|Year : 2016 | Volume
| Issue : 2 | Page : 142-147
Which peer teaching methods do medical students prefer?
Nithish Jayakumar1, Danushan Srirathan1, Rishita Shah1, Agnieszka Jakubowska1, Andrew Clarke2, David Annan1, Dekan Albasha3
1 School of Medicine, Barts and The London School of Medicine and Dentistry, London, United Kingdom
2 Clinical Education Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
3 Department of General Surgery, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, United Kingdom
|Date of Web Publication||19-Aug-2016|
Barts and The London School of Medicine and Dentistry, Turner Street, London E1 2AD
Source of Support: None, Conflict of Interest: None
Background: The beneficial effects of peer teaching in medical education have been well-described in the literature. However, it is unclear whether students prefer to be taught by peers in small or large group settings. This study's aim was to identify differences in medical students' preferences and perceptions of small-group versus large-group peer teaching. Methods: Questionnaires were administered to medical students in Year 3 and Year 4 (first 2 years of clinical training) at one institution in the United Kingdom to identify their experiences and perceptions of small-and large-group peer teaching. For this study, small-group peer teaching was defined as a tutorial, or similar, taught by peer tutor to a group of 5 students or less. Large-group peer teaching was defined as a lecture, or similar, taught by peer tutors to a group of more than 20 students. Results: Seventy-three students (81% response rate) completed the questionnaires (54% males; median age of 23). Nearly 55% of respondents reported prior exposure to small-group peer teaching but a larger proportion of respondents (86%) had previously attended large-group peer teaching. Of all valid responses, 49% did not have a preference of peer teaching method while 47% preferred small-group peer teaching. The majority of Year 3 students preferred small-group peer teaching to no preference (62.5% vs 37.5%, Fisher's exact test; P = 0.035) whereas most Year 4 students did not report a particular preference. Likert-scale responses showed that the majority of students held negative perceptions about large-group peer teaching, in comparison with small-group peer teaching, with respect to (1) interactivity, (2) a comfortable environment to ask questions, and (3) feedback received. Discussion: Most respondents in this study did not report a preference for small-versus large-group settings when taught by peers. More Year 3 respondents were likely to prefer small-group peer teaching as opposed to Year 4 respondents.
Keywords: Education, medical, undergraduate, instructional method, lectures, peer teaching, students, medical, tutorials
|How to cite this article:|
Jayakumar N, Srirathan D, Shah R, Jakubowska A, Clarke A, Annan D, Albasha D. Which peer teaching methods do medical students prefer?. Educ Health 2016;29:142-7
| Background|| |
Peer teaching refers to individuals of a similar social grouping who teach each other, and learn themselves by teaching.  Significant interest in peer teaching has been shown in recent years due to the benefits to the peer teacher, student, and faculty, which have been well described in the literature elsewhere ,,, However, there is little study of which method of instruction students prefer when taught by peers.
Burgess et al.'s systematic review  identified three activities that encompass peer-assisted learning: (1) peer teaching; (2) peer assessment; and (3) teacher training. The majority of studies reviewed by Burgess et al. reported on peer teaching activities, primarily concerning clinical skills teaching.  Another focus was peer teaching in problem-based learning (PBL) or case-based seminars to small groups of students.  Furthermore, Yu et al.'s  review showed that the number of students taught varied from 1 to 20 in different studies. However, the authors do comment on the lack of specific information available about the number of students taught by peer teachers.
Although the literature on peer teaching is generally positive, further work is required to identify the best or preferred instructional format through with medical students are taught by their peers.
Our aim was to evaluate medical students' perceptions small-group versus large-group peer teaching sessions within one institution in the United Kingdom (UK).
| Methods|| |
In the UK medical schools, the first two years of medical school involve teaching in basic medical sciences (pre-clinical years) and the final three years are based in hospitals and primary care (clinical years). These five-year MBBS courses admit both undergraduate and postgraduate students.
At our institution, a number of student-led peer teaching activities are organised each year, targeted towards pre-clinical and clinical students. These activities include weekly small-group tutorials offered to students in Years 1-3 while large-group formative teaching sessions for Years 1-4 are held in preparation for their semester and end-of-year exams.
The study population, therefore, comprised of Year 3 and Year 4 students who attended 6 large-group, peer-taught sessions in January 2015 prior to their summative exam at the end of their first semester. At this time point, both year groups-who commenced medical school in 2011 and 2012 respectively-would have attended small-group and/or large-group peer teaching during their previous years.
Questionnaires were administered to all students who attended the 6 sessions. Basic demographics were collected (age; gender; year of study; previous degree). Prior exposures to small-group and large-group peer teaching were also collected (number of sessions attended in medical school previously). The questionnaire compared small-group vs large-group peer teaching through ten themes, including interactivity, assessment, use of audio-visual techniques, and knowledge acquisition.
Five-point Likert scale responses (strongly agree, agree, neutral, disagree, and strongly disagree) were used to assess students' perceptions of the above criteria. Finally, students were asked to choose which type of peer teaching they preferred: small-group or large-group peer teaching, or no preference.
The authors defined small-group peer teaching as a tutorial, or similar, taught by one or more peer tutors to a group of no more than 5 students. Large-group peer teaching was defined as a lecture, or similar, taught by one or more peer tutors to a group of more than 20 students.
The size limits for the small-group and large-group sessions were based on the authors' personal experiences of peer teaching at our institution during the previous 5 years.
Our work follows the principles set out in the Declaration of Helsinki.  Completion of the questionnaire was taken as consent to participate in the study. Each respondent completed the survey anonymously. No personally identifiable information was obtained in the survey from any respondents, ensuring a thoroughly confidential process. None of the respondents were deemed to be vulnerable as they were all medical students at varying stages of their training. Therefore, there was no harm associated with taking part in this study and institutional approval was not sought.
Statistical analyses were performed on SPSS v22 (IBM). Statistical significance was set at the 95% level (P < 0.05).
Reliability of the Likert-scale questions was tested with Cronbach's α. Relationships between two nominal, or nominal and ordinal, variables were evaluated with Chi-square tests; where the sample sizes were small, Fisher's exact tests were used. Comparisons between independent variables, such as Year 3 and Year 4 students, were evaluated with independent T-tests.
| Results|| |
A total of 73 responses were received from 90 students (81.1% response rate) who attended the large-group sessions. Respondents had a median age of 23 and 53.5% were male. More Year 4 students responded than Year 3 students (54.8% vs. 45.2%, respectively) and there was an even split of undergraduate and postgraduate attendees.
Preferred method of peer teaching
Of all valid responses, 35/72 (48.6%) did not have a preference for a peer teaching method while 34/72 (47.2%) preferred small-group peer teaching [Figure 1].
A statistically significant relationship existed between respondents' year of study and preferences. The majority of Year 3 students preferred small-group peer teaching to no preference (62.5% vs. 37.5%, Fisher's exact test; P = 0.035). However, the majority of Year 4 students did not report a particular preference of peer teaching method in comparison to small-group peer teaching (65.7% vs. 41.2%, Fisher's exact test; P = 0.035).
Prior exposure to peer teaching methods
Small-group peer teaching
More than half of all respondents had previously attended a small-group peer teaching session (54.8%). Of those who had prior exposure, the majority had attended 4 to 6 sessions (45%).
Large-group peer teaching
A large proportion of all respondents reported prior attendance at a large-group peer teaching session (86.3%). Of those with prior exposure, equal proportions (30.2%) had attended either 4 to 6 or more than 10 sessions.
Undergraduate respondents were significantly likely to have attended more large-group peer teaching sessions in comparison to postgraduate respondents; 73.7% vs. 26.3% attended 10 + sessions, respectively (independent t-test; P < 0.001).
Of 72 valid responses from 73 respondents, 36 (50%) students reported prior exposure to both small-group and large-group peer teaching methods.
Perceptions about peer teaching methods
The five-point Likert scales, used to assess perceptions, displayed a high level of internal consistency (Cronbach's α = 0.804) [Table 1].
|Table 1: Statements evaluating respondents' perceptions towards two different methods of peer teaching (n=74)|
Click here to view
Respondents felt that large-group peer teaching was not as interactive as small-group peer teaching (mean 2.48). Of the 38 respondents who disagreed with this statement, over a third had attended more than 10 large-group sessions compared to 6 respondents who had never attended any sessions (Fisher's exact test; P < 0.001).
Comfortable environment to ask questions
Respondents also disagreed that large-group sessions were a comfortable environment to ask questions (mean 2.45) in comparison to small-group sessions.
Feedback to students
Respondents disagreed that students were more likely to receive feedback in large-group sessions (mean 2.32) compared to small-group sessions.
Respondents felt that they were not likely to be assessed in-session during large-group teaching compared to small-group sessions (mean 2.73).
Small-group peer teaching: Exposure versus no exposure
Interestingly, little difference was noted in the perception of different peer teaching methods between students who were exposed to small-group teaching and those who were not. Respondents who were exposed to small-group teaching felt that audio-visual techniques were more likely to be used in large-group peer teaching compared to those who had no prior small-group teaching (Fisher's exact test; P < 0.001).
| Discussion|| |
Little research has been done to evaluate students' preferences for peer teaching methods.
The majority of respondents in this study did not report a preference for either small-group or large-group peer teaching, despite a large proportion of students reporting prior exposure to large-group peer teaching. However, respondents reported negative perceptions of large-group peer teaching in comparison to small-group peer teaching. Comparisons between year groups revealed that respondents in Year 3 preferred small-group peer teaching whereas Year 4 respondents did not show any preference.
Students and teaching method: Evidence from the literature
There is limited evidence regarding student preference towards teaching and learning methods, and none on peer teaching methods. Besides, the published evidence predominantly focuses on the benefits of small-group teaching.
In the literature, the most frequent small group activities evaluated usually involved groups of up to 10 participants.  It has been previously reported that a smaller learning environment fosters better recall of information, encourages individual and collaborative knowledge construction, and increases students' motivation and productivity. ,, Moreover, small-group sessions provide an opportunity for students to express views and form opinions, which is more difficult to achieve in a large group setting. 
Other benefits of small-group teaching include an enhanced student-teacher relationship and interaction, better understanding of the content, increased attendance  and greater satisfaction with inter-professional learning experiences. 
Comparing small-group and large-group teaching
A randomised trial of 107 students showed that students preferred small-group work rather than a large-group interactive seminar primarily because they felt that small-group work enhances retention of information.  Another randomised trial involving 77 students found that participants in both small- and large-group teaching scored the respective sessions similarly on content, but rated small-group teaching higher on the style of presentation. However, two different clinicians delivered the small- and large-group sessions, which may account for the difference in scores for presentation. 
When comparing small discussion groups with large lectures, Fischer et al.  reported that students in small-group teaching showed a significantly higher level of enjoyment and sense of educational stimulation. However, the negatives included students' embarrassment in participating and the inability to cover all of the material thoroughly.  The benefits of large-group lectures appeared to be high-yield material whilst negative feedback commented on the lack of engagement. 
Furthermore, small-group discussions and large-group lectures can complement each other. Students report that small-group discussions allow for debate and clarification over topics taught in lectures, especially ethical and cultural issues.  Interestingly, the benefits of small groups can be replicated when large groups are made to seem small by dividing the class into subsets to introduce member familiarity, which enhances social cohesion and group learning behaviours. 
| Understanding our results|| |
No preference for peer teaching method
Results from this study revealed that 48.6% of students in this sample population did not have an overall preference when they were asked to choose between a small group and large group peer-teaching method.
A potential explanation for this finding may be that the sample population did not have adequate exposure to small-group peer teaching in order to make a valid comparison-only 54.8% of respondents reported prior exposure to small-group peer teaching, in comparison to 86.3% of respondents with experience of large-group peer teaching. This is understandable considering the fact that small-group peer teaching was introduced two years ago to Year 3, but large-group peer teaching has been ongoing at our institution since the last ten years. Also, at our institution, both small-group PBL and large-group lectures are utilised as part of the medical curriculum. Students may, therefore, perceive both small-group and large-group teaching methods as complementary to each other and hence express no preference for either method.
Small-group versus large-group peer teaching
Small-group peer teaching was a close second choice (42.6% of respondents' preference) whilst large-group peer teaching was a distant last (4.2%). This is further supported by Likert-scale responses where most of the students held negative perceptions of large-group peer teaching, in comparison with small-group peer teaching, with respect to  interactivity,  a comfortable environment to ask questions, and  feedback received. Evidence shows that participation is likely to decrease with an increased group size of greater than 10, when some students are likely to 'hide' and refrain from clarifying any queries they may have in order for them to fully understand the content that is being taught. 
The difference in preferences may also be due to the variation in the amount of content covered in the two teaching methods. Students in both Year 3 and 4 typically attend large-group peer-taught sessions which focus on a review of key material across an entire module e.g., cardiology. The small-group peer-taught sessions, on the other hand, run parallel to Year 3 students' placements over 9 weeks and cover subtopics within a module in detail, i.e., heart failure or cardiomyopathy, as subtopics within cardiology. Gardner  acknowledges that deep engagement requires time and covering large quantities of content in a short space of time can compromise on understanding, which may reflect in our respondents' non-preference of large-group peer teaching.
Moreover, students who were previously exposed to small-group teaching felt that large-group teaching was more likely to use audio-visual techniques (e.g., Powerpoint etc.,) compared to those who had no prior small-group exposure. Large-group teaching is held in a lecture theatre or a large classroom with access to audio-visual equipment (projector, screen, computer, and microphone) whereas small-group teaching was often conducted in smaller classrooms which only had a computer and a large monitor. Understandably, students who attended small-group sessions in these smaller classrooms may perceive large-group teaching as utilising more audio-visual equipment. On the other hand, it's also worth considering why small-group teaching may not use audio-visual aids as well as large-group teaching - it may well be that instructing a large cohort of students requires facilities mimicking a formal lecture whereas smaller groups may be managed with alternative means, such as a whiteboard. Variations in instructional methods between small-group and large-group peer teaching appears to be an interesting avenue for further research.
Year 3 versus year 4
The majority of Year 3 respondents preferred small-group peer teaching compared to the majority of Year 4 respondents who showed no preference (P < 0.05). A possible explanation for this may lie in how recent the respondents' experiences were of the different methods of peer teaching. Year 3 respondents had the opportunity to attend weekly small-group, peer-taught tutorials in the 9 weeks preceding this study's data collection timeline, which may introduce bias due to the recency effect. This cohort also has small-group PBL as part of their curriculum. However, Year 4 respondents would have experienced small-group peer-taught tutorials in the preceding academic year and, moreover, do not participate in PBL. The recent exposure of small-group peer teaching in Year 3 respondents may have contributed to the significant preference they showed towards this peer teaching method whereas Year 4 respondents may not remember much of their own experiences of small-group peer teaching.
Strengths and limitations
We have conducted a study of students' preferences of peer teaching methods and described novel findings which add to the literature on peer teaching. Due to our institution's extensive experience in near-peer-led teaching activities, we have been able to test two peer teaching methods in two year groups.
The five-point Likert scales used in this study offer respondents a meaningful range of options to choose from, without significantly limiting the viewpoints they could offer. Also, the large range of criteria used to evaluate large-group and small-group peer teaching provided a thorough overview of respondents' perceptions of peer teaching methods.
For this study, a large group was defined as a group of 20 or more students, whereas a small group was defined as a group of 5 or less students. The overall lack of preference for a particular teaching method may also imply that students may not perceive much of a difference in the numbers - i.e., a group of 20 or so students may still be perceived as 'small' in comparison to a typical lecture consisting of more than 200 students. Results may have varied had a higher number of students been used to distinguish a large group from a small group.
Furthermore, the survey utilised in this study is a snapshot of students' preferences at a point when it may not be representative of their true preference. Heterogeneity in prior exposure to peer teaching as well as confounding factors between Year 3 and Year 4 cohorts may have introduced bias. As this was a single-centre study, these results may not be representative or generalizable to other medical schools.
Besides, the context for small-group and large-group peer teaching was slightly different. Although both methods were utilised to prepare students for their summative examinations, large-group peer teaching - in view of its temporal relationship to the examinations - may have been viewed as more relevant to exam preparation than the weekly small-group teaching. Controlling for this effect by identifying students' reasons for attending either method of peer teaching may have been ideal.
Future work needs to assess the underlying reasons for students' preferences of either small-group or large-group peer teaching. Furthermore, this work needs to be utilised in identifying the roles peer teaching can play in the medical curriculum.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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