• Inamullah Shah Foundation University Medical College, Islamabad
  • Usman Mahboob Khyber Medical University, Peshawar
  • Sajida Shah Shifa International Hospital, Islamabad


Background: All students cannot be individually trained in physical examination skills due to faculty and time limitations. Peer-assisted learning (PAL) can solve this dilemma if it is used in undergraduate curriculum. Empirical effectiveness of horizontal peer-assisted learning model has not been reported previously. The objective of this study was to compare horizontal peer-assisted learning (PAL) with expert-assisted learning (EAL) in teaching of physical examination skills. Methods: This is a randomized controlled study (Solomon four group design) carried out at a medical school. A total of 120 undergraduate year 5 students were randomized into two groups to undergo training in four areas of physical examination. Stratified random sampling technique was used. Group 1 was trained by EAL while Group 2 by PAL.  Half students from both groups were given a pre-test to assess the testing effect. Both groups were given a post-test in the form of an OSCE. Independent samples t-test and paired sample t-test were used as tests of significance. Results: Group 2 scored significantly higher than Group 1. There was significant difference (p=.000) in mean post-test scores of Group-1 (69.98±5.6) and Group-2 (85.27±5.6). Difference in mean scores was not significant (p=.977) between students who had taken the pre-test and those who had not. Conclusion: This study has implications in curriculum development as it provides quantitative evidence indicating that horizontal PAL as a learning strategy can actually replace, rather than augment, expert-assisted learning in teaching clinical skills to undergraduate students.Keywords: Clinical education; horizontal PAL; Peer-assisted learning; Quantitative; Assessment; Randomized controlled trial; Solomon’s four group design

Author Biographies

Inamullah Shah, Foundation University Medical College, Islamabad

Associate Professor Surgery

Usman Mahboob, Khyber Medical University, Peshawar

Assistant Professor, Institute of Health Professions Education and Research

Sajida Shah, Shifa International Hospital, Islamabad

Assistant Consultant, Department of Radiology


Buckley S, Coleman J, Davison I, Khan KS, Zamora J, Malick S, et al. The educational effects of portfolios on undergraduate student learning: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11. Med Teach 2009;31(4):282–98.

Topping KJ, Ehly SW, editors. Peer-assisted learning. Mahwah, N.J: L. Erlbaum Associates; 1998. p.371.

Olaussen A, Reddy P, Irvine S, Williams B. Peer-assisted learning: time for nomenclature clarification. Med Educ Online 2016;21(1):30974.

Liew SC, Sow CF, Sidhu J, Nadharaja VD. The near-peer tutoring programme: embracing the “doctors-to-teach” philosophy – a comparison of the effects of participation between the senior and junior near-peer tutors. Med Educ Online 2015;20:27959.

Khaw C, Raw L. The outcomes and acceptability of near-peer teaching among medical students in clinical skills. Int J Med Educ 2016;7:188–94.

Preece R, Dickinson EC, Sherif M, Ibrahim Y, Ninan AS, Aildasani L, et al. Peer-assisted teaching of basic surgical skills. Med Educ Online 2015;20:27579.

Mortel TF, Silberberg PL, Ahern CM, Pitt SW. Supporting near-peer teaching in general practice: a national survey. BMC Med Educ. 2016;16:143–54.

Riaz I. Peer assisted versus expert assisted learning: A Comparison of effectiveness in terms of academic scores. J Coll Physicians Surg Pakistan 2014;24(11):825–9.

Berghmans I, Druine N, Dochy F, Struyven K. A facilitative versus directive approach in training clinical skills? Investigating students’ clinical performance and perceptions. Perspect Med Educ 2012;1(3):104–18.

Burgess A, McGregor D, Mellis C. Medical students as peer tutors: a systematic review. BMC Med Educ 2014;14:115–22.

Menezes A, Burgess A, Clarke AJ, Mellis C. Peer-assisted learning in medical school: tutees’ perspective. Adv Med Educ Pract 2016;7:31–8.

Kodabux A, Hoolash BK. Peer learning strategies: Acknowledging lecturers’ concerns of the Student Learning Assistant scheme on a new higher education campus. J Peer Learn 2015;8(1):59–84.

Saleh M, Sinha Y, Weinberg D. Using peer-assisted learning to teach basic surgical skills: medical students’ experiences. Med Educ Online 2013;18(1):21065.

Weberschock TB, Ginn TC, Reinhold J, Strametz R, Krug D, Bergold M, et al. Change in knowledge and skills of Year 3 undergraduates in evidence-based medicine seminars. Med Educ 2005;39(7):665–71.

Ringsted C, Hodges B, Sherpbier A. ‘The research compass’: An introduction to research in medical education: AMEE Guide No. 56. Med Teach 2011;33(9):695–709.

Larsen DP, Butler AC, Roediger HL 3rd. Test-enhanced learning in medical education. Med Educ 2008;42(10):959–66.

Mayer R, Wittrock M. Problem-solving transfer. In: Berliner DC, American Psychological Association, editors. Handbook of educational psychology: a project of Division 15, The Division of Educational Psychology of the American Psychological Association. Mahwah, NJ: Erlbaum; 2004. p.47–62.

Teddlie C, Yu F. Mixed Methods Sampling: A Typology with Examples. J Mix Methods Res 2007;1(1):77–100.

Fraenkel JR, Wallen NE, Hyun HH. How to design and evaluate research in education. 8th ed. New York: McGraw-Hill; 2012. p.642.

Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health. [Internet]. [cited 2017 May 31]. Available from: http://www.openepi.com/Menu/OE_Menu.htm

Lawshe CH. A quantitative approach to content validity. Pers Psychol 1975;28(4)563–75.

DeVon HA, Block ME, Moyle-Wright P, Ernst DM, Hayden SJ, Lazzara DJ, et al. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh 2007;39(2):155–64.

Bannerji M, Capozzoli M, McSweeney L, Sinha D. Beyond Kappa: A review of inter-rater agreement measures. Can J Stat 1999;27(1):3–23.

Weir JP. Quantifying test-retest reliability using intraclass correlation coefficient and SEM. J Strength Cond Res 2005;19(1):231–40.

Viera JA, Garrett JM. Understanding inter-observer agreement: The Kappa Statistic. Fam Med 2005;37(5):360–3.

Blank WA, Blankenfeld H, Vogelmann R, Linde K, Schnieder A. Can near-peer medical students effectively teach a new curriculum in physical examination? BMC Med Educ 2013;13:165–70.

Bangert-Drowns RL, Kulik CC, Kulik JA, Morgan M. The instructional effect of feedback in test-like events. Rev Educ Res 1991;61(2):213–38.

Kang SH, McDermott KB, Roediger III HL. Test format and corrective feedback modulate the effect of testing on long-term retention. Eur J Cogn Psychol 2007;19(4-5):528–58.

Kulik JA, Kulik CC. Timing of feedback and verbal learning. Rev Educ Res 1988;58:79–97.

Pashler H, Cepeda NJ, Wixted JT, Rohrer D. When does feedback facilitate learning of words? J Exp Psychol Learn Mem Cogn 2005;31(1):3–8.

Sayma M, Williams HR. A new method for teaching physical examination to junior medical students. Adv Med Educ Pract 2016;7:91–7.

Hoad-Reddick G, Theaker E. Providing support for problem-based learning in dentistry: the Manchester experience. Eur J Dent Educ 2003;7(1):3–12.

Bibb CA, Lefever KH. Mentoring future dental educators through an apprentice teaching experience. J Dent Educ 2002;66(6):703–9.

Glynn LG, MacFarlane A, Kelly M, Cantillon P, Murphy AW. Helping each other to learn – A process evaluation of peer assisted learning. BMC Med Educ 2006;6:18.

Wadoodi A, Crosby JR. Twelve tips for peer-assisted learning: a classic concept revisited. Med Teach 2002;24(3):241–4.

Allikmets S, Vink JP. The benefits of peer-led teaching in medical education. Adv Med Educ Pract 2016;7:329–30.

Nestel D, Kidd J. Nurses’ perceptions and experiences of communication in the operating theatre: a focus group interview. BMC Nurs 2006;5:1–9.

Lockspeiser TM, O’Sullivan P, Teherani A, Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Heal Sci Educ Theory Pract 2008;13(3):361–72.

Meller SM, Chen M, Chen R, Haeseler FD. Near-Peer Teaching in a Required Third-Year Clerkship. Yale J Biol Med 2013;86(4):583–9.