Peer Teaching in Undergraduate Medical Education: What are the Learning Outputs for the Student-Teachers? A Systematic Review

Introduction

Peer teaching, defined as teaching performed by “A person who is the same age or has the same social position or the same abilities as other people in the group” is being used worldwide both in undergraduate and postgraduate medical education.^1,2 Studies have shown that students learn as much from being taught by peers as they do from expert teachers.^3,4 In addition, it has been argued that the social and cognitive congruence that characterize the student-learner and student-teacher relationship creates psychological safe learning spaces, mutual understanding of difficulties and customized models for explaining the learning content.^5–7 Also, it is argued that peer teaching alleviates teaching pressure for faculty.⁶

Whitmans description of “teaching as learning twice” from 1988^8,9 suggests that peer teaching also benefits the student-teacher. Previous studies point to improved written and/or practical examination scores for students that were teaching peers in basic sciences,¹⁰ participated in a small-group based Gastroenterology/Hematology course where they alternated being group facilitators¹¹ and students acting as student-teachers in musculoskeletal ultrasound interpretation compared to their same year peers.¹² Burgess et al¹³ found that the benefits of peer teaching for the student-teacher can be described in two main categories: Development in understanding of knowledge content and development of professional attributes. The two categories include increased awareness of facilitation, teaching and feedback techniques, leadership qualities, confidence, open-mindedness and autonomy. Finally, a review conducted in 2020 by Bower et al¹⁴ documented opportunities for student-teachers to consolidate their own learning while contributing to the medical school community. However, the 2020 review focused on informal near peer teaching and not formalized peer teaching initiatives.¹⁴ For peer teaching to have positive learning outputs for the student-teacher, the literature highlights the need for teacher training and support from faculty.¹⁵

Many of the competencies used to evaluate learning outputs of student-teachers are reflected in medical curricula worldwide as part of the CanMEDS framework designed by the Royal College of Physicians and Surgeons of Canada. CanMEDS identifies and describes the competences required of medical doctors to meet the health care needs of patients. The competences are organized under a set of roles: medical expert, communicator, collaborator, leader, health advocate, scholar and professional.¹⁶ This framework enables us to organize the potential learning outputs gained from peer teaching and to explore how being a peer teacher can facilitate the development of core competencies among student-teachers.

While the CanMEDS framework provides a useful basis for identifying key competencies, systematizing the available knowledge about learning outputs of student-teachers is challenged by overlapping definitions of peer teaching in the literature. Peer teaching is often used as an umbrella term including both collaborative learning, peer-assisted learning, near-peer teaching, teaching assistants, peer and near-peer supervision, mentoring and more. As a result, the student-teachers role can become unclear as it can both entail being a collaborative resource for fellow students within the same program and having a dedicated role as an educator for same level or more junior students. While recognizing that the role of an educator might entail assessment, feedback and supervision, we limited our screening to studies that described teaching activities where students had a clear and formalized role as an educator. This means that peer assessment, peer feedback and reciprocal learning activities, where peers take turns teaching each other or engage in group learning activities, were excluded. While previous reviews have focused more broadly on the effectiveness of peer teaching, this systematic review focuses on the learning outputs for student-teachers in formalized peer teaching settings. To further limit our review, we focused on undergraduate medical education, thus excluding postgraduate education, residency training and interdisciplinary studies. Previous reviews provide sufficient summaries of evidence prior to 2012,¹³ hence, we limit our review to qualitative and quantitative studies focusing on learning outputs for student-teachers published between 2012 and 2022. Knowledge regarding outputs of peer teaching for the student-teachers might help medical faculties design peer teaching regimes with benefits for all the parties involved. Thus, our aim was to describe what learning outputs student-teachers have from peer teaching, and map what research methods are used to assess these outputs.

Materials and Method

To achieve our aim, a systematic search in four databases was conducted. The findings from the studies were summarized in tables, and the results were set up against CanMEDS framework.

The literature search was conducted during October and November 2021, and updated in November 2022, in Embase, ERIC databases, MEDLINE and PubMed. The search was conducted using search terms: “near peer teaching”, “peer assisted learning”, “peer mentor”, “peer tutor” and “peer teacher(s)”, additionally the search was restricted to undergraduate medical education (Table 1). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 2020 was used as a guide to record the review process (Figure 1).¹⁷ All articles were retrieved in the bibliography management program EndNote X9. Duplicates were removed before the remaining articles were uploaded in Rayyan AI where the articles were screened using the inclusion and exclusion criteria outlined below (Table 2). The inclusion and exclusion criteria were developed based on our aim to gather information about student-teachers at undergraduate medical education level.

Table 1 Search Terms and Keywords Used in the Literature Search

Table 2 Inclusion and Exclusion Criteria for Screening of Articles

Figure 1 Flow chart displaying the whole process of assessing and selecting articles for this review.

One reviewer (first author) screened all the 668 articles that were retrieved in the original search, whereas the co-authors (four researchers from University of Bergen, and three researchers from Karolinska Institutet) screened approximately 100 articles each, ensuring a double blinded review process. Conflicts were resolved by discussion between four of the authors (MAT, TM, MK and HHA). Out of 668 records, 100 articles were contained initially and subjected to full-text screening. After the initial full-text screening and data extraction 40 articles were selected. After the updated search 45 articles were included in this review as the final material.

To ensure reliable and valid data, the quality of the quantitative studies included was evaluated by two reviewers (MAT, IGS) using The Medical Education Research Study Quality Instrument (MERSQI).^18–20 The instrument is based on 10 items, reflecting six domains of study quality: (1) study design, (2) number of institutions studied and response rate, (3) data type, (4) validity evidence for evaluation instrument, (5) data analysis sophistication and appropriateness, and (6) outcome level. The maximum domain score is 3, and a minimum of 0–1, producing a potential range of 5–18 MERSQI scores.²⁰

The results were critically synthesized by multiple reviewers using categories based on past literature and CanMEDS framework. The findings from the studies are summarized in tables, giving an appropriate schematic informative focus to this review.

Results

A total of 45 articles were included in the review. Table 3 gives an overview of the included articles and presents each publication with authors, quality assessment using MERSQI score, country of origin, number of student-teachers and student-learners, study design, and teacher training intervention. Furthermore, dimensions of teaching encounters are described using three subcategories: frequency and dimension, group size and teaching subject. The last category reports learning outputs for student-teachers and what methods that were used to assess the outputs.

Table 3 Schematic Overview of Included Articles

Description of the Student-Teachers

The included studies describe peer teaching activities set in 14 different countries with the USA, Australia and the UK as the most predominant. Student-teachers in the articles reviewed were recruited from all levels of medical school. Most of the studies reported having a one-year gap between the student-teachers and student-learners. Number of student-teachers included in the studies ranged from 3 student-teachers⁵⁵ to 481 student-teachers,³⁵ and number of student-learners included in studies ranged from 5 student-learners⁵⁵ to 1053 student-learners.⁴²

Anatomy, clinical skills and communication were the most frequent subjects taught by the student-teachers. The amount of teaching sessions varied in frequency from only one teaching session⁴⁸ to 26 sessions.⁵⁷ They also varied in duration from 30 minutes^51,60 to 4 hours.⁵³ Furthermore, peer teaching was deployed in various group sizes of learners ranging from 4 students in the smallest group^47,49 to 25 in the biggest group.⁴⁸ Some articles did not specify group sizes.

Reported Learning Outputs

Most of the studies reported multiple learning outputs for the student-teachers (see Table 4). In the following section, outputs for the student-teachers are reported in four domains set by the reviewers based on previous literature and CanMEDS framework: subject-specific learning outputs, pedagogical knowledge and skills, personal outputs and generic skills.

Table 4 Overview of Studies Reporting Types of Learning Outputs

Subject-Specific Learning Outputs

Several studies reported that student-teachers increased their learning about the content they were teaching. Additionally, improved skillset and technical performance were also frequently reported. One article reported better results in objective structured clinical examination (OSCE)³⁹ and another article reported better results in anatomy examinations.²¹ Furthermore, two articles reported that student-teachers felt better prepared for OSCE after completing the peer teaching program.^38,41

Pedagogical Knowledge and Skills

Improved pedagogical knowledge and skills were reported in several articles, where student-teachers reported developing better understanding and awareness of the teaching process and feedback strategies. In one study the student-teachers reported improved teaching skills, which they in turn considered helpful to their future roles as residents and attendings within the field of surgery.⁴³

Personal Outputs and Generic Skills

Many of the studies found teaching activities to be useful related to personal outputs such as confidence, self-awareness and courage. In one longitudinal mixed method study within anatomy, student-teachers reported strengthened confidence, optimism and resilience.²⁴ In several studies, student-teachers thought of the experience as helpful in improving their generic skills such as communication, teamwork, leadership and becoming role models for their junior peers. The teaching experience was also considered as supporting students’ professional identity formation.^55,57,64

Three studies reported unwanted outputs of peer teaching.^29,30,34 Two of those found that student-teachers experienced lack of control and authority.^29,30 One of the three studies found that student-teachers felt uncomfortable teaching their peers due to the lack of necessary skills.³⁴ The authors suggested that this is likely caused by student-teachers receiving inadequate training before taking on the teacher role.³⁴

Methodological Quality of Studies

Quality Assessment

All the included quantitative studies were quality assessed using MERSQI. The scores ranged from 6 (lowest)^50,58,64 to 13 (highest),^22,40 and the average score for all the included quantitative studies was 10. As eight of the studies reported qualitative research, they were not subjected to MERSQI score assessment.^{26,27,32,33,48,49,55,57} No articles were excluded based solely on their MERSQI score.

Study Design

A mixed-method study design was used in 67% (30/45) of the included studies, with qualitative and quantitative data extracted from student-teacher(s) and/or student-learner(s). Qualitative study design was used in 18% (8/45) of the studies, and 16% (7/45) had a quantitative study design. As shown in Table 5, most of the studies included in this review used self-reported data to gather information about learning outputs from peer teaching experiences. Questionnaires and interviews were the most frequently used data collection methods. Most questionnaire-based studies included closed-ended questions with Likert scale response options, whereas some also used open-ended questions or comments to collect qualitative data. Six studies included external data sources such as exams, practical/oral exams, and evaluation by student-learners.

Table 5 Overview of Studies Reporting Learning Outputs for Student-Teachers Using Various Data Sources

Relation Between Learning Outputs and Data Source of Studies

Among studies using self-reports as data source, 61% (25/41) reported subject-specific learning outputs, 49% (20/41) reported learning outputs related to pedagogical knowledge and skills, 34% (14/41) reported learning outputs related to personal outputs and 44% (18/41) reported learning outputs related to generic skills. Of the studies using external data sources, 4/6 reported subject-specific learning outputs, 4/6 reported increased pedagogical knowledge and skills and 1/6 reported learning outputs related to personal outputs.

Discussion

This review included findings from 45 different studies published 2012–2022 on student-teachers in undergraduate medical education.¹³ In line with previous review (including 19 articles published before 2012), we found improved learning outputs for student-teachers within several domains, including better knowledge retention, improved skills, improved leadership, improved communications capabilities and increased confidence.¹³ Most of the evidence available was based on qualitative interview data or survey responses, whereas only six documented learning outputs using external data such as students’ exam results.^{21,23,28,39,44,61} We found limited, but encouraging, evidence suggesting that peer teaching programs enhance student-teachers’ performances on exams. In most cases, senior students have already passed their exams in the courses in which they later teach junior students and seldom retake the exam after having functioned as student-teachers. Therefore, comparable knowledge or skills tests are available only in designs where students are teaching fellow students and are taking the same exam, as was done in the study by Aguis et al,²¹ or in a retrospective cohort study design such as Iwata et al.³⁹ Furthermore, final exam scores might not include testing in the topics where student-teachers have gained peer teaching related learning outputs.

We found that student-teachers tend to rate themselves higher than non-teaching students on competence areas in the CanMEDS framework related to academic knowledge. However, research suggests that student-teachers do not perform better on final exams compared to other academically well-performing students who do not participate as student-teachers, thus suggesting that students’ academic knowledge obtained by being student-teachers, can be explained by a recruitment bias rather than a peer teaching effect itself.⁶¹ The evidence base for other competence areas in the CanMEDS framework, is somewhat different. The CanMEDS framework recommends physicians to promote a culture that recognizes, supports and responds effectively to colleagues.¹⁶ By being a student-teacher, students become role models for their junior peers, thereby promoting the mentioned culture.⁵ Furthermore, professional skills such as skills in leadership, communication, feedback and collaboration are all part of the CanMEDS framework.¹⁶ Amongst the 45 studies we reviewed, 31 articles reported positive learning outputs related to confidence, leadership skills and professional attributes. However, only one article used the CanMEDS framework to assess student-teachers.⁶¹ In 14 of the articles included, peer teaching was associated with increased confidence, which is considered important for the professional development of physicians⁶⁶ and for reduced feelings of imposter syndrome.⁶⁷ In line with previous reviews, we identified increased learning outputs in similar domains of CanMEDS framework as a result of being a student-teacher.¹³ A judicious suggestion may therefore be to encourage medical schools to expand teaching and learning opportunities for student-teachers and facilitate the development of their CanMEDS competencies by incorporating peer teaching into their curriculum. This approach would provide a platform for students to enhance their leadership and teaching skills, which are critical components of the CanMEDS framework.^6,13

Three articles presented negative outputs of being a student-teacher such as lack of authority due to teachers and student-learners being at the same level,^29,30 and feeling uncomfortable teaching their peers due to the lack of necessary skills.³⁴ Despite being reported as a negative experience for the student-teachers, the lack of authority and social congruence associated with peer teaching is elsewhere highlighted as one of the key explanations as to why peer teaching works.⁶⁸ Negative experiences can likely be avoided with proper training in learning facilitation and group management, clarification of expectations and attention given to building mutual respect in the student-teacher and student-learner relationship.⁶⁹

Future research could consider developing theory-driven designs that test students’ capabilities in all physician roles. Validated tools for assessing professional skills are readily available, yet infrequently used to test learning outputs of peer teaching for the student-teachers.⁷⁰ Research should look at the methodological approach of peer teaching programs including recruitment, training interventions, design and content. A deeper understanding of the factors contributing to successful student-teacher practices and outputs has the potential to inform a discussion on how peer teaching activities can be applied more systematically in undergraduate medical education programs, thus securing learning benefits for all parties involved.

Strengths and Limitations

Although we did a thorough search in four databases, our findings are likely inexhaustive due to our exclusion of articles not available in full text, not published in English or not matching the search string. Furthermore, unpublished and/or grey literature was not included. To decrease the risk of bias, eight independent reviewers screened the articles using “blind mode”.⁷¹ The results were critically synthesized and interpreted by multiple reviewers to enhance the validity of our findings.

Conclusion

Results from this review indicate that serving as a student-teacher during undergraduate medical school is likely to strengthen subject-specific learning outputs, pedagogical knowledge and skills, personal outputs and generic skills. Peer teaching has the potential to foster professional development in many of the competencies outlined in the CanMEDS framework including communication, collaboration, leadership and health advocacy. Hence, peer teaching programs may be strategically planned and designed to enhance learning outputs for all parties involved, including student-teachers.