It was a non- randomized, Interventional study, with mixed methods design. Locus of study was Department of Physiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi (M), Wardha, India. Ethical clearance was obtained and Informed consent was taken for participation in the study. Two hundred students of first MBBS were divided into four groups of 50 students each (Batch A,B,C&D). This is a routine method of splitting 200 students into 4 groups during conduction of tutorials in physiology. For the current study, two of the four batches (Batch B & D) were taken as cases (n=100) and two groups (Batch A&C) were taken as controls (n=100), as per convenience sampling. All the four batches were seated at four different demonstration rooms. The cases recruited had 42 male and 58 female students between age group of 17-18 years. Control group had 47 male and 53 female students between age group of 17-18 years. No student had any previous experience with Peer teaching.

Controls: The controls underwent tutorials conducted by faculty members on specified topics which were already taught by didactic method. As a routine practice, the tutorial topic is displayed at the beginning of the month and students are asked to be prepared with the topic. All the topics are taught by didactic method before hand. During tutorials, the given topic was discussed by the faculty and doubts were clarified.

Cases: Cases (n=100, batch B & batch D) were asked to be well prepared with the topic displayed at the beginning of the month. During actual class; each batch of 50 students were divided into 5 subgroups (10 students in each group). The topic to be discussed was split into five subtopics and each group was given one subtopic. After distributing the topics, each group was asked to prepare the topic for teaching in a large group. The students were made aware that the selection of tutors will be based on the lottery system, which prepared them mentally for the role. Lottery system of selection was intended to avoid bias. They were briefly sensitized about teaching skills and how they should conduct the teaching session. An orientation as to what is not PAL viz. it should not be targeted at weak students i.e. all participants should be benefitted and it is not a means of reducing existing faculty-student contact, was provided. Fifteen minutes were assigned to prepare the topic for teaching, after which one student was selected from each subgroup based on lottery system. All selected students enthusiastically agreed to be peer tutors. All 50 students were re-assembled and the selected students came forward sequentially to teach respective sub-topics. The media allowed for teaching was chalk and board. After teaching sessions were over, peer teachers were provided with group feedback where the faculty along with five peer teachers were seated together and discussed about: 1) What went well; 2) What needs to be improved and; 3) How it should be improved. The opinion and reflections of peer teachers were encouraged during feedback session and it was taken on record [Table/Fig-1].

[Table/Fig-1]:

Plan of work

A total of 4 topics were discussed by both the methods over a span of two weeks; each week comprising of two Tutorial/Peer teaching classes, of one hour duration. The four topics taken were: 1) Regulation of Respiration; 2) Mechanism of Urine formation; 3) Regulation of Blood pressure and; 4) Thyroid hormone.

Multiple Choice Questions (MCQ) based Pre-test and Post-test were taken for both cases and controls. Ten MCQs were framed for each topic which included MCQs of simple recall-4, understanding -3 and application (problem based)- 4. Pre–validated questionnaire based feedback was obtained from peer teachers and students who witnessed peer teaching sessions, regarding their perception about peer teaching. Verbal Opinions and reflective statement of peer teachers were recorded. A surprise class test was conducted for both cases and controls after a month, which consisted of questions from the four topics which were discussed as a part of study. The test comprised of 20 MCQ - 1 mark each, 7 Short answer questions (SAQ) - 2 marks each, and two long answer questions LAQ- 8 marks each, making a total of 40 marks.

Parametric test of significance, Paired t-test was applied for comparing the pre and post test scores of cases as well as controls. Unpaired t-test was applied for comparing post test scores between cases and controls (p<0.5 was considered significant). Class average normalized gain was calculated for pre and post test of cases and controls, as follows:

〈g〉 = {〈% Post test 〉 - 〈% Pre test〉}/ {100% - 〈% Pre -test〉}[11]

A predefined target 〈g〉 of 30% was taken as defining the minimum value at which the educational intervention could be regarded as effective [16–18]. The results of surprise test of cases were compared with controls. The marks were analysed for total score and for scores in different sections of question paper; viz MCQ, SAQ and LAQ. The percentage of responses was analysed for closed ended items of feedback questionnaire.

Open ended responses were analysed by categorization and charting percentage of responses. The reflective statements were recorded verbatim and categorized into five type of reflective statements.

During course of the study, 3 cases and 4 controls were excluded from the study because they were absent in one /two sessions.

The average pre and post test scores were calculated for the entire 4 sessions taken together. The average pre and post test score was 2.9 and 7.012 respectively in controls (p = 0.023) and 2.8 and 7.4 respectively in cases (p = 0.011); both statistically significant (p < 0.05 was considered statistically significant). The average post test scores between cases and controls were more for cases (7.4), though not statistically significant. The class average normalized gain was 〈g〉 for Tutorials were 49% and for peer teaching was 53%.

The surprise class test had average scoring of 36 marks (out of 50) for control group and 41 marks for cases. Analysed section wise, the average scoring in MCQ (MM – 20), SAQ (MM – 14) and LAQ (MM – 16) was 14, 10 and 9 for controls and 15, 10 and 12 for cases. The section wise analysis suggested that through peer teaching, retention was better for descriptive answers as LAQ has better average score in cases. Rest of the sections (MCQ & SAQ) had almost similar average scores.

According to student perception, 66.16 % of them felt that Peer Teaching was stressful and taxing; however, they agreed to strongly agree that it made them more confidants about the topic and helped in learning. The peer teachers endorsed feedback as helpful (100%) and prompted them to reflect upon their own teaching and knowledge gaps (98.22%) [Table/Fig-2]. The students attending peer teaching (n=87) found it motivating and helpful and depicted positive inclination towards such practices in future. Majority of the students agreed that it prompted them to pay attention in the class (96.19%), though a small percentage of students disagreed (3.81%) [Table/Fig-3].

Open ended responses to “What was the best part about my experience as a teacher?” were categorized into: 1) Self directed learning; 2) Self Assessment; 3) Enjoyable; 4) Motivating, & 5) Enhanced learning [Table/Fig-4]. Most of the peer teachers found the whole exercise enjoyable, encouraging and helpful in learning. Responses of peer teachers to “How I could have done better?” could be sorted into three categories i.e. Better preparation, More guidance and Alternate teaching media [Table/Fig-5]. They felt that more preparation time, added guidance and permission to use power point presentations might have helped them to perform in a better way. With regards to best part about peer teaching method, students who attended the sessions felt that it made the class interesting and prompted them to learn together [Table/Fig-6]. Ninety six percent of students felt that this should be practiced often as it will help them in comprehensive learning in and interesting way [Table/Fig-7]. The verbal opinion and reflective statements were categorized into reflection in action, reflection on action, claiming evidence, describing experience, and recognizing discrepancies [Table/Fig-8].

Tutorial being mainly a teacher-controlled activity, though students were encouraged to participate, there was a limited opportunity to express their opinions [15]. Faculty tutors reported active participation by only few motivated students, whereas others were mere passive listeners.

PAL has been effective in learning process, self directed and collaborative learning [19]. Medical students, as a part of their professional career, are always involved in teaching, as they become sources of health information for patients, family, friends and during their clerkship. While undergoing the process of preparing to teach, they show better understanding of complex concepts [20]. This is believed to occur through learners’ detection and repair of defective mental models [21,22]. Since its conception, there have been many attempts by medical educationists to formalize peer-teaching, a method of PAL, in both undergraduate [23–26] and postgraduate settings [27–29]. In United Kingdom, acknowledgment of peer-teaching and its associated benefits has been formally expressed by the General Medical Council (GMC) whose statement maintains that medical graduates “must be able to demonstrate appropriate teaching skills” [30].

The current study was an attempt to generate evidence about the potential of teaching practice as an effective method of self-directed learning in Physiology. There are significant hours dedicated to tutorials as a method of teaching Physiology at our Institute. However, challenges of decreased faculty strength (as per regulatory requirements) and increased number of students are major limiting factors. We directed our efforts to suggest and evaluate the efficacy of an alternative method without disturbing the curricular framework and yet ensuring maximum participation with better learning. Similar rationale was shared by a study conducted by Durá CE et al., for teaching anatomy course by final year medical students due to low faculty strength [31]. Other aspects of learning like working in a team, presentation skills, and critical-thinking were also fostered by peer teaching, which is often neglected in tutorials.

Most of the learners found teaching exercise enjoyable and helpful in learning. Similar observations were recorded by Bardach et al., in “Teach how to Teach” sessions of Final MBBS students where the students strongly endorsed the program and agreed that formal instruction in teaching should be a required part of medical education [32]. A plausible explanation is that in response to learners’ questions, teachers must generate sensible self-explanations before offering explanations to their students, and this self-explanation stimulates further learning on the part of the teacher. The process of preparing to teach helps the students to organize and authenticate their knowledge [33]. Comparable annotations were recorded by Darrell J et al., regarding advantage of using near-peer teachers to reinforce and expand their own learning and develop essential teaching skills [34]. Feedback from participants, in the same study, suggested that the program fulfill its aim of providing an effective environment for developing deeper learning through teaching, which is also analogous to the findings in current study.

Though, only four teaching sessions were conducted in the present study and that two with different peer tutors, their readiness for further such sessions (in feedback) evidences their enhanced confidence levels. They found themselves better prepared for subsequent teaching sessions. Almost all peer tutors agreed that this exercise should be a part of their regular teaching learning activities. Consequentially, better average score in LAQ amongst cases can be contemplated as an indicator for better understanding, comprehension and retention of physiological principles and elucidations. Peer tutors strongly agreed that feedback (after teaching) helped them to diagnose their learning needs and how they can improve their teaching skills. The importance of self- reflection was well recognized in perceptions recorded as it consolidated the learning process [35,36]. Prompting reflections encouraged them to learn from personal experience and inculcate the habit of taking responsibility for one’s actions and decisions. Though very few studies have been undertaken in undergraduate medical education in this context, almost all of them report positive reaction from the learners and a general perception to be included as a part of routine teaching learning activity [14,23,37–39]. The reported benefits are seen through a greater openness in classes, with increased access, involvement, interest in learning, and confidence in participating [40,41].

The study also recorded feedback of students who actually attended the peer teaching classes. They found the whole activity motivating and encouraging. Being taught by fellow student was a reason which prompted them to be attentive and it alsoprovoked them to be well prepared with the topic. According to education theory, medical students learning and applying teaching principles may become active participants in their own learning process. A systematic review of Medical students-as-teachers, in this regard states that Peer-teaching in undergraduate medical programs is comparable to conventional teaching when utilized in selected contexts with a strong evidence to suggest that participating student-teachers benefit academically and professionally, though most of the outcomes are short term without any evidence of long term impact [42].

Advantages which emerged, can be listed as follows:

Teaching can stimulate further learning by the teacher as it involves interplay of three processes: metacognitive awareness; deliberate practice, and self-explanation. Coupled with immediate feedback and reflective exercises, learning can be measurably enhanced along with improved teaching skills in subsequent sessions. Not only is it useful for peer teachers, but also for students attending those classes, as they get intrinsically motivated to learn and to teach. It is effective in inculcating teaching skills right from undergraduate years and goes a long way in building professional competencies required at every phase of a medical professional. Efforts should be directed to incorporate peer teaching as a part of curricular strategies on a larger scale for re-enforcement of knowledge and learning in a collaborative manner.