: -Some language editing was carried out according to the recommendations of the reviewers.
-We added information on how the questionnaires were constructed and validated by facilitators who checked the conformity of questions with set course targets (under 'Course admission and conduct').
-We have added details of our holistic review that we used in the selection of course participants (under 'Course admission and conduct').
-The exact tool used in the measurements of medical English knowledge was described (under 'Results') which involved using a set of questions that were far from the self-assessment of competence.
-We highlighted the difficulty in analysing or drawing attention to patient satisfaction as an important outcome of this program (under 'Study limitations'), and described our approach using peer-to-peer simulation.• Familiarity with a list of English medical abbreviations (Figure 1)

Any further responses from the reviewers can be found at the end of the article
Self-report of familiarity with a list of English medical abbreviations.

Course admission and conduct
The Medical English Conversation course was publicized on social media, and interested applicants were required to complete a three-elements pre-admission appraisal.The first element was a self-assessment of five English language skills (case presentation, writing a clinical report, explaining details to patients, familiarity with sections of a research paper, and reading an English medical text).The second element was a review of previous experience with medical English language (attending medical English courses, public presentations in English, electives in an English-speaking country, clinical rounds or history-taking, writing research projects or reading English articles).For this element, the five-point Likert scale was used to measure attitudes directly, with one referring to 'very uncomfortable' and five referring to 'very comfortable'.
The third element was an objective measurement of medical English knowledge (knowledge of methods of administration of therapeutics and human body parts in English) along with a self-report of familiarity with a list of English medical abbreviations.For this element, applicants were asked to indicate terms that they are familiar with from given vocabulary [Table 1, Figure 1-Figure 2].This questionnaire was validated beforehand through distributing it among a group of medical students who did not join the course, but whose English language is very good according to external placement tests at local English language institutes.The questionnaire was then reviewed by facilitators who checked the conformity of the questions with set targets.
The selection of course participants was based on this appraisal and admission was focused on 'intermediate level' applicants according to external placement tests at local English language institutes which had to be taken no more than one year before joining the course.There were no cutoff scores of students in our questionnaire or cutoff scores in other standardized English evaluation tests such as TOEFL or IELTS, but we rather did a holistic review of the applicants in order to select candidates with sufficient basic English skills to enroll in the course.Accepted applicants were then requested to respond to a set of statements related to the importance of medical English skills for doctors from non-English-speaking countries.The five-point Likert scale was used to measure attitudes directly, with one referring to 'strongly disagree' and five referring to 'strongly agree'.
Participants were organized into groups of four to five students, and each group was assigned a final year medical student from the Clinical Sciences program who was deemed to have appropriate English language experience to qualify as a 'peer-teacher'.This required having attended a four-weeks' clinical elective at the American University of Beirut Medical Center (conducted in English), in addition to achieving at least an upper-intermediate level in the standardized English tests of the Damascus University Languages Center.In addition, every peer teacher was enrolled in a one-day-training on facilitation, motivation and general considerations in teaching English language.The course took place between the beginning of April and end of May 2019.All sessions were held in university lecture rooms except for one 'field session' which was held at the university hospital to allow practical application of given concepts.Each session lasted 90 minutes and incorporated interactive teaching methods (workshops, group discussions, role-playing scenarios, etc.).In addition, daily medical topic discussions were held on social media (a Facebook group) among all course participants.Each participant was required to write one communication every week relating to a chosen topic, and other participants were asked to discuss those topics and comment in writing.
Upon completion of the course, participants were asked to re-fill the three-elements' appraisal and to respond again to the previous set of statements.In addition, participants were requested to respond to a set of statements related to the usefulness of peer-assisted teaching of medical English skills in real life scenarios [Figure 3].The five-point Likert scale was used again to measure attitudes directly, with one referring to 'strongly disagree' and five referring to 'strongly agree'.

Results
84 students from the Clinical Sciences program applied to the Medical English Conversation course and completed the pre-admission questionnaire, of whom 48 were accepted to the course and attended all sessions.42 students (87.5%) completed both pre-admission and post-course appraisals in full and they comprised our study group, while four students did not finish the course due to transportation issues and two due to personal reasons.Demographics and pre-admission appraisals are shown in Table 2. Most participants (85%) projected their English language skills to be intermediate or good.Even though 45% of them had previously attended general English language courses, experience with medical English was largely limited to reading articles written in English.
Answers to the five-point Likert scale before and after the course were compared using the paired-sample t-test.This showed a statistically significant increase in participants' confidence in speaking medical English in public, with an increase in the percentage of students responding 'comfortable' or 'very comfortable' from 26% prior to attending the course to 50% afterwards (p<0.001).Similarly, self-assessments of participants' confidence in using English in other medical settings (presenting and discussing cases, writing clinical reports, interviewing patients, and reading English medical texts) showed a statistically significant increase in students' confidence levels [Table 3].
Given the unavailability of standardized and objective tests of medical English language skills (such as the OET medicine) in our country, we attempted to use a set of questions in our pre-and post-course questionnaire that are far from the self-assessment of competence, such as identifying correct medical terminologies.This fairly objective measurement of medical English knowledge confirmed a significant increase in participants' knowledge of methods of administration of therapeutics and of human body parts in English.In addition, participants reported better familiarity with a list of English medical abbreviations [Table 4].
Changes in responses to the set of statements among course participants are shown in Table 5. Students unanimously agreed that medical English skills are necessary for doctors in non-English speaking countries.Importantly, most course participants (88%) agreed that peer-education was effective in teaching medical English skills to non-native English-speaking students and in increasing their confidence when using English in real-life medical scenarios [Table 6].No significant correlation was found between students' demographics or previous experiences and any of the responses.

Discussion
The demand for medical English education in countries where medical school instruction is carried out purely in native languages has been rising with globalization 10 .Conducting medical education purely in native languages is believed to lessen graduates' ability to absorb and to contribute to scientific advances, and to hold back opportunities for international collaboration among physicians and researchers 17 .On the contrary, a sound medical English curriculum can support students' lifelong independent pursuit of medical knowledge.Consequently, proficiency in medical English grew to be a crucial pre-requisite for medical graduates 18 .
Medical English education in our country has traditionally been conducted through didactic lectures, focusing on basic medical terminology as well as on reading and writing skills.This method, however, is ineffective in promoting English communication and may decrease students' motivation 10 .As a result, recent guidelines concerning medical English curriculum development called for a shift from repetition and mastering grammar toward an emphasis on functional, communication-oriented teaching and the development of listening and speaking skills 19 .
Peer-assisted methodologies have been utilized successfully for teaching certain medical skills, such as basic life support and basic surgical skills 20,21 , and it has been shown that medical students perceive peer-teaching to be appropriate and beneficial when implemented in medical education 22 .For example, a previous study showed that students preferred to discuss conceptual problems with peers who were closer to them than with faculty teachers who may not understand their reasons for difficulty with a subject matter, or who might have limited interest in communicating with novices 23 .Peer teachers were able to create a comfortable and safe educational environment, provide access to role models, and enhance intrinsic motivation to study 23 .
Literature pertaining to peer-assisted teaching of medical English skills remains very limited 24 .The present preliminary study validates the effectiveness of peer-assisted teaching of   medical English skills to non-native English-speaking medical students.The Medical English Conversation course focused on motivating students to learn English by sharing experiences, creating opportunities and helping them envisage themselves in a clinical environment.The course attempted to familiarize participants with medical English terminologies in line with words used in colloquial jargon as this would support effective communication with both patients and colleagues.Peer education was appropriate for this purpose.
Participants not only understood the terminologies but were also able to explain them to their peers during their presentations using simple terms.This is likely to reinforce better understanding and retention of knowledge 24 .Similar to previous reports 24 , our study shows that participants' knowledge of English medical terminologies and abbreviations increased significantly, with a substantial improvement in participants' confidence in using English in various real-life medical settings, including presenting and discussing cases, writing clinical reports, interviewing patients, and reading English medical texts.

Study limitations
One limitation to this study is the lack of objective evaluations of medical English skills, and the use of subjective changes in self-assessments among course participants to validate the effectiveness of peer-assisted teaching.An inherent bias may exist in this methodology as enthusiastic participants are likely to report an increase in their confidence in using English immediately following the course.This does not take into account the decay of information over time where early enhancements do not translate into actual improvements in English language skills later on or when put into real hospital environment.
A second limitation is that it was difficult to analyze or draw attention to a key outcome of all medical programs, which is patient satisfaction, but this was not possible as the patient population is non-English speaking.Hence, our assessment was carried out using peer-to-peer simulation rather than getting real-time feedback from actual patients.
Finally, this study was conducted in a country where medical students are prominently engaged in foreign language learning activities in order to advance their immigration potential.Further studies are needed to establish the effectiveness of peer education and its application in other societies where medical students may not be so enthusiastically engaged in English language learning activities.

Conclusions
The medical profession is becoming even more competitive, embracing scholar-centeredness and continued learning pursuit.The present preliminary study verifies the effectiveness of peer-assisted teaching of medical English skills to non-native English-speaking medical students.Further validation is required and should implement objective evaluations of medical English skills, both within-subjects and between-subjects, and should compare the effectiveness of traditional versus peer-assisted teaching approaches.
This project contains the following extended data: • MEC registration form.pdf. (Blank copy of MEC form).
focusing on basic medical terminology as well as on reading and writing skills."This is kind of outdated.A lot has progressed in Medical English teaching in recent decades, with the integration of web technologies and innovative methodologies.
"A second limitation is that it was difficult to draw attention to hard outcomes, such as patient satisfaction, as the patient population is non-English speaking, which makes the validation of the tool hard to achieve."Unclear.Please elaborate.

Anne D Souza
Department of Anatomy, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India I would like to commend the authors of this longitudinal study for analyzing the impact of 'peerassisted teaching' on the English language skills of non-native English-speaking students.The study has a precise aim and methodology, and its results are reported accordingly.I find the topic exciting and relevant, as it addresses the language improvement needs of the target group.
While the pre-post test approach used in the study provides elaborative information on the results, I suggest that the authors add information on how they validated the questionnaires.It would be helpful to know who constructed and validated them and if any pilot work was conducted.
Moreover, I noticed that a small percentage of students disagreed with most statements about the importance of medical English skills.It would be beneficial to understand their reasons better by including open-ended response questions in future studies.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? No
If applicable, is the statistical analysis and its interpretation appropriate?Yes

Have any limitations of the research been acknowledged? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Simulation, 3D printing in medical education, ethics in medical education, designing and planning learning I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

11 -
Abstracts and research articles 12-Presentation skillsThese topics were organized into eight sessions, each lasting 90 minutes, to be delivered over four consecutive weeks.

Figure 1 .
Figure 1.Participants were asked to check medical abbreviations and parts of the body which they are familiar with.

Figure 2 .
Figure 2. Self-assessment of comfort and confidence in several areas.

Table 1 . The three-elements' pre-admission appraisal. Element Contents
Data was entered in Microsoft Excel 2020 and exported to IBM SPSS v.26 (https://www.ibm.com/spss) for both descriptive and inferential statistical analysis.PSPP software application (http://www.gnu.org/software/pspp/) is also able to run the same analysis in this study.Paired-sample Student t-test was used to compare pre-admission and post-course self-assessments of English language skills.Independent sample Student t-test and ANOVA tests were used to correlate responses with students' demographics.Statistical significance was indicated by p<0.05.

Table 4 . Objective measurements and self-reports of English knowledge before and after the course.
* paired-sample t-test

the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Have any limitations of the research been acknowledged? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? No Competing Interests:
No competing interests were disclosed. ○Is

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work.The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions.