Optimal timing of faculty teaching when combined with near-peer teaching: A mixed methods analysis

Abstract

Background

Near-peer teaching is increasingly used in medical education, supporting or replacing faculty teaching. It has positive aspects for learners and tutors, some of which are explained by higher social and cognitive congruence between learners and near-peer tutors (NPTs). This study investigates the optimal combination of faculty tutors (FTs) and NPTs in an abdominal ultrasound course.

Methods

Sixty-four third-year medical students underwent a basic ultrasound course, with 75% of lessons taught by NPTs and 25% by FTs. Each of four groups had a different faculty teaching timing. A mixed methods approach used a survey and semi-structured interviews at the course end to elicit learners’ preferences, and end-of-course examination scores to look for differences in outcomes.

Results

Most learners preferred having faculty teaching in the second half of the course, saying it would be overwhelming to start with FTs. Learners preferred between a quarter and a third of the teaching to be from FTs, with NPTs rated better at teaching basics, and FTs contributing unique, helpful clinical knowledge. There was no significant between-group difference in examination scores.

Conclusions

Medical students preferred most of their teaching to be from NPTs, with some faculty input in the second half of the course.

Keywords:

• Teaching methods
• medical education
• ultrasound
• near-peer teaching

Practice points

• Near-peer teaching in a basic ultrasound course was very acceptable to learners.

• Learners liked the combination of near-peer and faculty tutors (FTs) as it brought different perspectives. While learners generally preferred near-peer teachers, FTs were more able to share valuable clinical experience.

• If combined, faculty teaching should take place after initial near-peer teaching, as FTs were perceived to overwhelm learners when used early on, and near-peers were better at teaching the basics.

Introduction

Near-peer teaching, when the learner and the teacher participate in the same curriculum with up to several years’ difference in their academic year, is increasingly and effectively used in medical education to support or replace faculty teaching in a variety of courses. Such settings include teaching clinical examination skills (Rashid et al. 2011; de Menezes and Premnath 2016), critical appraisal skills (Widyahening et al. 2019), ultrasound including point-of-care-ultrasound (Smith et al. 2018), echocardiography (Ahn et al. 2014; Ben-Sasson et al. 2019), musculoskeletal (Knobe et al. 2010; Ahn et al. 2014), and abdominal ultrasound (Ahn et al. 2014).

While increasing the number of available tutors by using near-peer tutors (NPTs) allows for smaller group sizes that can stimulate students’ motivation to learn (Schwill et al. 2020), there is mixed evidence on the effects of replacing faculty with near-peers on students’ learning efficiency. Most studies have found equal or better learning for groups taught by NPTs, when measured by written tests (Haist et al. 1997; Tolsgaard et al. 2007; Knobe et al. 2010; Ten Cate et al. 2012; Widyahening et al. 2019; Boecker et al. 2022) or skills tests like objective structured clinical examinations (OSCEs) (Tolsgaard et al. 2007; Knobe et al. 2010; Ben-Sasson et al. 2019; Boecker et al. 2022). However, in one early study learners taught by NPTs scored significantly lower on a test designed to measure higher order cognitive skills (Moust et al. 1989). In another early study, learners taught by NPTs achieved significantly less learning objectives immediately after the teaching, but two months later there were no differences (Nestel and Kidd 2003).

Near-peer teaching has several positive effects on learners. It has been found to be highly acceptable to learners (Rashid et al. 2011), and improves the learning atmosphere by creating a safer atmosphere (Tamachi et al. 2018) in which learners feel more comfortable about exchanging views (Cusimano et al. 2019), making mistakes or asking questions (Massy-Westropp et al. 2021), and reducing anxiety as well as improving confidence (de Menezes and Premnath 2016; Cusimano et al. 2019; Massy-Westropp et al. 2021). It also has positive effects on NPTs by deepening their knowledge (Onorato et al. 2022), improving their professional behaviour, confidence, and study motivation (de Menezes and Premnath 2016; Yang et al. 2022), and improving their teaching skills (de Menezes and Premnath 2016; Yang et al. 2022) with teaching being considered a key competency for physicians that should be covered in medical school (Dandavino et al. 2007; Onorato et al. 2022). The advantages of near-peer teaching have mainly been explained by higher levels of both social congruence (when tutors and learners share similar social roles) and cognitive congruence (when they share a similar knowledge base) (Lockspeiser et al. 2008). Both support the tutors’ teaching and the learners’ learning. This happens through a variety of mechanisms, for example the tutors’ ability to understand the learners’ problems and to communicate with them in an informal way (Schmidt and Moust 1995; Lockspeiser et al. 2008).

When asked to compare NPTs with faculty tutors (FTs), learners rated them similarly overall (Knobe et al. 2010; Widyahening et al. 2019). Learners have reported that NPTs explained difficult concepts at a more appropriate level, are ‘closer’ and better understand the learners’ challenges, and learners felt more comfortable about asking questions with NPTs (Bulte et al. 2007). In contrast, learners said that FTs have the advantage of more knowledge, clinical experience, and confidence (Bulte et al. 2007; Massy-Westropp et al. 2021).

Whilst previous studies have found positive aspects of both near-peer and faculty teaching, little is known on how to best combine the two. One study examined near-peer senior residents supervising junior residents in primary care, while being supervised themselves by a faculty physician: the residents liked the near-peer supervision but felt that the observation by a faculty physician was required to ensure patient safety and teaching adequacy (Ince-Cushman et al. 2015). We have found no pre-existing evidence on the optimal timing in a programme using alternating faculty and near-peer teaching. But it has been suggested that having NPTs before any FT contact could be more challenging and force the NPTs to be more formal, thereby losing some of the benefit from their social and cognitive congruence (Border et al. 2017).

We designed this study to explore how, in the context of an ultrasound course for undergraduates, the combination of near-peer and faculty teaching could help to capitalise on the strengths of both tutor groups. Our research questions were:

1. What do learners consider is the optimal timing of faculty and near-peer teaching, and why?

2. Does the timing impact the learning outcome?

3. What do learners consider would be the optimal ratio of faculty and near-peer teaching, and why?

Methods

Study design

In this mixed-methods study, 64 medical students underwent a basic course on abdominal ultrasound taught by both FTs and NPTs. The primary quantitative outcomes were learners’ satisfaction with the timing of the faculty-led lessons, and their preferred ratio of FT and NPT teaching, as measured by Likert-scale questions. A secondary outcome was the effect of FT timing on learners’ performance measured by OSCE scores. To explore the reasons for students’ preferences and outcomes, a qualitative component included free-text answers in a survey and semi-structured interviews.

Setting and intervention

This study was organised in the context of a blended-learning programme in basic abdominal ultrasound (Raschle and Hari 2018), which took place between October 2020 and February 2021 at the University of Bern. The programme focuses on abdominal ultrasound, but also includes thorax, neck, and basic musculoskeletal sonography and a theoretical part (Supplementary Appendix 1: ultrasound course programme).

The regular course programme consists of five hours of e-learning, followed by 16 h of small-group hands-on NPT teaching (2–4 learners per session), concluding with a mandatory OSCE. For this study, four of the hands-on hours were taught by FTs and 12 by NPTs, with different FTs timings for each group. Each of the participants’ 12 near-peer lessons could have been taught by a different NPT as the participants booked the near-peer lessons themselves online independently to their group. For the four faculty-led lessons, each group had four different FTs. This made a total of 16 FTs and 30 NPTs that were used.

The FTs were experienced physicians, averaging 11.5 years of ultrasound and 4.5 years of ultrasound-teaching experience, and a frequency of 27.5 ultrasound scans and two hours of ultrasound-teaching per month. The NPTs were fourth-year to sixth-year medical students with 1–3 years of ultrasound and ultrasound-teaching experience. They were trained by completing a basic abdominal ultrasound course plus three tutor-training-days with didactic and ultrasound experts. All FTs and NPTs teach the content of this course on a regular basis outside the study setting and were well aware of the learning goals.

Participants, recruitment, and allocation

Participants were recruited from the 220 students in their third year of human medicine at the University of Bern, Bern, Switzerland, through email invitation and a live promotional presentation. To apply, students had to agree to pay the course fee of 200 CHF (used to compensate the tutors), fill out a baseline questionnaire, confirm that they did not have previous ultrasound experience, and agree to a possible interview.

A total of 64 participants (limited to this number because of tutor availability) were randomly selected to join and allocated into four study arms using block randomisation to ensure equal group sizes (16 per group).

Data collection

We used an OSCE, a questionnaire and semi-structured interviews to collect our data.

The end-of-course OSCE was validated for this setting (Vetsch et al. 2020) and consisted of six stations. In each station, participants were asked to perform a four-minute ultrasound examination that focused on one organ, followed by one minute to answer predefined, theoretical questions. For every station, the examiners gave points using a predetermined checklist, with a maximum of 50 points per station. Station tasks were built around the course’s learning objectives. There was one OSCE examiner at each station, so six for each day, of which two were course NPTs, two were experienced ultrasound physicians (of which one was a course FT) and two were ultrasound NPTs from other universities who had not taught during this course. OSCE scores for each participant were collated by an OSCE committee and sent to the research team.

The questionnaire was completed immediately after the OSCE; participants were allocated to a quiet room and asked to access the online survey tool (SurveyMonkey, San Mateo, CA). The questionnaire was written in German and consisted of questions about demographics and group identification, followed by five-item Likert-scale questions, a sliding scale question (with 20 steps ranging from 0% to 100%), and free-text questions (Supplementary Appendix 2: questionnaire). The questionnaire items were designed by the study team. Minor changes were made following pilot surveys with five medical students who were not participating in the study. The questionnaire took about 15 min to complete; all questions were mandatory.

The interview participants were selected using their questionnaire answers, stratified by sex, group allocation and preference for faculty or near-peer teaching. The semi-structured interviews were carried out either face-to-face or by video call. With participants’ consent, interviews were digitally recorded to create an accurate record for data analysis. Interviews lasted between 40 and 88 min and took place in April 2021. They were in Swiss German, which is a spoken but not a written language. They were transcribed in Swiss Standard German by medical students who spoke both languages and had had training to ensure consistency and to avoid loss or change of interview data. No further changes were made to the topic guide during the interview phase.

LA performed three interviews and RW 12. Both were University of Bern medical students in higher years than the participants and were NPTs who together taught 8.5% of all the lessons in this study. To reduce risk of bias, they were trained by MH and RH, who were experienced qualitative researchers, and they had to use the interview guide (Supplementary Appendix 3: interview guide). This guide was based on a review of the existing literature, discussion within the study team, issues raised by the free-text answers given in the questionnaire, and two pilot interviews.

Some questions in the questionnaire and interviews, relating to a comparison of FTs and NPTs and the organisation of the lessons, were not used for this analysis and have been published separately (Alt et al. 2022).

Data analysis

The quantitative data were analysed with an intention-to-treat approach. For the Likert-scale question on satisfaction with the FT timing, we performed a one-way ANOVA test followed by a post hoc Tukey test. For the OSCE data, we calculated the mean scores and standard deviations (SDs) for each group and compared them using a one-way ANOVA.

The qualitative data were analysed using an inductive thematic analysis, so that codes and themes were suggested by the data rather than by a theoretical framework. To define a coding strategy, independent coding of two interview transcripts by two researchers (LA and RW) was compared for consistency in a consensus meeting. Once the coding was finished, themes and sub-themes were decided upon in discussion meetings, analysing interviews and questionnaire separately at first, then combining them.

Ethics

An ethics request (BASEC number Req-2020-01087) was submitted to the Cantonal Ethics Committee of Bern, Bern, Switzerland, which declared this study did not need ethical approval as it was not subject to the Swiss Human Research Act.

Because unexpected pathological findings are frequent in ultrasound courses, a reporting system was set up in which a senior staff member would contact participants with incidental findings within 24 h. The University of Bern arranged that an ultrasound expert would review the findings if needed. All participants gave informed consent.

Results

Of the 64 study participants, two did not complete the course. Four did not finish per-protocol as they did not participate in any faculty-teaching but were included in the analysis as part of the intention-to-treat approach (Figure 1).

Figure 1. CONSORT flow diagram.

Of the 62 participants who completed the questionnaire, 47 were female and 15 were male. Their mean age at the date of the questionnaire was 22.5 years (range 19–26). Of the 15 learners who were interviewed, 11 were female and four were male.

No new themes emerged from the last two interviews, indicating data saturation.

Effect of faculty-led lesson timing on OSCE scores

There was no statistically significant difference between the mean OSCE scores of the four groups, F = 0.35 (df = 3, 58), p = .79. Mean OSCE scores (maximum 300 points) of the groups with SD and 95% confidence intervals (95% CIs) were as follows:

• Faculty first 234.5 (SD 20.5, 95% CI 224.2–244.9),

• Faculty early 236.6 (SD 21.8, 95% CI 226.0–247.3),

• Faculty late 240.9 (SD 14.8, 95% CI 233.7–248.2),

• Faculty last 239 (SD 16.3, 95% CI 230.8–247.2).

Learners preferred faculty teaching in the second half of the course

Learners who received faculty teaching in the second half of the course were more satisfied with its timing than those that had it during the first half (Figure 2).

Figure 2. Mean Likert-scale scores with 95% confidence intervals for ‘the timing of the faculty-led teaching in the quarter I received worked well for me’ from 0 = strongly disagree to 4 = strongly agree; SD*: standard deviation.

The mean values of the Likert-scale score answers to ‘The timing of the faculty-led teaching in the quarter I received worked well for me’ showed a significant difference between group scores, F = 17.32 (df = 3, 58), p < .001, with the ‘Faculty first’ and ‘Faculty early’ groups having significantly lower mean satisfaction scores than the groups ‘Faculty late’ and ‘Faculty last’, p < .05. There were no significant differences between groups ‘Faculty first’ and ‘Faculty early’, or between groups ‘Faculty late’ and ‘Faculty last’ (Supplementary Appendix 4: Tukey test results).

When asked for their preferred timing of the faculty-led lessons, 52 out of 62 learners would have preferred the second half, with the third quarter being the most popular for 31 learners. Two stated that it did not matter to them.

The qualitative analysis of the free-text answers in the survey and the interviews confirmed the participants’ preference of FT timing in the second half of the course. None of the learners from the ‘Faculty late’ group and few from the ‘Faculty last’ group could have named any disadvantages of their timing of the faculty-led lessons. However, some learners from ‘Faculty last’ group would have preferred not to have had the faculty-led lessons last:

I would have preferred if I first (…) [had the] hours, that I had with the students and then with the physicians, and lastly before the test with students. Because the students simply still gave such helpful tips for the test. (N36, Faculty last, Interview)

Starting with faculty teaching was overwhelming

Many learners did not want faculty teaching to take place at the start of the course. They stated that they preferred to be well prepared when faced with FTs, and that early faculty teaching would require too much knowledge. Learners from groups ‘Faculty first’ and ‘Faculty early’ stated that there were too high expectations of FTs and that they had an overload of information:

For me, this time was very badly chosen, because I have never used ultrasound. I wasn’t able to understand the tips of the doctors and therefore I didn’t gain anything. (N59, Faculty first, Survey)

I would maybe rather start with a round of students because they eventually take a bit more time to show everything (…) I had the physicians first (…) I was too far away from the material, had too little knowledge. (N11, Faculty first, Interview)

In addition, learners from groups ‘Faculty early’, ‘Faculty late’, and ‘Faculty last’ liked the ability to gather ultrasound knowledge and experience before they had the faculty-led lessons:

It was good to already have had some courses and some understanding of the ultrasound images. This way you could benefit a lot from the tips of the doctors. (N50, Faculty late, Survey)

Interviewer: ‘What did you like about the timing of these physician lectures?’ Learner: ‘That I already did every module two times and already was roughly skilled a bit in everything.’ (N08, Faculty late, Interview)

In contrast, a few learners from the ‘Faculty first’ group liked the ultrasound introduction from the FTs:

It gave a good overview to start with. (N19, Faculty first, Survey)

So, I think it is good that someone with a lot of experience (…) comes as first [tutor] directly, [someone] that could also teach the content adequately without doubt. (N64, Faculty first, Interview)

Learners benefitted from gaining experience before their faculty teaching so they could ask appropriate questions

Learners from groups ‘Faculty late’ and ‘Faculty last’ felt that, with faculty-led lessons being in the second half of the programme, they were better able to prepare questions for the FTs:

You already had a bit of an idea of the subject matter, which is why I thought it was a good time – so you could ask some more detailed questions that weren’t already clear. (N04, Faculty late, Survey)

[I liked] that I went to the course already prepared for the exam, so to speak, and was able to repeat everything again and ask questions. (N31, Faculty last, Survey)

Faculty teaching at the end could have been helpful as examination preparation

Some learners from the ‘Faculty last’ group considered the faculty-led lessons to be useful examination preparation and good repetition. One participant called it ‘A kind of exam preparation with experts’ (N35, Faculty last, Survey).

Preferred amount of faculty tutor teaching time

Participants preferred to have less than 50% of teaching with FTs

When asked about the preferred ratio of FT and NPT teaching (a sliding-scale question with 20 steps ranging from 0% to 100% faculty-led), the mean response was 35.6% FT teaching (SD 16.5%) (Figure 3).

Figure 3. Preferred percentage of faculty-led teaching, indicated by learners.

The qualitative analysis of the free-text answers in the survey and the interviews confirmed the participants’ preference of the ratio of FT to NPT teaching for the course. Most learners expressed satisfaction with the ratio they experienced (25% FT and 75% NPT teaching):

I thought the way it was arranged was good. (N64, Faculty first, Survey)

Like that I would find it cool. So, four courses with physicians, the rest with students, so just like now but in a different order. (N19, Faculty first, Interview)

While some learners saw no need for FTs at all, others wanted more than a quarter of all lessons with FTs:

[Faculty-led lessons] from my point of view do not necessarily need to be [included]. (N31, Faculty last, Interview)

Two-thirds students, one-third physicians, because (…) students can focus [on] what they need to learn, but (…) it of course continues after the exam. And there, maybe the physicians (…) play an important role. (N33, Faculty late, Interview)

NPTs were preferred in this course, because they are better at teaching basics

Some learners stated they wanted more teaching to be given by NPTs as they were better at teaching basics:

I would probably rather do everything with students, because here it is about the basics and not about super clinical skills (…). And I found that the students did that better than the physicians on the level that we now learned. (N60, Faculty early, Interview)

Just about what one can learn I think I slightly preferred the student lessons because it is more fitting to our needs. (N01, Faculty early, Interview)

Learners liked to learn from tutors with different perspectives

Many learners valued the combination of NPTs and FTs for their different perspectives and experience, and liked the FTs’ clinical expertise:

One can learn from both how they would proceed. (N25, Faculty early, Survey)

I really liked it like this. The students only teach one what is on the programme. (…) And the physicians (…) gave you tips, that maybe are not written in the programme. (N38, Faculty late, Interview)

Discussion

Learners who had their FT teaching in the second half of the course were more likely to be satisfied with, and prefer, this timing. NPTs were rated good at teaching basics, and starting the course with NPT teaching allowed learners to be better prepared by the time they met the FTs. Having FT lessons in the second half of the course was felt to be a useful exam preparation. In contrast, earlier FT teaching was felt by many to be overwhelming, with FTs expectations perceived to be too high. Despite these preferences, there was no significant difference between the OSCE scores of the four groups. Learners indicated that having about a quarter to a half of the course taught by FTs seemed optimal. They commented that they benefited from the different perspectives that the combination of FTs and NPTs gave them, as the FTs provided clinical expertise and the NPTs were better at teaching the basics.

The higher cognitive congruence between learners and NPTs may explain leaners’ perceptions that the NPTs were better at teaching basics. On the other hand, the mismatch between FTs’ expectations and learners’ skills at the start of the course could be explained by a low cognitive congruence between them, as FTs may have had more difficulty remembering what their main problems were when they were themselves learners.

The FTs had a lot more clinical and ultrasound experience than the NPTs: it is likely that the learners valued their ability to use this in their teaching, and this may explain why most learners still wanted some FT teaching on the course.

It appears that the learners who had their FT teaching early in the course were, despite their perceptions of the disadvantages, able to compensate for this by the time of their OSCEs. It may be that they achieved this by organising additional training sessions with other learners or through self-studying.

Our results fit in well with other studies, which have found that, while learners value the expertise of FTs, NPTs can better understand their problems and needs (Bulte et al. 2007; Massy-Westropp et al. 2021). Our study confirmed previous research showing that learners preferred NPT-led courses to those led by FTs (Cusimano et al. 2019; Widyahening et al. 2019). While some studies show that NPT teaching results in better test scores (Tolsgaard et al. 2007; Ten Cate et al. 2012; Ben-Sasson et al. 2019), we have found no other research that has focussed on whether the timing of faculty-led teaching in combined settings also makes a difference. Despite a previous concern that starting the course with NPTs would ask too much of them or restrict the use of their social and cognitive congruence (Border et al. 2017), our data show no evidence that this happened.

Implications

In the context of this basic abdominal ultrasound course, our findings support regular use of NPTs and suggest that, if combined with FTs, then the FT input should not be until the second half of the course. There is a need to explore whether we will get the same results with NPT and FT teaching in other settings. Our findings are from a learners’ perspective, and further research is needed to elicit NPTs’ and FTs’ views.

It is unclear why learners’ strong preferences for timing of FT teaching later in the course were not reflected in better OSCE scores in those that experienced it, and the reasons for this should be explored.

Strengths and limitations

This study was triangulated by use of both a questionnaire and interviews, improving the reliability of the results and giving explanations for the quantitative findings.

Both our NPTs and FTs were experienced in teaching ultrasound, but FTs were less used to the specific course concept in this study and, while all NPTs had been through a similar training process including a didactic training, the FTs’ backgrounds varied.

Our learners were all third-year medical students, so the sample is not representative of all years: there is different anatomical and ultrasound knowledge and experience for students in the other years of medical school, and this may have influenced their teaching preferences.

The learners had to pay 200 Swiss francs for the course, and it may be that some students were unable to afford this payment, or that those who found the money to pay for it were particularly motivated.

During their curriculum, NPTs had originally taken the same course, including the OSCE, themselves. They therefore knew some of the OSCE questions and may have been able to better prepare learners for this exam. This may have positively affected learners’ overall perception of NPTs. However, it would not have affected the final OSCE result because all learners underwent the same number of peer-led lessons.

Since this study was limited to the context of a basic ultrasound course, we are unable to state whether the findings would be the same in other settings like more advanced ultrasound courses, where the cognitive congruence between learners and FTs might be higher than in more basic courses.

Conclusions

As little is known about how combined FT and NPT led courses should be organised, this mixed-methods study explored the views of medical student learners on a basic ultrasound course being taught by both NPTs and FTs. The learners had a clear and consistent preference for having FT teaching only in the second half of the course, after NPTs had taught the first half of the course. Learners reported that input from FTs in the early stages of the course could be overwhelming, and that NPT teaching at this timing was easier to understand. They preferred having some faculty-led lessons towards the course end so that they could ask more complex questions and learn from a different, more clinical perspective. Most learners wanted FTs to teach between a quarter and a half of the course. While the timing of the FT teaching did not affect learners’ OSCE scores, the positive feedback on the NPTs’ input leads us to recommend a broad use of NPTs in practical basic ultrasound courses, with some FT teaching in the second half of the course.

Glossary

Near-peer teaching: A teaching method, where a student acts as teacher for other students studying the same curriculum as him, with up to several years’ difference in their academic years.

Cognitive congruence: A concept to describe the cognitive proximity between tutor and student. It is higher, for example, when tutors and learners share a similar knowledge base or have similar semantic networks, and this leads to more effective teaching.

Social congruence: A concept to describe the social proximity between tutor and student, which is for example higher if they share similar social roles impacting their relationships and cognitive congruence.

Acknowledgements

We thank everyone from ‘Young Sonographers Bern’ and ‘Berner Institut für Hausarztmedizin’ (BIHAM) who helped organising the ultrasound course. We also thank all the learners, near-peer and faculty tutors taking part in the study and in the pilot questionnaires or interviews.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Funding

The authors report that there is no funding associated with this work. There was no external funding for this study.

Notes on contributors

Leander Alt

Leander Alt, certified physician, is a Doctoral Student at the Medical Faculty, former Medical Student, of the University of Bern, Bern, Switzerland.

Robin Walter

Robin Walter, MD, is a Resident in internal medicine, former Medical Student at the University of Bern and Research Associate at the Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

Michael Harris

Michael Harris, MB BS, FRCGP, MMEd, is a British General Practitioner and a Research Associate at the Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland and at the College of Medicine & Health, University of Exeter, Exeter, UK.

Roman Hari

Roman Hari, MD, MMEd, is a General Practitioner and dean of education at the Medical Faculty of the University of Bern, Bern, Switzerland and a PhD candidate at the School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.