Learning Assistants in Flipped-Classrooms: A New Pedagogical Strategy for Pre-Clinical Medical Education

Abstract

Problem-based learning has been widely incorporated into pre-clinical medical education to increase the applicability of pre-clinical knowledge. However, studies have demonstrated increased learning burden and decreased confidence in learning when adapting to this didactic medium. To the authors’ knowledge, limited interventions target these shortcomings in real time. Thus, we adapted and implemented a “Learning Assistants” (LA) program that can be deployed in pre-clinical didactic sessions. In this prospective pilot study, trained LAs were deployed in the classroom to assist students in their clinical case vignettes under instructor supervision. Learning assistants and students completed pre-session and post-session evaluation surveys to assess LA helpfulness, student confidence, and interest in study material. Paired observations were evaluated using Wilcoxon signed-ranks tests, ANCOVA, and paired t-tests. Unstructured responses were evaluated using thematic analysis. A significant improvement in both student interest (p < 0.001) and confidence (p < 0.001) in the course material was observed after each surveyed session. No significant difference was observed in student-perceived LA helpfulness across the sessions (p = 0.12). Thematic analysis revealed common themes in student knowledge gaps, including challenges with understanding drug mechanisms of action and drug interactions. The results suggest that this program may consistently positively impact student interest and confidence. However, further research is needed to evaluate the impacts of this intervention on learning outcomes and standardized assessments. This study highlights the potential for such a program to bolster pre-clinical didactic sessions that utilize the problem-based learning instructional modality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01958-x.

Introduction

The advent of problem-based learning (PBL) and its widespread adoption in MD and DO pre-clinical curricula [1, 2] signals the shifting learning paradigm in medical education from a more didactic to a more contextual one. PBL helps better address the deliverables set for students through “competency-based” curriculum structures, which require medical students to meet specific knowledge and skill-based competencies before advancing to the next step in the educational pipeline [2]. The premise of PBL in medical education involves the use of case-based problem sets or clinical vignettes that students solve in a lecture or small group setting, with concepts learned during their pre-study sessions or at-home studying prior to the lecture. Through a problem-based system, students are more likely to understand the practical application of pre-clinical knowledge in a clinical setting [3]. It is essential to acknowledge that the interpretation and implementation of PBL can vary. In our study, PBL is characterized by the use of case-based problem sets surrounding a series of clinical vignettes, which students initially engage with individually and then explore further in group settings, in the small-group classroom setting. This approach emphasizes the application of pre-clinical knowledge in clinical settings and fosters self-directed learning, where students identify their learning needs, set goals, and employ strategies to meet these needs. The flipped classroom model used in this study involves students completing preparatory work before class and engaging in active, problem-solving activities during class sessions. This model aligns with PBL by encouraging the practical application of knowledge and addressing misconceptions in real-time. The flipped classroom model used in this study involves students completing preparatory work before class and engaging in active, problem-solving activities during class sessions. The Learning Assistant (LA) program developed for this study is adapted from the Colorado Learning Assistant model, a pioneering initiative in educational reform. Our LA program is designed to address specific needs within our medical school’s PBL and flipped classroom context, aiming to enhance student learning outcomes and engagement in a challenging and evolving educational landscape.

While initially more prevalent in undergraduate education, the flipped classroom approach is increasingly utilized in medical education, contradicting the notion that it is solely an undergraduate strategy. Moreover, a PBL curriculum employs student initiative as a driving force and supports a system of student-faculty interaction in which the student assumes primary responsibility for the learning process [3]. In theory, through a more interactive didactic session, PBL also encourages the real-time correction of knowledge misconceptions, thereby more readily addressing knowledge gaps [4]. A meta-analysis of PBL methodology implementation demonstrated consistent improvements in student satisfaction, communication, and self-learning skills [5]. In this way, the PBL model helps foster a greater motivation and interest in self-directed learning amongst students, in which students diagnose their learning requirements, develop learning goals, and implement learning strategies to address these requirements [6, 7].

However, the heterogeneity in the definition of PBL along with the variety of outcomes or metrics measured in practice results in a profound variability of success when deploying this model [8]. Furthermore, literature analysis indicates that PBL-based curricula bring their own slew of hurdles ranging from student confidence in learning to decreased reusable resource development by faculty. For example, an investigation by Chakravarti and Vijayan demonstrated significantly reduced “perceived self-directed learning readiness scores” in first-year medical students [9]. Additionally, PBL-based curricula have been shown to dissuade lecturers from refining educational materials and identifying knowledge gaps in students, possibly due to the onus of “self-teaching” placed on students [9, 10]. Finally, institutions face logistical challenges when implementing a PBL model in larger classroom settings [10]. Although some techniques, such as “peer-feedback” mechanisms, have been used to mitigate this, they prove to be less repeatable and reliable [11].

Such shortcomings are not limited to the pre-clinical education setting. In the undergraduate (pre-medical) space, some instructors employ a “flipped classroom” blended instructional strategy [12]. In the flipped classroom setting, pupils complete pre-reading and come to class to work on live instructor-guided problem-solving. However, many of the problems seen in PBL are conserved in this pre-medical space. Some institutions have deployed peer assistance programs in the pre-medical undergraduate flipped classroom to address these limitations. Such programs have been implemented at institutions with sizeable undergraduate student bodies, usually as part of a comprehensive curricular transformation accompanied by a pedagogical switch to active learning [13]. In this situation, the prototypical peer facilitator is an undergraduate student that has completed and excelled in the desired course and maintains a self-identified passion for teaching and a past engagement in teaching (through activities such as peer-tutoring). Peer facilitators are tasked with the following in the flipped-classroom setting:

• Facilitating conceptual learning and association-forming as students work through the case.

• Assisting faculty during in-class activities (such as handing out activities or answering technical questions)

• Functioning to improve inter-group and intra-group cohesion through discussion.

These functions are reminiscent of the teaching assistant role typically observed in other instructional settings (such as the anatomy lab). The implementation of facilitator support in our program has been observed to positively increase students’ performance on common exam questions that require higher-order cognitive skills. This enhancement in performance underscores the effectiveness of our facilitator-led approach in promoting deeper understanding and application of complex concepts and is consistent with the literature [14].

The flipped classroom instructional strategy shares significant similarities with the pre-clinical PBL teaching modality employed at many medical schools. Given the relative efficacy of the peer-facilitator augmented classroom experience, the research team sought to determine this strategy’s efficacy in the pre-clinical flipped classroom setting. By piloting the LA program in a novel setting, the authors of this study investigated the impact of this in-classroom intervention on student confidence, group cohesion, student interest in subject matter, and real-time misconception clarification. To the author’s knowledge, such a program has not yet been deployed in other pre-clinical PBL settings. Through a prospective survey-based study, the research team attempted to identify early trends in specific components of the cognitive and affective domains in Bloom’s taxonomy [15]. This involved assessing student learning confidence, interest in subject material, classroom attendance, and collecting feedback on the difficulty of content or extent and propagation of concept misconceptions. In developing the LA program, the authors aimed to create a more collaborative, friendly, and inclusive environment for attending medical students during PBL sessions. Finally, the research team hoped to establish the feasibility constraints of implementing such a program and its limitations with scaling.

Methods

This study was conducted at a single site, at the California University of Science and Medicine’s (CUSM) main campus in Colton, CA. The governing institutional review board granted the study expedited approval. The data collection process began with recruiting LAs in December 2022 and ended with the final student surveys administered in early February 2023. The LA program was deployed during the Cardiopulmonary block for M1 students.

Prior to detailing the training and activities of the LAs, it is crucial to outline the specific tasks of the students they were assisting. Prior to each class, students were required to independently study the relevant material, focusing on the pre-assigned case-based problem sets or clinical vignettes. This preparatory work was designed to equip students with foundational knowledge and insights to actively engage in the upcoming PBL sessions. During the class sessions, students were organized into small groups to collaboratively work through the problem sets, with faculty support provided by one faculty member for the entire class as necessary. These activities were structured to promote critical thinking, application of pre-study knowledge, and active learning. Students were encouraged to discuss, debate, and explore various aspects of the case studies, guided by the principles of case-based exploration. The role of the LAs in these sessions was to facilitate discussion, clarify misconceptions, and provide targeted feedback to enhance learning outcomes. The small-group format not only allowed for peer interaction and learning but also ensured that each student could actively participate and contribute to the problem-solving process.

By integrating both individual preparatory work and collaborative in-class activities, the program aimed to maximize student engagement and learning efficiency. This methodological approach reflects our understanding and application of PBL, case-based learning, and small-group learning in the context of medical education at our institution.

LA Program Recruitment

Prospective LAs were recruited using a campus-wide email flyer circulated to students in the M2, M3, and M4 classes within the CUSM MD program. Supplementary Resource 1 demonstrates the selection criteria that LAs had to meet to be eligible for an interview. Candidates were subsequently interviewed to clarify logistic requirements, including availability and scheduled absences.

LA Activities

Selected LAs participated in a range of program-related educational opportunities to develop pedagogical skills and broaden their understanding of educational research. LA activities are based on the LA Model developed at the University of Colorado, Boulder in 2001 [16].

1. Pedagogy Seminar

Table 1 outlines the major topics covered in the pedagogy seminar series. LAs attended this seminar weekly before starting their in-classroom facilitating experience. The pedagogy seminar was an active learning, feed-forward system in which LAs answered questions and received immediate performance data after answering them. LAs engaged in group-learning activities, self-reflection, and developed communication skills during each seminar. The seminar series was taught by the research team, consisting of two M4 student instructors and a faculty supervisor. LAs also attended a “mini journal club” at the end of each seminar. This portion of the session was devoted to discussing high-quality, peer-reviewed research in medical education. Pedagogy seminar materials were adapted and modified from the Undergraduate Learning Assistant Program at the University of California, Los Angeles [17].

• 2.Content Meetings

Table 1.

Outline of pedagogy seminar lecture topics

Week	Topic	Journal club discussion topic
0	Orientation to active learning	-
1	Mental models	Problem based learning in medical education Active learning methodologies
2	Open ended questions Teaching styles Collaborative learning theory	Cognitive load theory Learning styles
3	Theory of learning	Spaced repetition and learning enhancement techniques
4	Metacognition Expertise in skill (novice vs. expert)	Metacognition in medical education
5	Growth Mindset Coping and self-care Imposter syndrome Biases in learning and teaching	Medical student coping skills Diversity in medical organization

Throughout the seminar series, LAs attended “content meetings” with relevant faculty to discuss the material and learning objectives of each PBL session they would attend. Faculty from the Department of Medical Education and Pharmacology at CUSM guided these meetings. LAs addressed potential misconceptions or errors in clinical vignettes and clarified their own content understanding during these sessions. LAs also reviewed specific material relevant to board exams and in-clinic experiences during this time.

• 3.In-Person PBL Lectures

Upon completion of the pedagogy seminar, LAs were scheduled to attend in-person cardiac pharmacology PBL flipped classroom sessions planned for the M1 MD class, wherein students solved clinical vignettes in the context of learning cardiac pharmacological concepts. During this time, LAs completed a series of specialized tasks. Teaching facilitation by LAs enhanced the efficiency and effectiveness of faculty-led sessions, enabling faculty to cover more ground within the PBL framework. To do this, LAs directed student attention towards faculty as needed, assisted with handing out and collecting materials, facilitated technical issues with devices and conveyed the goal of the PBL set to student groups. LAs also played a role in engaging students by identifying and prompting those who could provide insights or answers during class discussions.

LAs facilitated student learning to enhance student learning performance, engagement, and attendance. They did this by building rapport with students and student groups, moving from group to group to evaluate group cohesion, assisting students on PBLs via teaching techniques learned in the seminar, identifying student or group conceptual weaknesses and addressing them in real time or requesting faculty clarification and helping students better understand the activity and goal of the specific problem set.

• 4.Program Benefits

LAs were offered a statement of recognition on their Medical School Performance Evaluation (MSPE) letters upon completion of the program.

Survey Series

Learning Assistant Surveys

One week prior to the start of each PBL session, the LAs were surveyed on their overall comfort with the material, types of study resources used, and duration of studying using an ordinal Likert-scale-based questionnaire with rating options from one through ten (where ten is the highest possible rating).

LAs also completed a post-session survey after each session within 48 h of session completion. This survey assessed changes in confidence and collected feedback on common student misconceptions or knowledge gaps through unstructured free responses. LAs received two surveys (pre and post) at the first session, and two surveys (pre and post) at the final session, for a total of four surveys. LAs also submitted reflections on their experience through an unstructured free-response section.

Student Surveys

Thirty minutes prior to the first PBL session, participating M1 students were also provided an ordinal Likert-scale-based questionnaire with rating options from one through ten (where ten is the highest possible rating) assessing interest in the subject matter and self-confidence in crucial learning skills through the Short Instrument for Confidence in Key Skills (SICKS) scale [18], shown in Table 2. Students were able to respond using a 5-point categorical Likert scale with the options “Strongly disagree,” “Disagree,” “Neutral,” “Agree,” “Strongly agree”.

Table 2.

Questions included in the modified SICKS scale

My learning is self-directed in medical school

I am a strong communicator

I regularly use technology to supplement my learning

I am good at problem solving

I am good at collaborative work

I enjoy thinking about problems that don't necessarily have definitive solutions

Students were then offered a post-survey assessing the overall helpfulness of the LA in teaching facilitation, concept clarification, and inclusiveness through the same categorical Likert scale responses. The pre-survey and post-survey were also completed during the final session. Students received two surveys (pre and post) at the first session and two surveys (pre and post) at the final session, for a total of four surveys.

Survey data were obtained using secure online surveys distributed by an encrypted intra-institutional email. Survey data did not collect student identifying information and was stored in a secure online database. Please see Supplementary Resource 2 for a complete list of qualitative and quantitative variables assessed.

Statistical Analysis

Statistical analysis for discrete, ordinal Likert-scale data was conducted using non-parametric methods. To account for related subject populations, the Wilcoxon signed-rank test was used. Categorical variables were analyzed using the chi-square test, while continuous data were examined using the unpaired t-test. ANCOVA was used to assess significant differences across both sessions. An alpha of 0.05 was set for all calculations. Unstructured data was pre-processed using grouping to identify common themes based on thematic analysis. Only the unstructured data for key concept difficulties was analyzed for this study. Data analysis was conducted using IBM SPSS Statistics for Windows (Version 27), Armonk, NY: IBM Corporation. Data were plotted using the data visualization features in SPSS and edited in Adobe Illustrator.

Thematic Analysis

In order to tailor the LA program to effectively meet the specific needs of our PBL sessions, we conducted a thematic analysis of common challenges and misconceptions encountered by students. This analysis was pivotal in shaping the curricular content and focus of our program, ensuring that LAs were well-prepared to address these areas in future sessions. This approach not only informs future training but also provides a framework for in-class facilitation. The insights gained from this thematic analysis are crucial for other institutions to assess the applicability of our LA program to their own curricular content. By understanding the specific student challenges we addressed, educators can determine the similarity and relevance of our program to their own educational settings.

The analysis revealed four main themes in the interview responses: knowledge gaps in drug names, challenges with understanding mechanisms of action, the need for greater understanding of drug use in disease processes, and a limited understanding of drug applicability across multiple therapy options. Students expressed unfamiliarity with cardiovascular and pulmonary drugs, with difficulty understanding key drug interactions, and challenges in relating mechanism of action to underlying receptor physiology.

Results

Table 3 outlines the descriptive statistics for the LA programs pilot run.

Table 3.

Descriptive statistics for LA program pilot

Variable	Value
Total number of LAs	4
Total students at first session	24
Total students at last session	23
Survey completion rate	95.5% of initial respondents
Average student interest before first session	6.00 out of 10
Average student interest after first session with LAs	7.41 out of 10
Average student confidence before first session	4.83 out of 10
Average student confidence after first session with LAs	6.83 out of 10
Number of LAs per session	4 (100%)
Average number of interactions with students at first session	11.25
Average time per interaction at first session	15 min
Average number of interactions with students at last session	17.75
Average time per interaction at last session	13.2
Average LA helpfulness	7.79 out of 10
Average pre-review time spent by LA before first session	1.1 h
Average pre-review time spent by LA before final session	1.8 h
Average student perception rating of engagement	4.45 out of 5
Average student perception rating of appropriate clarification/misconception	4.68 out of 5

A Wilcoxon signed-ranks test indicated that student post-session interest in subject material (average 7.41) after the first session with the LAs was significantly higher than the pre-session interest (average 6.00) (z = 224.5, p < 0.001). Student post-session interest in the last session (average 7.27) was significantly higher than pre-session interest (average 5.81) (z = 245.5, p < 0.001). Figure 1 depicts two box and whisker plots evaluating the before and after session results for the first and last session.

Fig. 1.

Comparative analysis of student responses pre- and post-learning assistant (LA) intervention across two sessions. This figure presents the results from student surveys conducted immediately before and after the first and final PBL sessions. It includes a whisker plot representation of students’ self-assessed interest, as measured using a Likert-scale questionnaire. The “pre-survey” indicates students’ responses prior to the LA intervention, while the “post-survey” reflects their responses after experiencing the LA-facilitated sessions (p < 0.001 for both comparisons). The comparison aims to highlight the changes in student interest attributable to the LA program over the course of these two key sessions

A similar result was observed in student confidence. A Wilcoxon signed-ranks test indicated that student post-session confidence in subject material (average 6.83) after the first session with the LAs was significantly higher than the pre-session interest (average 4.83) (z = 148.0, p < 0.001). Student post-session confidence in the last session (average 7.60) was significantly higher than pre-session interest (average 5.82) (z = 182.7, p < 0.001). A one way ANCOVA was used to compare pre-session student confidence to post-session confidence, normalizing for SICKS (perceived student self-confidence in overall learning ability) score as a covariate. Normality checks were carried out using the Levene’s test. There was a significant difference in mean confidence between the pre- and post-sessions [F(8, 15) = 8.214, p < 0.001].

Given that the LAs were learning to better interact with students over each session, student-perceived LA helpfulness was compared across each session using a paired t-test after determining the data was normally distributed. However, no significant difference was observed between the two sessions [t = 1.76, df = 22, p = 0.12 (95%CI 1.8 to 9.8)].

Categorical Likert scale metrics including “LA engagement with students,” “LA friendliness,” “Creation of an inclusive learning atmosphere,” “Appropriate answering of concept questions by the LA,” “Improvement in understanding with LA assistance,” and “Improved cohesion with LA involvement” were measured during the post-session surveys for the first and last session. A Wilcoxon signed-rank test was conducted on each variable to determine if there was a significant change in the rating distribution between sessions. Students reported significantly higher “Appropriate answering of concept questions by LA” (z = 2.02, p = 0.043) and “LA engagement with students” (z = 3.05, p < 0.01) between the first and last sessions. Other variables demonstrated a consistent distribution. For example, students rated LA friendliness was consistently high ([session 1: 63% strongly agreed, 27% agreed], [session 2: 69% strongly agreed, 24% agreed]). LA-facilitated group cohesion was also consistently high ([session 1: 71% strongly agreed, 23% agreed], [session 2: 70% strongly agreed, 22% agreed]). Appendix Tables 4 and 5 outline the frequency distributions for each variable across both sessions.

Table 4.

Session 1 student-perceived ratings of LA

Question	Likert scale rating
	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
From my observations, LAs effectively engaged with students today	1%	7%	34%	52%	6%
LAs were friendly and inclusive	0%	2%	8%	27%	63%
LAs helped create an atmosphere conducive to learning	0%	0%	2%	22%	76%
LAs appropriately answered questions and clarified misconceptions	3%	7%	21%	34%	35%
LAs augmented my understanding of a specific topic, subject matter or concept	0%	0%	12%	33%	55%
LAs improved the cohesion between myself and other students in my group	0%	0%	6%	23%	71%

Table 5.

Session 2 student-perceived ratings of LA

Question	Likert scale rating
	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
From my observations, LAs effectively engaged with students today	0%	0%	14%	18%	68%
LAs were friendly and inclusive	0%	1%	6%	24%	69%
LAs helped create an atmosphere conducive to learning	0%	0%	1%	19%	80%
LAs appropriately answered questions and clarified misconceptions	0%	0%	1%	27%	72%
LAs augmented my understanding of a specific topic, subject matter or concept	0%	1%	10%	36%	53%
LAs improved the cohesion between myself and other students in my group	0%	0%	6%	23%	71%

Discussion

This pilot program is the first of its kind to be implemented within the pre-clinical curriculum at the host institution. Other studies have highlighted the improvements in student performance and conceptual understanding in undergraduate science courses [19–21]. However, as these were conducted in a different educational setting, it is difficult to generalize the findings across multiple disciplines. The results of this study suggest that the use of LAs within the pre-clinical flipped-classroom setting is associated with a positive impact on student interest and confidence in specific subject matter in relation to the affective domain of Bloom’s taxonomy. Additionally, the use of LAs appears to positively affect student perception of engagement and appropriate clarification of misconceptions in real time. Students reported high ratings for both variables across both sessions, indicating that the LAs were effective in engaging with students and clarifying misconceptions. This suggests that the LAs might be effective in facilitating higher levels of learning in the cognitive domain of Bloom’s taxonomy. However, definitive testing of knowledge acquisition, analysis, and synthesis should be conducted to confirm this. Our findings show that students reported significantly higher levels of interest and confidence after the first session with LAs compared to their pre-session levels. Moreover, these improvements in interest and confidence were maintained in the last session. This effect was also seen when normalizing student confidence by the modified SICKS score (a measure of global perceived learning ability). The developers of the SICKS score indicate that higher scores portend improved increased key skill acquisition [18]; however, our findings may indicate that LAs were effective in enhancing confidence independent of global perceived ability to learn new material. Furthermore, students perceived a significant improvement in the LA’s ability to appropriately answer concept questions and engage with students from the first to the last session. These findings suggest that LAs may help distribute the higher cognitive burden on medical students during flipped classroom sessions.

Interestingly, no significant difference was found in student-perceived LA helpfulness between the first and last sessions. This suggests that the LAs’ effectiveness in assisting students was consistent across sessions, despite the LAs learning to better interact with students over time. This consistency in effectiveness may reflect the effectiveness of the pedagogical seminar training and faculty support, which is an important factor to consider when implementing and scaling such a program. LA friendliness and the facilitation of cohesion was also consistently high when rated by students. This indicates that LAs were potentially able to foster a learning-conducive, inclusive environment for student learners. We postulate that this may be due to the relative similarity in age and educational attainment between LAs and students. The LAs were able to provide a relatable perspective or experience when problem-solving. This is consistent with data examining the effectiveness of LAs compared to graduate teaching assistants [22]. When examining the time spent per student, we see that LAs spent, on average, a similar amount of time per student in the second session (13.2 min) compared to the first (15 min) despite interacting with more students in the second session (17.75 students) compared to the first (11.25 students). This may highlight an increased efficiency in explanation or even a better familiarity with student learning styles. LAs may thus be able to help mitigate the variability in learning by offering increasingly personalized support through targeted feedback as they become more familiar with the student. The findings indicate that the number of LAs (4 total) was also sufficient for the average number of students attending the session (23). Although the ratio of roughly 1 LA to 6 students appears to be sufficient, further investigation will need to evaluate the optimal balance of LAs to students, to optimize LA-student interactions.

The qualitative analysis of LAs’ notes revealed several themes related to students’ knowledge gaps in drug names and mechanisms of action, as well as the importance of understanding drug use in disease processes. The data indicates the capacity for LAs to act as real-time information gatherers on common student misconceptions. Such data can regularly guide faculty when updating or changing PBL materials. Furthermore, targeted training and support for LAs during the “content meetings” may be able to further improve an LA’s effectiveness in addressing these areas for subsequent classes. This is consistent with other literature that demonstrates how LAs may inform broader curriculum reform in the undergraduate domain, particularly in large classroom settings [23, 24]. This also addresses the investigation by Chakravarti and Vijayan on faculty motivation to update course materials [9].

Despite these salient findings, there are limitations to this study. First, the study was conducted in a single institution, and the results may not be generalizable to other institutions with different student populations, course structures, or teaching styles. Additionally, the study only included a small number of LAs and students, which may limit the statistical power and precision of the results. Second, the study relied on self-reported data from students and LAs, which may be subject to response biases or inaccuracies. To mitigate this, we ensured confidentiality of survey responses and utilized validated survey instruments when available. However, the potential for response bias or inaccuracy cannot be entirely ruled out. Third, the study did not control potential confounding variables such as prior knowledge or experience with the course material, which may impact student outcomes and perceptions. Future studies could incorporate such variables to provide a more comprehensive analysis. Finally, the study only assessed short-term outcomes and did not examine the long-term impact of the LAs on student learning or performance. It is possible that the effects of the LAs may diminish over time or that other factors may come into play. Long-term studies could provide valuable insights into the sustained impact of LAs on student learning and performance. Despite these limitations, our study provides evidence supporting the use of LAs as a valuable tool for improving student engagement, interest, and confidence in the subject material. The research team hopes to address these limitations in future iterations of this pilot study, to gain a more comprehensive understanding of the program’s effectiveness upon expansion.

These results may also have implications for other institutions and disciplines that seek to enhance student learning outcomes and engagement. However, the availability of qualified and interested LAs becomes progressively tricky as students increase their involvement in clinical activities. Additionally, faculty members may hesitate to relinquish or alter their course structure to accommodate LAs. It may be necessary to provide faculty members with training and support to help them understand the benefits of LAs and how to incorporate them into their courses effectively. While implementing an LA program may present some challenges, the potential benefits for student learning and engagement may make it a worthwhile investment for institutions seeking to enhance pre-clinical didactics.

In conclusion, the results of this study suggest that the use of LAs can have a positive impact on student interest, confidence, engagement, and clarity of concepts. These findings provide support for the use of LA programs as a potential tool to enhance student learning outcomes in pre-clinical learning settings that utilize the PBL instructional model.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author Contribution

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by OD, MG, and Dr. AJ. The first draft of the manuscript was written by OD, MG, and Dr. AJ, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Data Availability

Survey Data and Results: The data supporting our analyses in the Results section, particularly the survey results presented in Table 2 and the statistical analyses detailed on pages 7 and 8, are available upon reasonable request. Due to the nature of the data, which includes responses from medical students, we must maintain confidentiality and privacy. Therefore, these data are not publicly available but can be accessed under specific conditions that ensure the privacy and confidentiality of participants.

Conditions for Data Access: For researchers interested in accessing our data, requests can be directed to our research team. Contact details are provided in the manuscript, ensuring continuity of access even as corresponding author details may change over time.

Declarations

Ethics Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of the California University of Science and Medicine (IRB application number: HA-2023–05).

Informed Consent

Informed consent was obtained from all participants in the study.

Conflict of Interest

The authors declare no competing interests.