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

Figures & data

Table 1 Search Terms and Keywords Used in the Literature Search

PubMed	Embase, ERIC Databases and MEDLINE
In PubMed the search was conducted using search terms: “near peer teaching”[Title/Abstract] OR “peer assisted learning”[Title/Abstract] OR “peer mentor”[Title/Abstract] OR “peer tutor”[Title/Abstract] OR “peer teach*”[Title/Abstract] combined with search terms “Education, medical, undergraduate”[MeSH Terms] OR “undergraduate medical”[Title/Abstract] using the Boolean operator AND	The search on Embase, ERIC databases and MEDLINE was conducted using search terms: “exp Medical school” or “exp Medical student” combined with search terms “near peer teaching.mp” OR “peer assisted learning.mp” OR “peer mentor.mp” OR “peer tutor.mp” OR “peer teach$.mp” using the Boolean operator AND.

Notes: *Truncation symbol in PubMed. $ Truncation symbol in Embase, ERID databases and MEDLINE. exp = “explosion”, meaning this search not only look for the subject term selected but also many related subjects. mp = “multi-purpose”, meaning this search look at several fields at once, including title, abstract, keyword, original title and heading word.

Table 2 Inclusion and Exclusion Criteria for Screening of Articles

Inclusion Criteria

Exclusion Criteria

All study participants are undergraduate medical students Quantitative and qualitative studies Empirical research where learning outputs for student-teachers are reported Studies where students have a dedicated role as student-teachers. Student-teachers may have different assignments, but studies including interchanging roles between teacher and learner are excluded Original research articles published in the last decade (2012–2022)

Programs involving postgraduates, residents or other health professions than medicine Interdisciplinary studies involving medical education students Studies involving peer assessment or peer supervision in clinical settings Reciprocal peer teaching (studies with interchanging roles between teacher and learner) Studies reporting solely on outputs for the student-learners and not student-teachers Articles focusing on student-teacher training courses Studies published prior to 2012 Full-text article not available Article not available in English Review studies, comments, letters to editor and grey literature

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

Table 3 Schematic Overview of Included Articles

Authors (Article Quality Assessment)	Country of Origin	Student-Teacher (N)	Student-Learner (N)	Study Design	Teacher Training Intervention	Dimensions of Teaching Encounter			Reported Learning Outputs and Method
						Frequency and Duration	Group Size	Subject
Agius & Stabile^Citation21 (12.5/18)	Malta	Year 1–2 (12)	Year 1–2 (191)	Comparative longitudinal study – Quantitative	No	6 sessions	Not specified	Anatomy	Student-teachers scored significantly better in anatomy spotting exam Student-teachers scored significantly better in upper limb and biomedical sciences written exam
Ahmad et al^Citation22 (13/18)	USA	Year 4 (36)	Year 3 (75)	Non-inferiority – Mixed method	Yes	1 session	Not specified	Rheumatology	Student-teachers reported deeper understanding, experience in teaching, developing skills as future educators and residents in reflective comments
Ahn et al^Citation23 (12/18)	USA	Year 4 (20)	Year 1 (155) and Year 2 (155)	Evaluation research – Quantitative	Yes	1–5 sessions	1:14; tutor tutees	Ultrasound/ Physical examination	Improved teaching effectiveness score and ultrasound skill from first to last session Student-learners evaluated student-teachers using Likert scale; students who taught more tended to have better evaluation score
Alvarez et al^Citation24 (11.5/18)	Germany	Year 2 (24)	Not specified	Longitudinal mixed method	Yes	18 months, sessions not specified	Not specified	Anatomy	Improvement in professional behavior, communication skills and gross anatomy skills reported in semi-structured interviews and questionnaire using Likert-scale Improvement in stress management, self-confidence and self-awareness reported by student-teachers
Blohm et al^Citation25 (10.5/18)	Germany	Year 3–5 (10)	Year 1 and 2 (135)	Longitudinal mixed method	Yes	2 sessions	1:20; tutor:tutees	Internal medicine	Good preparation for clerkship and development of leadership skills reported in acceptance ratings, pre- and post- self-assessment ratings and interviews
Bugaj et al^Citation26 (n/a)	Germany	Year 3–5 (10)	Not specified	Qualitative study	Yes	Not specified	Not specified	Physiology & internal medicine	Improvement in social, theoretical and cognitive skill reported in semi-structured interviews
Burgess et al^Citation27 (n/a)	Australia	Year 3 (46) and Year 4 (60)	Year 1 (50) and Year 2 (51)	Qualitative study	No	1 h session per week. 1 year	Not specified	Multiple subjects	Improved medical knowledge and teaching skills reported in focus group interviews
Cansever et al^Citation28 (8/18)	Turkey	Year 1 (11)	Year 1 (330)	Survey study – Mixed method	Yes	Not specified	Not specified	Biochemistry, medical genetics, histology and embryology, anatomy and microbiology	Improved teaching, self-confidence and benefited their own learning Student-teachers were assessed by other students on a 5-point scale.
Cho et al^Citation29 (8/ 18)	Korea	Year 2–4 (Not specified)	Year 2–4 (Not specified)	Mixed method	Yes	Not specified	Not specified	Multiple subjects	Increased motivation and self-development reported in survey and focus group interview
Chopra et al^Citation30 (7/18)	USA	Year 4 (14)	Not specified	Mixed method observational study	No	Not specified	Not specified	Ophthalmology	Improved teaching skills and benefited their own learning reported in survey and telephone interview
Clarke et al^Citation31 (7/18)	Australia	Year 3–4 (42)	Year 1–2 (66)	Mixed method	Yes	1 h × 1–13 sessions. 7 months	2:3–4; tutor: tutees	Clinical skills, professionalism	Gain in clinical skills, better preparation for exam and future job reported in Likert-scale from 1–5 and open-ended questions
Cusimano et al^Citation32 (n/a)	Canada	Year 3 (20)	Year 1 (100)	Qualitative descriptive research study	Yes	2 h × 3 sessions	1:20; tutor:tutees	Ethics, professionalism, behavior	Gain in leadership skills, adjustment in behavior online and professionalism reported in semi- structured focus group interviews
de Menezes et al^Citation33 (n/a)	Australia	Year 5 (30)	Year 3 (40)	Longitudinal qualitative study	Yes	1 h × 6 sessions	1:4–6; tutor:tutees	Multiple subjects	Gain in knowledge, preparation before internship and overall confidence reported in questionnaire prior to exam and focus group interview after the exam
Dickman et al^Citation34 (10/18)	Israel	Year 2 (4–6)	Year 1 (ca. 70)	Mixed method	Yes	Not specified	Not specified	Anatomy, ultrasound	Gain in confidence and skill reported in questionaries in quantitative Likert scale ratings from 1–5 and qualitative comments
Engels et al^Citation35 (10/18)	USA	Year 1–5 (481)	Year 1–5 (Not specified)	Cross sectional study – Quantitative	Yes	Not specified	1:5–10	Anatomy, Neuro-Physiology	Shape course for younger students, gain more knowledge and support to lower students reported in questionaries
Gottlieb et al^Citation36 (10/ 18)	USA	Year 4 (12)	Year 2 (Not specified)	Mixed method	Yes	2 h × 7 sessions	Not specified	Respiratory pathophysiology	Social-, cognitive development and increased skills in subject and teaching reported in a multiple-choice survey and reflection essay
Hall et al^Citation37 (8/18)	UK	Not specified (51)	Not specified	Mixed method	Yes	Not specified	Not specified	Anatomy	Communication skills and improved subject matter reported in questionnaire consisting of rating of 0–10 and free text.
Gandhi et al^Citation38 (8/18)	UK	Year 6 (30)	Year 5–6 (140)	Mixed method	Yes	Not specified	1:2; tutor:tutee	Pediatrics	Better prepared for objective structured clinical examination, better confidence overall and better communication reported in questionnaire using Likert scale from 1–5 and free text.
Iwata et al^Citation39 (12.5/18)	UK	Year 6 (172)	Not specified	Retrospective cohort study	Yes	Not specified	Not specified	Multiple subjects	Better results in final exam and long-station objective structured clinical examination
Khaw et al^Citation40 (13/18)	Australia	Year 6 (45)	Year 1–2 (348)	Survey study – Mixed method	Yes	Not specified	Not specified	Physical examination, history taking	Improved knowledge and better overall confidence reported on Likert scale from 1–5 and free text questionnaire
Kumar et al^Citation41 (10.5/18)	UK	Not specified (10)	Not specified (61)	Longitudinal study- Quantitative	Not specified	80 min × 6 sessions	Not specified	Orthopedic examination	Better prepared for objective structured clinical examination, less anxious and better confidence reported using pre- and post-session test and feedback form using Likert scale from 1 to 5
Liew et al^Citation42 (12/18)	Malaysia	Year 3–5 (51)	Year 1–3 (1053)	Longitudinal study- Quantitative	Yes	2 h ×4 sessions	Not specified	Communication and clinical skills	Increased skills, motivation for study and better exam preparation reported in pre- and post- questionnaire using rating from 1 to 6
Lin et al^Citation43 (12/18)	USA	Not specified (6)	Not specified (55)	Retrospective cohort study – Mixed method	Yes	Not specified	1:3; tutor:tutee	Basic surgery skills	Teaching and surgical skills improved reported using pre- and post-narrative reflection and pre- and post-survey using Likert scale from 1–5
Lufler et al^Citation44 (11/18)	USA	Year 4 (32)	Year 1 (402)	Longitudinal study- Mixed method	Yes	Not specified	Not specified	Anatomy	Better teaching- and anatomy skills reported using pre- and post-test questionnaire using 1–10 scale and open-ended comments
Mohd Shafiaai et al^Citation45 (10.5/18)	Malaysia	Year 2 (40)	Year 1 (Not specified)	Longitudinal study- Mixed method	Yes	Not specified	Not specified	Communication	Communication, leadership, interpersonal skills and personal growth reported using pre- and post-test questionnaire using Likert scale and a focus group interview one year later
Naeger et al^Citation46 (11/18)	USA	Year 4 (17)	Year 1 (120)	Survey study – Mixed method	Yes	1.5 h × 1 session	1:5–6; tutor:tutees	Radiology	Improved teaching skill and benefited their own learning reported using questionnaire using Likert scale and open comments
Nelson et al^Citation47 (10/18)	Australia	Year 6 (24)	Year 1–2 (358)	Longitudinal mixed method	No	2 h sessions × 4 times a week	1:4; tutor:tutees	Clinical skills	Improved own clinical skill, consolidating previous knowledge and developed teaching skills reported using a survey using a scale form 1–7 and focus group interview two years after the rotation
Nshimiyimana et al^Citation48 (n/a)	Rwanda	Year 5 (Not specified)	Year 5 (Not specified)	Qualitative study	No	3 h × 1 session	1:18–25; tutor:tutees	Paediatrics	Enhanced learning of content, overcoming anxiety and developed teaching skill reported in semi-structured interview
Prunuske et al^Citation49 (n/a)	USA	Year 2 (9)	Year 1 (31)	Qualitative study	No	4 weeks	1:4–5; tutor:tutees	Multiple subjects	Beneficial to their own skill development, communication and professionalism skill reported in semi-structured or focus group interview within 1 year
Reyes-Hernández et al^Citation50 (6/18)	Mexico	Year 2–5 (120)	Year 1 (Not specified)	Cross-sectional study – Quantitative	Yes	Not specified	1:6–5; tutor:tutees	Anatomy	Improved teaching skill and benefited their own learning reported in a survey using a scale from 1–10-point Likert scale
Sahoo et al^Citation51 (9.5/18)	Malaysia	Year 4 (6)	Year 4 (98)	Longitudinal mixed method	No	0.5 h × 1 session × 4 week	1:9.5; tutor:tutees	Ophthalmology	Better understanding, improved confidence and improved presentation reported using pre- and post-test questionnaire using Likert scale and focus group interview
Siddiqi et al^Citation52 (12.5/18)	Pakistan	Year 1 (10)	Year 1 (62)	Cross-sectional study – mixed method	Yes	Not specified	1:7–11; tutor:tutees	Pharmacology & physiology	Improved confidence, communication, presentation and teaching skills reported using questionnaire with closed-ended and open-ended questions and Kahoot.
Silbert et al^Citation53 (11/18)	Australia	Year 4–6 (64)	Year 3 (321)	Longitudinal quantitative study	Yes	4 h session × 6	1:12; tutor:tutees	Multiple subjects	Increased confidence in teaching and improvement in knowledge reported in surveys completed using Likert scale
Srivastava et al^Citation54 (12/18)	India	Year 1 (20)	Year 1 (87)	Non-randomized interventional mixed method	No	4 sessions	1:10; tutor:tutees	Physiology	Consolidating previous learning and improved teaching reported using pre- and post-test score containing closed-ended questions and open-ended questions. Average post score was more for cases, though not significant
Tamachi et al^Citation55 (n/a)	UK	Year 4 (3)	Year 3–5 (5)	Qualitative study	Not specified	Not specified	Not specified	Multiple subject	Increased learning, professional congruence and camaraderie reported through individual interviews
Walser et al^Citation56 (9.5/18)	Germany	Year 3+ (38)	Year 2 (388)	Longitudinal mixed method	Yes	16 sessions	1:10; tutor:tutees	Anatomy	Student-teacher met the requirements of the course and adjusted their activities reported using semi-structured reports; pie-chart for quantitative data and open-ended questions for qualitative data
Yang et al^Citation57 (n/a)	USA	Year 3 (Not specified)	Year 3 (Not specified)	Longitudinal qualitative study	No	26 sessions or more	Not specified	Clinical clerkship	Personal and professional development reported using semi-structured interviews
Young et al^Citation58 (6/18)	UK	Year 4 (103)	Year 3 (245)	Cross-sectional study – Mixed method	No	3 sessions	Not specified	Multiple subjects (Objective structured clinical examination)	Motivation to continue with peer-assisted learning and improved teaching reported using questionnaire involving qualitative responses and closed-ended questions in a survey using scale from 1–4
Nomura et al^Citation59 (9/18)	Japan	Year 5 (6)	Year 4 (58)	Mixed method	Yes	1.5 h–3 h × 4 sessions	Not specified	Medical interview training	Tutor act as role models, create comfortable learning environment, effective feedback and practical advice based on clinical experience, all data reported in focus group interview
Zuo et al^Citation60 (8/18)	USA	Year 2 (52)	Year 1 (240)	Survey study – Mixed method	Yes	30–45 min × 2 session	1:6; tutor:tutees	Anatomy	Value of giving back, making means of experience, and continued learning through peer teaching reported in survey and focus group interview
Avonts et al^Citation61 (9/18)	Belgium	Year 3–5 (Not specified)	Year 3–5 (78)	Retrospective cohort study –Mixed method	Yes	3–5 sessions per year	5–8:30–50; tutor: tutees	Multiple subjects (Objective structured clinical examination)	Better performing medical students are more likely to volunteer for peer-teaching program No evidence of additional benefits related to score compared to fellow-students Improved competencies related to CanMEDS framework
Aydin et al^Citation62 (8/18)	Turkey	Year 1–2 (159)	Year 3 (43)	Cross-sectional study – Mixed method	Yes	2 hour × 10 days	Not specified	Clinical skills	Open-ended question showed tutors believed peer-assisted learning is beneficial for tutors The tutors answers to Likert scale was not significant
Diebolt et al^Citation63 (8/18)	USA	Year 3 (106)	Year 4 (40)	Prospective study – Mixed method	Yes	2 days	Not specified	Surgery clerkship	Tutors reported statistically significant increase in self-efficacy and confidence in teaching skills scores increasing with each session reported on survey including close- and open-ended question
Orsini et al^Citation64 (6/18)	Italy	Year 1–2 and 4 (Not specified)	Year 3–6 (348)	Retrospective study – Mixed method	Yes	Not specified	1:6–8; tutor: tutees	Anatomy	Tutors develop educational, professional, and personal skills reported on survey including close- and open-ended question
Shah^Citation65 (7/18)	UK	Year 4 (72)	Year 5 (13)	Longitudinal study – Mixed method	No	22 session × 3 months	2:11–49; tutor: tutees	OSCE	Tutors thought the program helped them better understand and retain material answered on questionnaire including close-ended and open-ended question

Table 4 Overview of Studies Reporting Types of Learning Outputs

Reported Outputs	Number of Studies	References
Subject-specific learning outputs	62% (28/45)	[21–24,26,27,30,31,34–39,41–44,46,47,49,50,56,60–62,64,65]
Pedagogical knowledge and skills	49% (22/45)	[22,23,27,28,30,35,36,43,44,46,48,50,52–54,58,59,61–65]
Personal outputs	31% (14/45)	[24,28,29,33,34,40,51–53,59,62–65]
Generic skills	38% (17/45)	[22,24–26,32,37,38,45,49,52,55,57,59–62,64]

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

Data Source	Research Instrument	Number of Studies	References
Self-reports 91% (41/45)	Interviews	18	[24–27,29,30,32,33,45,47–49,51,55,57,59–61]
	Reflection essay	2	[36,43]
	Questionnaire (open-ended questions)	17	[22,31,34,37,38,40,44,46,49,52,54,58,60,62–65]
	Questionnaire (closed-ended questions)	31	[24,26,29–38,40–47,50–54,58,61,63–65]
External data source 13% (6/45)	Practical/oral exam/written exam	3	[21,39,61]
	Evaluation by student learners	3	[23,28,44]

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