A Near-Peer Interprofessional Educational Fellowship Program for Training Pre-Clinical Medical Students in the Best Practices of Teaching and Learning

Abstract

Medical school often has opportunities for students to engage in peer or near-peer teaching, however structured teacher training is rarely conducted. We present an Educational Fellowship for rising M2 students as teaching assistants for first year Physician Assistant students. In this near-peer interprofessional teaching model, the M2 students learn pedagogical theory and best practices for teaching and learning. The curriculum and experience may be used by any healthcare profession. Since many healthcare professions have classes during the summer, we present our program as a conceptual model for other institutions.

Introduction

Teaching is an integral communication skill central to the practice of medicine. The art of teaching extends beyond disseminating information: the interaction requires a partnership akin to dancing in which both partners are perceptive and expressive, and are mutually interested in the empathetic and creative exchange toward improving each others’ performance. The skill directly translates to health provider-patient communication, the success of which is positively correlated with improved patient outcomes [1–3].

Although undergraduate medical education (UME) has ample—and required—opportunities to practice communication skills through service-learning and outreach activities [4–7], and students are encouraged to peer-teach in engaged learning environments such as team-based learning (TBL) and problem-based learning (PBL) [8], published opportunities for near-peer teaching in the pre-clinical years are limited [9–13]. Moreover, near-peer interprofessional teaching and learning is rare, and yet inclusive teaching and feedback moments foster interprofessional teamwork [14, 15].

Physician assistants (PAs) work closely with doctors on a regular basis, and in a number of different specialties. They are an important and growing part of the healthcare system [16–19]. Although much has been reported about doctors and nurses learning in interprofessional education (IPE) environments, PA and medical students typically do not encounter each other in the learning space until after PAs have graduated, and medical students are in their clerkship years [20].

At Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, rising second year medical students (M2) have an opportunity to teach first year PA students (PA1) in foundational basic science courses during the first semester of the PA program. The uniqueness of this program is that these same students will join together as a learning cohort in pathology, pathophysiology, pharmacology, and microbiology in body system modules just prior to the undergraduate clinical phase of training. We report the program structure of this near-peer IPE teaching and learning paradigm that could be useful in any health professions school.

We present our experiences and lessons learned from establishing an Educational Fellows program that (1) introduces select medical students to PA students in the context of a near-peer teaching framework during pre-clinical training; (2) trains the medical students in best practices of teaching and learning; and (3) provides an additional source of instructors for basic science courses.

Principles, Integrating, Science and Medicine (PrISM) Course

The 1st year medical school course, Principles, Integrating, Science and Medicine (PrISM), integrates the foundational sciences of medicine within a hierarchy of increasing biological sophistication, from molecules to human body systems. This course ran from 2015 to 2022, when it was replaced by Principles Integrating Science, Clinical Medicine and Equity (PISCEs), an 18-month integrated course of basic sciences and clinical sciences with health equity. The PrISM course goals included the following:

1. Provide students with the knowledge base and cognitive skills that serve as a foundation for their further pre-clerkship and clinical training in medical school and professional practice.

2. Strengthen students’ appreciation of the scientific foundation of medicine and foster skills in critical thinking and appraisal in both foundational and clinical science and in basic and clinical research.

3. Provide students with the professional skills necessary for lifelong self-directed learning, including the recognition of gaps in knowledge, the evaluation and acquisition of medical information, and the communication of information as part of a medical team.

By the time medical students participated in the Educational Fellows program, they had completed all of the first-year basic sciences topic modules.

Disease and Therapy (DRx) Course

Disease and Therapy (DRx) is a two-semester course with 14 body system modules. Within each module, the course addresses pathology, pathophysiology, pharmacology, and microbiology. The MD and PA students take the same course and examination, and work in small groups together. The DRx course goals included the following:

1. Provide students with the knowledge base and problem-solving skills that will serve as a foundation for their clinical training in medical school and in professional practice.

2. Strengthen students’ appreciation of the scientific basis of medical practice and foster a spirit of inquisitiveness both in clinical practice and in basic or clinical research.

3. Provide students with the professional skills necessary for lifelong, self-directed learning, including the acquisition and evaluation of medical information and the communication of information with other health care professionals as part of a medical team.

PA Program

In general, PA education is modeled after medical education and includes didactic and clinical phases and focuses on preparing PA students for patient care upon graduation. Unlike medical school, there are no residencies and PAs work within the scope of their supervising physician. Professionally, they are certified through a national certifying exam taken after graduation and they may change practice areas throughout their career.

The PA program at BU Chobanian & Avedesian SOM is a 28-month program with three semesters of didactic education. The first semester consists of basic science courses in anatomy, physiology, biochemistry, immunology, and histology. The PA students then join the second-year medical students for a two semester systems–based course, Disease and Therapy (DRx), described earlier and illustrated in Fig. 1.

Fig. 1.

Medical and PA courses and timing of the Educational Fellowship

Theoretical and Conceptual Frameworks

The Educational Fellows program began at the inception of the Boston University PA Program in 2014 with the goal of providing a summer opportunity of near-peer teaching with a stipend for rising second year medical students. As the BU PA program was just starting, a secondary goal was to introduce medical students to the PA program curriculum and to the PA students who would become their classmates (see Fig. 1). A third goal was to provide teaching and lab assistants for PA students in the anatomy, physiology, and histology courses.

The rising second year medical students had completed courses in the integrated first year medical student curriculum, PrISM, which includes anatomy, physiology, biochemistry and histology. The PA first semester is front loaded with a course on biochemistry, genetics and immunology which overlaps the end of the PrISM and requires less teaching assistance. The PA first semester curricula in anatomy, physiology, biochemistry, immunology, and histology begin in earnest in late April allowing the Fellows to assist in the curriculum they have just completed.

The Educational Fellows program was developed primarily with the frameworks of De Lisi’s Peer Teaching Learning Theory [21] and Vygotsky’s Sociocultural Theory of Learning in mind [22]. Specifically, near-peer IPE teaching opportunities accompanied by inclusive classroom training for rising M2 students would reinforce basic science knowledge for both PA and medical students while promoting interprofessional trust. The conceptual framework of the Educational Fellows program is based on principles of creating significant learning experiences [21] and universal design for learning [23]. Fellows are trained in evidence-based pedagogy skills to develop sound objectives, engaging learning activities, and fair assessments. The primary teaching objectives of the Fellowship was to provide in-class teaching instruction and out-of-class tutoring to the PA1 students in the subjects of Biochemistry, Anatomy, Histology, and Physiology.

Table 1 summarizes the logic model we used to address the needs and development of all stakeholders—Educational Fellows, PA students, and faculty—in the near-peer IPE, coaching, and mentoring program.

Table 1.

Logic model for Educational Fellowship

Group	Inputs	Activities	Outputs	Impacts
Educational Fellows (M2 students)	Application; Readings; Reflection pieces	Preparation for teaching in labs and review sessions; Weekly meetings; Readings; Reflection	Teaching; Review sessions; Reflection pieces	Consolidation of knowledge; Interprofessional education and appreciation for PA profession; Appreciation of teaching; Career interest in academia; Professional experience; Patient education comfort
Students (PA1 students)	Time to attend review sessions	Attending class and lab sessions; Attending review sessions	Questions answered at sessions without having to attend office hours; Ability to ask questions without the professor	Increased awareness of medical education of medical students; Meeting students who will be future classmates
Faculty	Recruitment and selection of fellows; Stipend; Classroom reservations	Development of interest for teaching assistants; Development of curriculum; Meeting time; Administration of fellowship	Teacher training curriculum for fellows; Scheduled review sessions; Feedback to fellows on teaching	Assistance with teaching; Need to offer fewer review sessions

Application Process

Educational Fellows are recruited from the M2 class via the medical school Student Affairs Office, which has a list of summer opportunities (Table 2). We select 5–6 fellows from a pool of 8–15 fellows with the following advertisement:

We are seeking several BUSM first-year medical students who are interested in medical education to work with the PA faculty as Education Fellows with the incoming class of PA students. For those interested in exploring medical education and interprofessional training and practice as a career, this is a great opportunity to learn basic skills related to education in a supportive environment. Fellows will develop skills tutoring first year physician assistant students in the basic sciences, participate as an instructor in the anatomy laboratory, actively participate in curriculum design assessment, and lead small group learning sessions under the direction of the PA faculty.

Students interested in medical education must be in good academic standing and submit their resume and an essay outlining their interest in medical education and previous teaching experience as well as one letter of reference from a faculty member. There are two phases - Phase 1 occurs during the school year and is 5 hours/week and Phase 2 occurs during the summer and is 30 hours per week with the weekly time commitment items for each phase noted below. Fellows can choose to participate in either or both phases, and are paid accordingly based on school human resources policy for student employees. The applications are reviewed by PA Program faculty members and graded on previous teaching experience, team or collaborative experience, previous healthcare experience, as well as whether they expressed interest in medical education and/or interprofessionalism.

Table 2.

Time commitment for Educational Fellows in each phase

Item	Phase 1	Phase 2
Weekly meeting	1 h	1 h
Journal Club/Teacher Training	30 min	1 h
Self Directed Learning	1 h	2 h with 2 h of classroom prep
Classroom Time	2.5 h	24 h
Total	5 h/week	30 h/week

Journal Club-Style Training

The 4–6 rising M2 students selected for the program participate in a weekly journal club-style meeting that is coupled with administrative course correlation with the different PA course directors. At the beginning of the program, the PA Fellows are guided through a goal setting exercise, in which they develop teaching and learning goals that they would like to accomplish during the program. They are asked to reflect upon their progress in reaching these goals throughout the 10-week program. In addition, each week the M2s independently engage with literature that covers topics of evidence-based inclusive teaching and learning while they are serving together as TAs in the PA courses. In this manner, the Fellows experience the best practices they are learning simultaneously with their teaching. During the journal club portion of the weekly meeting, students are provided with prompts to express their thoughts about what they learned from their readings and what they learned experientially from the classroom. Then, in the forthcoming week, the Fellows write 250–300-word reflections on the progress of their goals, and upon what they learned from the literature, from the classroom, and from journal club. Table 3 summarizes the topics, literature, and reflection question prompts the Fellows receive.

Table 3.

Journal club-style training topics, literature, and reflection question prompts

Topic	Literature	Reflection questions
Orientation
Theoretical Frameworks for Learning	Read Chapter 1 or Chapter 8 in: Brown PC, Roedinger HL, McDaniel MA. Make it stick: the science of successful learning. 2014. The Belknap Press of Harvard University Press. Cambridge, Massachusetts; London, England. [24]	Please answer the following questions based on your readings this week from Make it stick Describe how you normally learn. Based on the chapters you read, describe what you would maintain, and what you would change, from your normal learning paradigm to become a better learner. Explain the importance of the learning or working culture to help you become a better learner. What are you teaching and learning “secret weapons”? In other words, what is your one teaching and one learning technique that never fails to inspire learning? Explain your secret weapons in detail and describe why you think they are so effective. If you don’t have secret weapons, develop each one here. (After your answer this message, it will self-destruct.)
Course/Curricular Objectives and Expectations	Adams NE. Bloom’s taxonomy of cognitive learning objectives. J Med Libr Assoc. 2015 Jul;103(3):152–3. https://doi.org/10.3163/1536-5050.103.3.010. PMID: 26,213,509; PMCID: PMC4511057. [25]	Please answer the following questions based on your readings this week about Learning Objectives How can you help students move up the Blooms taxonomy triangle in their learning experience? When you use Learning Objectives verbs to prepare assessments, which ones are most useful? What Bloom’s levels do you have a preference for assessing?
Assessments as Feedback	Archer E. The assessment purpose triangle: balancing the purposes of educational assessment. Front. Educ. 2017; 2:41. https://doi.org/10.3389/feduc.2017.00041. [26] Brame, C., (2013) Writing good multiple choice test questions.. From https://cft.vanderbilt.edu/guides-sub-pages/writing-good-multiple-choice- test-questions/. [27] Morton DA. Becoming the Riddler. Writing effective MCQ’s From YouTube. https://www.youtube.com/watch?v=9Tm-H4UsxnY. [28] National Board of Medical Examiners. Constructing written test questions for the basic and clinical sciences. Available at www.nbme.org. [29]	Please answer the following questions based on your readings this week about Assessments We’ve all taken hard tests, but were they all fair? Difficulty and fairness are totally different things. A test can be difficult, yet still be fair. Many tests you may have taken are difficult but not fair. The opposite is true. A test can be easy, and you might perceive it as fair. Tests can also be easy, but believe it not, not fair. Think about the tests you have taken and the tests you have written. What elements of a test make it fair, regardless of difficulty? Please elaborate. Consider the following guidelines for writing good multiple-choice questions: Tips for writing good MCQ’s Good, indeed excellent, MCQ’s need to have a clear stem and clear answers. The stem needs to be short and to the point, yet include enough information for students to be able to rule in or rule out possible choices. The answers need to be short, and written in the positive tense. Distractors are answer choices that may be possible, but because of the information included in the stem, are not correct. Avoid the following types of questions at all costs: • Questions that ask students to answer in the negative (i.e., “all of the following are correct except”) • Questions that ask students to choose between unrelated information • Questions that include a “throw away” answer • Questions that offer long answers • Questions that offer “all of the above” as an answer choice • Questions that offer one or more of the answers as direct opposite choices • Questions that offer one or more of the answers that are longer or shorter in the number of words than the other answers Write a good MCQ that assesses a student’s knowledge of a muscle’s action(s) or insertion(s). (Writing this question is more difficult that you think.) Explain WHY you think your question is a fair question Translate the principles for writing a good MCQ to the preparing an anatomy and physiology quiz question or midterm/final question. Describe (in detail, i.e. how would the specimen be laid out, where the pin would be located, etc.) a good exam question that assesses a student’s knowledge of the function of the median nerve. Explain WHY you think your question is a fair question.
Engaged Learning Tools	Revere L, Kovach JV. Online technologies for engaged learning: a meaningful synthesis for educators. The Quarterly Review of Distance Education, Volume 12(2), 2011, pp. 113–124. [30]	Please answer the following questions based on your readings this week about Engaged Learning Tools What were some online teaching techniques that you felt kept you engaged this past year? What, if any, online teaching techniques you listed previously would you like to incorporate into your own teaching with the PA students? What, if any, modifications or adjustments would you make?
Inclusive Teaching and Universal Design of Learning	Pick one: Acknowledging learner variability and seeing UDL in action in the classroom https://youtu.be/rlv6JJQOz64. [31] Universal design for learning (UDL) in action https://youtu.be/B7qYJY62X2s. [32] Super L, Hofmann A, Leung C, Ho M, Harrower E, Adreak N, Rezaie Manesh Z. Fostering equity, diversity, and inclusion in large, first-year classes: using reflective practice questions to promote universal design for learning in ecology and evolution lessons. Ecol Evol. 2020 Nov 24;11(8):3464–3472. https://doi.org/10.1002/ece3.6960. PMID: 33,898,003; PMCID: PMC8057341. [33] Balta JY, Supple B, O’Keeffe GW. The universal design for learning framework in anatomical sciences education. Anat Sci Educ. 2021 Jan;14(1):71–78. https://doi.org/10.1002/ase.1992. Epub 2020 Jul 16. PMID: 32,539,206. [34]	Please answer the following questions based on your readings this week about Universal Design for Learning, and Inclusive Classrooms What is something you would love for your professors to know about how you approach learning? What is something you would love for your students to know about how you approach teaching? Given the diversity of teaching and learning preferences, how might Universal Design for Learning help or hinder the fostering of an inclusive classroom learning experience?
Wellness	Take the abbreviated version of the Nicholson McBride Resilience Questionnaire (NMRQ). [35] Southwick SM, Bonanno GA, Masten AS, Panter-Brick C, Yehuda R. Resilience definitions, theory, and challenges: interdisciplinary perspectives. Eur J Psychotraumatol. 2014 Oct 1;5. https://doi.org/10.3402/ejpt.v5.25338. PMID: 25,317,257; PMCID: PMC4185134. [36]	Please answer the following questions based on your readings this week about Wellness Complete the Nicholson McBride Resilience Questionnaire (NMRQ) then reflect on your score below. What are your thoughts on the 10 suggestions for boosting your resilience? Which suggestions are more reasonable for you? Which ones don’t really apply at this time?
Near-Peer Teaching and Study Groups	Ten Cate O, Durning S. Peer teaching in medical education: twelve reasons to move from theory to practice, Medical Teacher., 2007; 29:6, 591–599, https://doi.org/10.1080/01421590701606799. [37]	Please answer the following questions based on your readings this week about Near-Peer Teaching and Study Groups Some of the benefits of Peer Teaching include preparing healthcare practitioners for their role as educators (both in academic medicine as well as for their patients). Describe how peer teaching (either formally via being a PA Ed Fellow) or informally (for example during a TBL session) has helped you step into this role. Imagine for a moment that you are a course director (or administrator). What are some reservations or concerns you might have about implementing a peer teaching program?
Mentoring and Coaching	Accelerate career growth through mentoring relationships. https://mymedia.bu.edu/media/t/1_o1el1x9d#. [38] Kowalski K. Differentiating mentoring from coaching and precepting. J Contin Educ Nurs. 2019 Nov 1;50(11):493–494. https://doi.org/10.3928/00220124-20191015-04. PMID: 31,644,809 no. [39]	Please answer the following questions based on your readings this week about Mentoring and Coaching Describe a situation from the past in which mentoring and/or coaching factored into your teaching and/or learning activities. Describe a scene in the future in which mentoring and/or coaching factors into your teaching and/or learning activities. In other words, what would that look like for you now? Would it be the same as past experiences? Different?
Creating Significant Learning Experiences	Read Chapter 1 and Chapter 2 in: Fink DL. Creating significant learning experiences: an integrated approach to designing college courses. [21]	Please answer the following questions based on your readings this week about Significant Learning Experiences Compare and contrast yourself as a teacher between the beginning of the semester and now. What would you do the same and/or differently the next time you are in a teaching role (formal or informal)? Compare and contrast yourself as a learner between the beginning of the semester and now. What would you do the same or differently the next time you are in a learner role?

Coaching and Mentorship

The weekly journal club-style meetings with the Fellows in combination with self-guided activities is pivotal to the success of the program as it provides a safe space for the rising M2 students to participate in a practice-based learning environment to improve upon their communication skills and self-reflection. Specifically, we employed techniques providing inclusive feedback based on the frameworks of Kahneman’s Two Systems Thinking [40], Argyris’ Ladder of Inference [41], and Dweck’s Growth Mindset [42], that fostered a practice-based learning environment.

Course directors provided feedback to the M2’s as they explored these pedagogical theories and acted as a safe and inclusive sounding board for their reflections and experiences. Part of these weekly meetings were dedicated to preparing the M2 Educational Fellows for the upcoming week’s PA course content. Any content with which the PA’s were having difficulty, e.g. based on student Piazza (https://piazza.com/signup) forum questions or formative assessments were announced as well as common misconceptions and misunderstandings of the material was noted. This allowed the M2’s to have a better understanding of the expectations of each course and informed their preparations for the weekly tutoring sessions. All tutoring materials were prepared in advance by the M2’s and tutoring sessions were a mix of Fellow-developed material and student-driven questions.

We employed both Coaching in the Moment (CiM) and Coaching over Time (CoT) styles when working with the Fellows in the classroom and in the journal club-style correlation meetings [43]. Many mentorship relationships lead to additional scholarly activities that were born during the years of the Fellowship since all parties involved worked closely together to develop the best learning experience possible for the PA1 students. We employed many of the mentoring principles that were eventually outlined in the IAMSE Mentoring Manual edited by Fornari and Shah [44] and many of the best practices that were eventually published in the Educational Scholarship Committee (ESC) Toolkit framework edited by Wisco [45]. For those seeking career advice, we employed the Committee for the Advancement of Medical Science Educators (CAMSE) Toolkit, edited by Dickinson et al. as a framework [46]. We use the definition of coaching offered by an Niewerburgh as “one-to-one conversation focused on the enhancement of learning and development through increasing self-awareness and a sense of personal responsibility, where the coach facilitates the self-directed learning of the coachee through questioning, active listening, and appropriate challenge in a supportive and encouraging climate.” [47]

Some projects have been submitted to journals, published and/or presented and scientific/education conferences, including the following: Describing the clinical relevance of anatomical variations discovered in cadaver donors [48, 49]; designing artistic techniques instruction to improve patient-provider communication [50]; reflecting upon lessons from engineering pedagogical techniques that can inform and improve upon medical education, teaching and learning best practices [51]; creating a workflow model of best practices to create, or to transform an existing curriculum into a TBL style [52]. Other projects are ongoing, and are either yet to be submitted for publication, or are programmatic improvements in the PA program and/or medical school.

In addition, many of the M2 and PA1 students have worked together in clubs or extracurricular activities that involve teaching and/or service to under-represented groups/under-represented minorities (URG/URM), gender-sex diversity (GSD), and disability demographics. Indeed, the M2 and PA1 students have played various roles in transforming the medical curriculum to its current form in PISCEs, which speaks to the importance of including pre-clinical trainees in the design and implementation of curricular change [53].

Discussion

This paper presents an outline of educational sessions to offer teacher training to health professions students engaged in peer-peer or near-peer teaching. The weekly hour-long sessions included formative feedback to the Fellows, a 30-min discussion of the pedagogical topic using assigned readings, and served as an organizational meeting for the week ahead. After each meeting, the Fellows wrote a reflection piece to reinforce their learning and encourage changes in their teaching.

Peer teaching is defined as students teaching students at the same level. The benefits of peer teaching include both teachers and learners playing a more active role in the learning process, and peer teachers attaining a better understanding of the material [54]. Published examples of peer teaching include teaching of ultrasound in a PA program and students tutoring each other [55–58]. Near-peer teaching involves the students in different cohorts teaching each other. It may be formal such as clinical phase students as teaching assistants in anatomy or informal as student-driven group sessions [59].

Our near-peer teaching fellowship also involved interprofessional learning (IPE). IPE is defined by the Interprofessional Education Collaborative (IPEC) as two or more professionals learning about, from and with each other [60]. Often IPE is a planned academic event involving students in two or more professions working together on a case or clinical scenario. In the Educational Fellowship, medical and PA students had the opportunity to understand the educational preparation of their future colleagues through tutoring and in class assistance. This may allow them to better understand the similarities and differences between the two professions.

Teaching in medicine extends beyond those interested in an academic career. The Accreditation Council for Graduate Medical Education (ACGME) expects residents to teach with specific competencies in educating patients, families, students, residents, and other health professionals [61]. Both medical school and PA program accreditation standards require instruction in communication skills for patients, families, colleagues, and other health professionals [8, 62]. In practice, daily clinical interactions with patients, staff, and colleagues often involve opportunities to educate either formally or informally for both professions.

Teacher training and instruction in pedagogy are important to maximize the effectiveness of teaching, and teaching skills are best acquired via training, practice, and feedback [63]. Several studies have shown improvement in teaching competency following participation in a teacher training program [63]. A systematic review by Burgess and McGregor in 2018 found 42 papers on peer teacher training for health professions students with only 19 reports including specific teacher training [55]. In their study of second year medical students involved in near-peer teaching tutors, Amorosa et al. demonstrated that tutors made the connection between teaching and their future role as a physician [59, 64]. A review of the PA educational literature found one study on peer-assisted learning within an ultrasound interest group [57]. The study introduced optional workshops and found both learners and tutors who participated had improved ultrasound skills but did not generalize to other types of peer- or near-peer teaching.

Studies have shown an increase in teaching competence following teacher training which would indicate the importance of training sessions for health professions students engaging in teaching [63]. Both PA and medical school accreditation standards address communication skills and patient education but do not stipulate specific instruction in teaching, pedagogy, or education. In medical school, tutoring and teaching is most often by third- and fourth-year students, and Burgess and McGregor found only two medical schools using second year students as tutors [55].

In our institution, the summer between the M1 and M2 years provide a time for teaching; however, we recognize that not all institutions have the same curriculum. Health professions schools such as PA programs often are in session all year and the PA education system is modeled after the curriculum of undergraduate medical education, with a didactic phase focusing on basic and clinical science followed by clinical rotations [65]. This may present an opportunity for near-peer teaching in lab type courses utilizing teaching assistants as well as tutoring students. The benefit to the teaching students would be creating a solid foundation in those topics especially as M2 students prepare for the United States Medical Licensing Exam (USMLE) Step 1 and clerkships.

Limitations for introducing formal teacher training include student interest, budget, time in the curriculum, and limited numbers of students to tutor. The volunteer nature of peer tutoring and teaching also limits formal training. PA program accreditation standard A3.05 states that PA students must not substitute or function as instructional faculty which may limit the ability of peer-peer and near-peer teaching in PA programs [62]. In addition, the fact that many health professions programs are in class during the summer may limit time available for those students to teach. For medical schools without a summer break, the 30 min of training per week does not pose a large time commitment and might be included in the expectations for tutors.

There were several limitations of the Educational Fellowship including budget, student interest, and timing. We selected rising M2s who were interested in teaching or an academic career, and other medical students who might have benefited from the experience. Students who required more monetary support during the summer than the offered stipend may not have applied, raising the question of selection bias. We also recognize that budget concerns at other institutions might limit the generalizability of this program. The presence of payment does elevate interest, provides incentive for participation, and protects the time of the Fellows. Timing of the Fellowship being during the summer months limits it to only rising M2 students.

One unique aspect of the medical and PA education at the Chobanian and Avedisian School of Medicine is that first year PA students and second year medical students are in the same Disease and Therapy (DRx) course together as illustrated in Fig. 1. This provides the opportunity for teaching in the PA program for the rising M2 students. While 15.7% of PA Programs are housed in schools of medicine, only two PA Programs combine medical and PA students for the majority of their pre-clinical education—Carver School of Medicine at the University of Iowa (https://medicine.uiowa.edu/pa/welcome), and BU Chobanian and Avedisian SOM (https://www.bu.edu/paprogram-1/academics/didactic-phase/) [66]. The presence of PA students within a medical school may allow for replication of the Fellowship. Future expansion of the Fellowship at our institution may include opportunities during the academic year which would open the program to more students. The educational sessions could be incorporated into medical education electives or interest groups. The program would be applicable to other health professional programs where students in one health profession may tutor or act as teaching assistants for another profession.

Outcomes

The Educational Fellowship attracts 8–18 applicants annually and 5–6 are selected. Successful applicants have expressed an interest in medical education and have participated in teaching activities. Participation in the program may be listed on CVs as professional experience, which may be helpful in residency applications, especially since Step 1 is now pass/fail. Fellows also often engaged with the course directors on an ad hoc basis to share their experiences and progress in more detail. The opportunity to work with the Fellows formally and informally was a valuable aspect of the learning experience and provided important feedback for the course directors regarding how to improve courses for future cohorts.

Representative quotes from the Fellows for each of the outcomes of the program are outlined in Table 4. We will be performing a more in-depth thematic analysis of the data as a follow-up to the work presented here.

Table 4.

Outcomes quotes

Outcomes	Quotes
Consolidation of knowledge	“This semester, I really grew as a teacher. There are a couple of things that I would keep, such as finding ways to relate the content to the students as well as using a bit of humor here and there to keep the learning environment fun. As for things that I would change, the biggest change that I would make is focus on clinical. I started to do that more over time this summer, but if I were to do it again, I would immediately go to clinical questions. By doing it at the beginning, it also helps the students start thinking in that way.”
Interprofessional education and appreciation for PA profession	“For anatomy in particular, I feel like understanding can come before remembering. The PA students have a lot of clinical knowledge, and so they understand a lot about pathologies and how a normal organ functions, but at this stage, they do not have as many structures memorized. As a result, we as PA fellows can use what they know clinically to help them better remember these structures.”
Appreciation of teaching	“In the future, in addition to being a peer leader for the incoming M1s, I would like to continue to offer support to medical students and residents as I move through my own career. In some ways I think this will look similarly to the support I’ve received from my M2 leaders and from faculty advisors, but there are also other ideas that I’d like to discuss with mentees. For me, I think that asking medical students about their lives outside of school has been very superficial and discussing issues at home seen as somewhat ‘unprofessional’ even though the school makes efforts to promote wellness. For example, my father has been receiving treatment for prostate cancer over the past year and it has been difficult to be away, especially during covid when communicating with providers has been extra difficult for my dad. When I brought up the stress of this in advising, I felt it just made the advisor uncomfortable since there was no easy “solution”—I wish someone could have just sat with me and acknowledged that this is hard—the education is hard, the pandemic is hard, trying to balance a life in the background is hard—creating a space for that shared understanding of someone’s struggle is something I’d like to do when I am in a position of greater experience.”
Career interest in academia	“I definitely think that peer teaching in this program and in previous programs has helped prepare me to be an educator in my role as a healthcare provider. Teaching my peers makes me take a step back and think about how I felt before I understood the material and the areas that I struggled to understand. I also like to try to anticipate the types of questions students will ask so that I am better prepared to provide them with a clear and structured answer that will clarify any confusion they might have.”
Patient education comfort	“Health literacy varies widely amongst people, patients, and even students in health care professions. Thus, in order to step into the role of educator for my future patients, I must be comfortable teaching to patients with a wide variety of previous knowledge. With my medical school peers in a TBL setting, as with the physiology review sessions and anatomy lab, I am able to teach to an audience that already has a pretty good level of understanding. Furthermore, in holding review sessions on Histology for the PA students that do not study histology before the sessions, I am teaching to an audience with a limited knowledge of the material. Practice in all of these areas of teaching will be, I hope, good practice for my future education of patients.”

Conclusion

As presented here, the Educational Fellowship offered a summer internship opportunity to rising M2 students teaching inter-professionally to PA1 students. The curriculum for the Fellows included a practice-based learning environment of teacher training and reflections. The model of brief teacher training may be applicable to other medical and health professions schools using peer-peer or near-peer teaching.

Author Contribution

All authors contributed equally to the development, inception, execution, and evaluation of the manuscript topic and its authoring.

Data Availability

The preliminary data supporting the outcomes of the study are available upon request.

Declarations

Conflict of Interest

The authors declare no competing interests.