Investigating the effect of distance between the teacher and learner on the student perception of a neuroanatomical near-peer teaching programme

The range of teaching methods available to the medical educator is constantly increasing under the pressure to maintain teaching quality in the face of diminishing curriculum time and resources [7, 8, 30]. Near-peer teaching (NPT) is an educational method that has widely been used through informal applications, such as teaching on the wards or, more recently, through it being integrated into a formal teaching programme. In anatomy education, the practice of NPT has a long established history, which is still very much part of existing teaching approaches [1, 11, 15, 18‐20, 24].

The defining characteristic of NPT is the proximity between the student and teacher both in terms of age and stage of training. The teacher, being only a short distance ahead of their students in educational training, is more able to accurately remember their own learning experiences, including the associated pitfalls of the process, which they can draw upon in the classroom [9]. Without the social barriers that may hinder academic discussion with faculty members, the students and teachers are able to engage in more open discourse regarding the learning and can easily identify any issues, where the students need extra assistance [18]. The significance of this close proximity in learning experiences was first recognised by Schmidt [27] who termed them cognitive and social congruence, respectively. Since then, the concept of congruence has been considered an important part of explaining NPT success [18, 21, 27].

The use of NPT in anatomy education has historically involved senior medical students and junior doctors assisting anatomy lecturers as demonstrators in practical sessions. Near-peer demonstrators use this experience as preparation for their future careers typically in surgery or radiology. However, NPT in undergraduate neuroanatomy has demonstrated that altering the proximity of learners and teachers in terms of educational distance has an important influence on how the teachers are perceived. Such studies identify that junior doctors tend to receive lower feedback scores for various aspects of the learning experience when compared to senior medical students [14]. One theory suggests that this variability is due to the declining strength of social and cognitive congruence [14, 21, 27]. However, as yet there is a paucity of examples in the published literature to fully delineate the dynamic nature of these congruencies along the NPT spectrum.

Given the evidence supporting the role of social and cognitive congruence in the success of the NPT learning experience, it has become increasingly important to identify when congruence is optimal between teacher and learner. When the distance increases to the point, where these elements no longer have a strong influence, it could mark the transition from NPT- to cross-level teaching. Moreover, further evidence in this area would allow more effective resource allocation and provide the best learning experience for the students.

The primary aim of this study was to determine how the student learning experience, and thus, the underpinning social and cognitive congruence, changes as the learner–teacher distance increases.

Faculty endorsed optional small-group neuroanatomy revision sessions were organised at the University of Southampton for the second-year medical students. These were delivered immediately prior to their head and neck module examinations in 2012–2013 and 2013–2014. Neuroanatomy was chosen for the revision sessions, since it is recognised that students find it the most challenging (so called neurophobia), and therefore, would benefit from extra support on the subject [16, 17]. All second-year students of their respective cohorts (n = 245 and n = 247) were invited to attend the sessions through group emails, posters, and lecture announcements during the duration of the semester.

Each year, the revision classes comprised three 1-h-long sessions, where the cranial nerves were split into two 1-h sessions and spinal tracts taught within 1 h. These topics were chosen based on their clinical importance and reputation, as being the most troublesome areas for students. The groups varied between 8 and 12 students depending on attendance. The sessions were taught by a series of the third- (3YMS), fourth- (4YMS), fifth (5YMS)-year medical students and junior doctors (JD) who were rotated, so that students received a different teacher type for each of the three sessions (Fig. 1). The teachers were all volunteers who showed an enthusiasm either for teaching or the subject area of neuroanatomy and taught all three sessions where logistically possible. They were selected for their enthusiasm and willingness to teach rather than their neuroanatomical knowledge. All student teachers subsequently received a certificate confirming their participation in the NPT sessions which could be used for their portfolios. The student learners completed a previously validated (Cronbach alpha score—0.83) paper-based Likert-style survey anonymously at the end of each session. The survey examined multiple perception criteria ratings of the session/teacher. These criteria were statistically determined to be part of either social or cognitive congruence and validated using the principal component analysis. Students were blinded to the academic status of their teachers and the purpose of the feedback forms.

The teachers were briefed to use standardised learning outcomes and resources which were reviewed by the Faculty’s anatomy department; however, the teachers were free to deliver their session in a format of their choice.

For a more meaningful comparison of NPT definitions within the existing published literature, the third-, fourth-, and fifth-year medical student groups were combined to give an overall senior medical student (SMS) group. This group was then compared to the junior doctors (JD).

All data were tested for the normality of distribution and the statistical analysis conducted using SPSS Ver 21. Ethical approval for this study was granted by the University of Southampton Ethics committee (Ethics ID 799).

Near-peer teaching is a concept that has been practiced for many years within anatomy education [1, 11, 15, 18‐20, 24]. The countless benefits of this approach for the students, teachers, and anatomy departments are already well documented [5, 10, 22, 24, 25]. In more recent times, the drive towards modern professionalism led curriculums has led to a decline in the amount of timetabled sessions available for basic science subjects like anatomy compounded by a reduced number of qualified anatomy educators [19, 29]. Therefore, NPT programmes can be viewed as one of a variety of possible solutions to maintain standards of knowledge and confidence in the subject. With this in mind, it becomes increasingly important to scrutinise the benefits of NPT, particularly if they are to become formally incorporated as part of curriculum delivery, as it has done at The University of Southampton.

The benefits of NPT to the teacher have been previously well-described by Reyes- Hernandez [24] and Bulte [4] with benefits to the faculty explored in a study by Duran [8]. Our investigations have focused more on the benefits to the student learners with aims and objectives similar to that of Evans and Cuffe [11] only with a stronger emphasis on the educational distance between tutors and students. Our sessions garnered a high overall rating for the quality of the session as well as consistently high ratings for all areas of feedback across all teacher types, highlighting the value of both the SMS and JDs acting as near-peer teachers. Furthermore, in the current study, students taught by all four-teacher types reported an increase in their perceived knowledge as a result of attending the session (Table 2). This would suggest that this type of teaching is an effective means to impart knowledge, and that all student teachers successfully fulfilled the role of tutor. This finding, in turn, adds further support to the growing weight of published evidence supporting the successful use of medical students as teachers in the education of their colleagues [1, 8, 10, 19, 22, 23, 26]. In addition, it not only argues in favour for the application of NPT initiatives within medical education, but also provides evidence to suggest that NPT revision programmes can be fully integrated into an established anatomy curriculum.

Previous work in this field suggests that increasing the educational distance between the student and teacher could have a detrimental effect on how the teacher is perceived by the student [14]. This could, in part, be explained by social and cognitive congruencies as well as the increase in professional identity associated with graduation. By identifying when the influence of social and cognitive congruence changes, it may be possible to not only better define NPT, but also reveal other potential factors, in addition to distance, which contribute to the success of NPT.

Our current study is in agreement with Hall [14] who reported that SMS significantly outperform JDs in multiple areas of NPT feedback. We found that 3YMS and 4YMS were rated significantly higher than 5YMS and JDs in multiple areas of the survey (Table 2). However, when assessing the feedback gained about the 3YMS and 4YMS, there was no significant difference between the two teacher types in any area of the evaluation. This was also the case when comparing 5YMS and JDs and might suggest a possible ‘drop-off’ in social and cognitive congruence along the NPT spectrum.

Specifically, two important areas of social congruence, approachability of the teacher and enjoyment of the session, were rated significantly higher for 3YMS and 4YMS compared to the 5YMS and JDs. This leads us to speculate that the teachers may no longer be able to be a ‘student among the students’; something frequently cited as a defining feature of social congruence [21, 27].

While it may be true that near-peer facilitators have less formal experience as teachers, their greatest asset may be their ability to bring a student’s perspective to their role [8, 9]. The student, to a large extent, relies on the expertise and experience of a teacher to select the most relevant knowledge and teach it in the most appropriate way [6]. Students reported that the content taught by the third- and fourth-year medical students during the sessions was significantly more relevant to their needs and delivered in a better way than the sessions by a 5YMS or a JD (Table 2). Junior doctor led NPT in prescribing and examination skills was rated as very relevant by the final-year students [29]. The material selected by JDs for NPT may be suitable for clinical subjects to senior students, but becomes less relevant for the second-year students, if they focus on the clinical aspects of the topics, as opposed to the core neuroanatomy principles needed for the second-year exams. This was a theme mirrored by anecdotal comments given by the students.

There are multiple factors involved as to what makes an effective teacher. One key factor is the motivation of the teacher themselves which will come along with cognitive congruence, but inversely with an increased learner- teacher distance. Teacher motivation will subsequently impact on other areas of how a teacher can be assessed, including preparedness of the session, teacher enjoyment of the session, and so forth. These are areas that could be assessed in future sessions as well as to incorporate teacher feedback to better understand what effect the motivation of the teacher has on how they are perceived by their students.

The results of the current investigation strengthen the theory that graduation appears to be an important threshold in terms of how a teacher is perceived by their students [14]. We have measured the learners experience based on the overall rating of the sessions and depicted the hypothesis (Fig. 2) that this is reduced over what we called a transitional zone period, which is represented around graduation time. Graduation is an academic, personal, and social transition, suggesting that it impacts on how a teacher is perceived [2, 12]. On entering the final year, the student is expected to behave less like a student and more like a practicing doctor. With this change comes the altered mindset, including the realisation of future job stresses, responsibility and the increased requirement for autonomy. Although this training equips the final-year medical students with the skills and attitudes required for working life as a doctor, the drawback is that they share less cognitive and social congruencies with their junior medical student colleagues, and this may impact on their success as a teacher at undergraduate level [3].

Interestingly, one of the only areas of feedback that did not show significant differences across all teacher types was how confident the teaching made the students feel about their forthcoming examinations; this was also the area of feedback that was universally rated the lowest. Asking medical students to rate their confidence about examinations may be insensitive to differences in teacher type because of student’s natural fear of examinations and failure to progress. It is well known that students are inherently poor at judging their own ability [13, 28].

Given the fact that NPT has a variety of conflicting definitions, these results may allow further refinement of the NPT definition [4, 11, 18, 26]. Bulte et al. [4] state that the students and their teachers must be ‘at the same level of the medical education spectrum’ for it to be truly near-peer teaching. From our experience, we propose that distance between the teacher and learner, irrespective of any hierarchical boundaries, should be considered in future enhancements of the NPT definition.

Educational distance along the NPT spectrum has been emphasised as an important factor within the application of NPT. Specifically, progression from 3rd year to 4th year had a little influence on the way, the teachers are perceived by learners. However, entering into the final year of medical school and the proximity to graduation seems to be important in terms of the differences between student-ratings of the teachers. We are in agreement with many previous investigations in concluding that changes in social and cognitive congruence are at least partly responsible for this. Not withstanding the value of an enthusiastic and pedagogical “classical” anatomy teacher, NPT has continued to show promise of being a useful tool in maintaining a satisfactory anatomical level of medical students given an ever growing pressure on curriculum time, diminishing resources, etc. If anatomy education begins to rely more on NPT programmes in the future; investigations, such as this may be an important step towards understanding how the student experience can be maximised.