MD Students Research Peer-assisted Learning in YSM's Physical Exam Course

When the COVID-19 pandemic reduced the number of faculty available to teach Yale School of Medicine’s (YSM) in-person Physical Exam (PE) course in 2021, then first-year MD students Madisen Swallow, MS, and Mitchel Wride saw it as an opportunity to study the peer-assisted learning (PAL) pedagogy. Swallow describes how one day after class she and Wride were talking with their peer instructor, who mentioned how different the course was when she took it pre-COVID. “This conversation sparked the idea that we could investigate the impact of this difference,” Swallow recalls. So, while they were taking the reworked course, Swallow and Wride decided to formally analyze how well the new methods worked.

Most literature on PAL focuses on students acting as supplementary, short-term instructors; a redesigned PE course provided the opportunity for a nine-week longitudinal study of the teaching approach. Swallow and Wride’s research recently was published in Medical Science Educator—"Peer-Assisted Learning in a Longitudinal Hybrid Physical Exam Course”—which they co-authored with their faculty mentor Joseph Donroe, MD, MPH, associate professor of medicine (general medicine) and director, Physical Exam Course, for Yale Medicine. “I am really proud that this research was designed, implemented, and driven to completion by Madisen and Mitch,” Donroe says.

Traditionally at YSM, a faculty member teaches PE to the same small group of students each week. When Swallow and Wride were taking the course, an upper-level student peer instructor served as the primary instructor for the learning group, with a faculty member as co-instructor. A student needed to have passed their first-year PE course and completed their core clinical rotations to serve as a primary instructor.

Each week, peer instructors met for 75 minute with the same two groups of four student learners and, afterwards, emailed faculty co-instructors, updating them on the material covered, learner progress, and maneuvers that would benefit from further explanation. Later in the week, the faculty co-instructor met with the student learner groups on Zoom, without the peer instructor present. Additionally, each week, peer instructors received in-person mentorship from course leadership to discuss PE and teaching techniques.

At the end of the course, all student learners were surveyed and asked to rate how well the course facilitated learning, and a sampling of student learners and peer instructors were interviewed to gather qualitative information. With a 70% survey response rate, 99% of student learners found the course organization conducive or very conducive to learning. This was better than the 91% conducive/very conducive response rate from the prior year, when only faculty taught the course.

Swallow and Wride interviewed eight of eleven peer instructors, all of whom described their experience as positive, as well as a student learner from 10 of the 11 learning groups. Eight student learners described the PAL hybrid design as positive, one expressed neutral feelings, and one provided a negative assessment. Additionally, while three of eight peer instructors were interested in medical education prior to teaching in the course, seven were interested afterwards. Seven of ten student learners said they would apply to be a peer instructor in the future.

In the interviews, peer instructors attributed much of their positive experience to personal growth and observing their students growing, finding weekly interactions with faculty mentors to be critical to honing their exam and teaching skills. One peer instructor shared, “I appreciate what great role models the faculty are for medical education and clinical skills.” As a first-year student at the time, Wride had not put much thought into the experience of the peer-tutors, and “was surprised by the substantial impact of the course on the tutors, not only reflecting but shaping their career aspirations.”

In their published article, the authors state, “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.” One student instructor said, “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.” Additionally, learners felt comfortable asking questions. As one explained, “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, some learners thought the model took away from the learning experience. As the authors write in their article, “by making the learning climate excessively comfortable it lowered the drive to prepare each week,” quoting an interview response: “If I’m being honest, I didn’t prepare for the sessions as much as I should have.” Moreover, the peer instructors’ limited clinical experience factored into the negative feedback: “If we ran into problems, peer instructors lacked experience to troubleshoot or comment on the clinical importance of maneuvers.”

The authors surmise that the negative factors “may be partially mitigated through the partnership of peer instructors with faculty co-instructors.” They write, “The presence of 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.” Donroe expanded on this idea: “Partnering in this scenario would include peer teaching as the foundation, but learners should have some independent time with faculty to support their learning—whether remotely or in person.”

The most important outcome of the study for Donroe “is the idea that all participants seem to benefit when there is a thoughtful combination of peer learner, peer instructor, and faculty.” Wride finds one of the most important and novel parts of their study is the insight into the advantages of a hybrid course: “While PAL has been studied in the past, we found that some of the disadvantages of this learning method can be offset when peer tutors and faculty instructors work together.”

Many students participated in interviews, says Swallow, “purely out of kindness and support of our research and hopes to improve our curriculum for the future.” This reinforced for her “what a great student community we have here at Yale.” Swallow also is grateful for Donroe’s mentorship “from start to finish. We came to him with a small idea and he helped us create a strong foundation that our entire project grew from.”