Moving Beyond the Near-Peer Teaching Model with the Rutgers New Jersey Medical School Teaching Assistant Program

Abstract

Medical students will become educators teaching peers, healthcare students, patients, and families. At Rutgers New Jersey Medical School, the “Teaching Assistants in Medical Education” program provides fourth-year medical students with the skills and experiences needed to prepare them as medical educators. The program goes beyond the near peer teaching model to support student development in curricular design, assessment, and communication skills through a Clinical Skills or Anatomy track. Investment in the development of medical students as future educators will yield immediate and long-term rewards.

Introduction

While there is a growing need and demand for skilled medical educators to train future-generation physicians, medical students do not often receive formal training to act as teachers [1]. Medical school curricula are designed to help students attain knowledge and develop clinical and research skills to be competent and compassionate physicians. In addition, students often assume the role of educators explaining the diagnosis and treatment to the patient and family. Formal training can prepare medical students for future teaching roles as residents and physicians, working with patients, as well as helping them understand foundational principles that can enhance their learning. As a result, there has been a growing trend of implementing forms of teaching assistant, student-as-teacher, or near-peer teaching programs in undergraduate medical education and fellowship programs in graduate medical education. These programs improve the students, residents, or fellows’ teaching skills, advancing academic research, and transforming physicians into clinician educators [2–8].

Rutgers New Jersey Medical School (NJMS) developed a longitudinal formal structured training curriculum called the Teaching Assistant (TAs) in Medical Education Program designed to help fourth-year medical students gain a robust skill set and understanding of medical education. The goal behind this program was to provide students with an early exposure to core principles of teaching that would be applied during residency, as well as provide the foundation for fellowship programs if the student decides to pursue a career in medical education. While TA programs are not a new concept in medical education, the Rutgers NJMS program has been expanded beyond near-peer teaching and student-as-teacher programs to include curricular design, assessment, and communication skills. This paper will outline the program framework utilized at NJMS and explore some of the “lessons learned” throughout the evolution of the program. With this framework, other medical schools can develop and customize their programs to help develop medical students into strong future educators.

Overview of Teaching Assistants in Medical Education Program

The Teaching Assistants in Medical Education program is designed to cultivate the educational development of fourth-year medical students who are interested in medical education. Students gain experience teaching through peer teaching, peer-assisted learning, or near-peer teaching, as this is a common aspect of undergraduate medical education [2–4] and receive feedback and mentoring from faculty. Near-peer teaching utilizes students or trainees in the same track that are close in educational levels (i.e., one or more years senior) [2, 5]. Integrating near peer teaching in medical education benefits all parties involved: the junior learners, the faculty, and especially the near peer teachers. For junior learners, benefits include learning in a non-threatening environment, fostering informal mentoring, gaining additional insights and comforts when learning from those who recently were in the course, and taking similar examinations [2, 5]. For the faculty and institution, using near peer teachers can alleviate pressure on faculty with increasing teaching demands [5]. Lastly, the near peer teachers will be able to improve their knowledge, motivation to learn, clinical and teaching skill sets, and ignite an interest in acting as formal teachers in the future [2, 3, 5].

A vital piece in the effectiveness of near peer teaching is ensuring that the TAs are prepared and comfortable with the content, teaching skills, and group facilitation. Each TA is paired with a faculty mentor to ensure that they receive formal feedback on their teaching.

The size of the TA program was determined by the number of pre-clerkship faculty who facilitate small group sessions (15 faculty) and the class size (approximately 180 students per class). In order to ensure that the TAs received proper guidance during the program, it was determined that each pre-clerkship faculty would mentor approximately three TAs. Four faculty members serve as the directors for the program, with a maximum number of 45 fourth-year students accepted each academic year. The additional 15 pre-clerkship faculty members serve as mentors for the TAs. Applicants must be in good academic standing (averaging 80 or higher on final course grades) and are required to submit a CV and a short explanation of their interest in medical education. When reviewing the CV, the program directors look for students with prior experience in education and evidence of leadership. Students with professionalism concerns are excluded.

The program offers two tracks that the applicant can choose from depending on their interest: clinical skills or anatomy.

The objectives for both tracks include:

1. Identify and develop a project to improve delivery of curriculum.

2. Establish skills to be an effective educator through feedback and mentoring from the learning community faculty.

3. Develop/write review questions and clinical reasoning vignettes.

4. Facilitate first- and second-year medical students during small group sessions with a faculty member.

5. Examine the process of assessing preclerkship students.

6. Share and discuss medical school experiences on student panels for the curriculum.

7. Train and perform as a standardized patient for different clinical scenarios.

Clinical Skills Track

The Clinical Skills track focuses on clinical skills such as eliciting medical history, performing the physical examination, clinical reasoning, and procedures. TAs facilitate small group sessions in the doctoring course during the pre-clerkship phase.

Anatomy Track

The Anatomy track focuses on the foundational principles of gross anatomy, embryology, and histology that are taught as part of the systems-based curriculum during the pre-clerkship phase. TAs work with anatomy faculty to facilitate small group sessions and anatomical dissections (See Table 1).

Table 1.

Overview of teaching assistant program and requirements

Content area	Timeline	Clinical skills track	Anatomy track
Curriculum Design	September*	• Identify a project
	April	• Complete revisions and submit final project
Curriculum Assessment	September	• Create 10 multiple-choice vignette questions with objectives
	Ongoing through Systems-Based Curriculum	• Create clinical reasoning vignettes • Grade written and oral presentations	• Create a mock practical exam • Grade anatomy practical exams
Communication Skills: Facilitation	Ongoing through Systems-Based Curriculum	• Co-facilitate physical examination small groups for preclerkship students	• Co-facilitate anatomy clinical case reviews, small group sessions, and dissections
Communication Skills: Feedback	August-December	• 2 Standardized Patient (SP) experiences	• 1 SP experience
	January-April	• 2 SP experiences	• 1 SP experience

*Note: Year 4 of the Rutgers NJMS Curriculum runs from May through April

The program provides opportunities for students in both tracks to develop skills in the following areas:

• Curriculum: Design and Assessment.

• Communication Skills: Facilitation and Feedback.

TAs develop these skills through first-hand experiences, faculty feedback within their respective tracks, and formalized training sessions throughout the year. All students attend four 2-hour mandatory workshops during the year as noted below.

• July: Orientation; Goals, objectives, and exam questions workshop.

• August: Grading write-ups and oral presentations workshop.

• December: Teaching to learn workshop.

• April: Next steps, reflections, and feedback workshop.

Curriculum Design

Medical students are often involved in the feedback and evaluation portion of medical school curriculum design through end-of-course or clerkship evaluations, task forces, and school committees. However, there is value in including them in other aspects of curriculum design. The addition of medical students in the curriculum design process has shown benefits for the curriculum and the students involved [7]. The curricular benefits include students providing a unique perspective for the curriculum (e.g., addressing gaps and identifying redundancies) and providing constructive criticism and possible solutions. For the students, benefits include understanding how the curriculum works, including the challenges found in negotiations of curricular design, and learning to look at what is feasible with the available resources. This integration allows for an improved medical curriculum for future students while also educating the students about what is needed to create and run a curriculum.

As part of the requirement for the program, TAs are a part of curricular design. TAs are expected to develop innovative ways to improve existing techniques within courses or create supplemental review sessions for students. In September, TAs work in a group of 2–5 and identify a project based on their experiences as a medical student. Each group is paired with one program director who serves as a mentor to ensure each tool’s plausibility and help secure the necessary resources. For each project, TAs are required to complete the following:

• Provide goals and objectives for the project,

• Complete a short literature review with citations to explain how this project will fit in the current literature,

• Describe the design, development, and implementation of the project, including problems they may foresee, and

• Explain their plans for evaluation and assessment, including sample questions for student feedback.

Project proposals are completed by April with the possibility that they will be implemented for the course they are designing for.

Assessment

One of the core skills required as a medical educator is learning proper ways to assess students. TAs are expected to learn how to write vignette-styled questions based on the sessions they teach through a structured exercise. The TAs attend a mandatory workshop on how to construct a good test question. During this workshop, students learn practical methods to write exam questions, apply Bloom’s Taxonomy to distinguish different-order learning and identify common mistakes made when writing exam questions. TAs submit 10 multiple choice questions with objectives related to their associated track and are provided constructive feedback from faculty. The final edited questions may be selected by course directors to be used for formative or summative assessments. If the questions are selected by the course director, statistical analysis of the questions (e.g., percentage distribution of answers, discrimination index) is provided to the students to demonstrate how well the questions were written.

In addition to writing vignette-styled questions, each track has unique expectations relevant to the competency. For the Anatomy track, TAs work together to develop a mock anatomy practical exam to prepare for the actual practical exam. They tag structures on anatomical donors, bones, models, histological and radiological images. The faculty reviews and suggest improvements to the practical questions. The TAs run the mock practical exam and respond to any student feedback or questions. For the Clinical Skills track, TAs work on clinical reasoning vignettes for small group sessions. They are provided a framework on how to develop cases and have the opportunity to develop a case with the guidance of a faculty member. TAs are also expected to grade history and physical examination write-ups and oral presentations utilizing a rubric.

Communication Skills

An additional valuable skill that a medical educator needs is communication skills. Good communication skills ensure a strong, trusting relationship between the learner and educator. It is also a critical element when working with patients and other professionals on a healthcare team. TAs learn effective communication skills through these roles: (1) facilitating small group sessions and (2) feedback.

Facilitating Small Group Sessions

Learning to manage group dynamics and different types of learners is an essential facilitation skill, that when mastered will provide the TAs the framework to continue to develop during residency. The primary focus for TAs during these sessions is to facilitate discussions and share their knowledge with the pre-clerkship students. TAs learn to lead a discussion, encourage open dialogue and direct conversations, and motivate pre-clerkship students to participate. They are provided rubrics to ensure that they communicate to the pre-clerkship students expectations and that each pre-clerkship student is assessed the same.

General TAs responsibilities include:

• Record attendance.

• Set ground rules and goals for the session.

• Stay on track with the content and timing of the session.

• Stimulate questions and discussions.

• Encourage active discussion among students.

• Engage students who do not participate during the session.

• Clarify content as needed.

• Manage group interactions.

• Provide individual and group feedback to students.

At the end of each session, TAs debrief with the faculty mentors to identify weaknesses and strengths and develop a plan to be implemented for the next session. The goal is to provide multiple experiences for the TAs so they can practice and improve their skills.

For the Clinical Skills track, two TAs and one faculty member are assigned to a group of 12 students. TAs co-facilitate the small group session on physical examination techniques and reinforce content. TAs participate in a total of 7 sessions, and each session is 2–3 h long.

For the Anatomy track, four TAs and five faculty members are assigned to a group of 90 students. TAs participate in anatomical and clinical discussions with the pre-clerkship students during the small group sessions and the dissection labs. The lab portion allows TAs to teach hands-on dissection skills. TAs participate in a total of 8 sessions, and each session is 2–3 h long.

Feedback

Feedback is a bidirectional process, where it is important to give and receive feedback [9]. It is a skill that needs to be developed across different facets of education which ranges from teaching and assessing students to improving the design and administration of a course [10]. An essential piece of giving feedback is doing it appropriately and effectively. Effective feedback must be timely, descriptive, constructive, and not judgmental [9, 11]. Receiving feedback, which should be seen as a way to grow, is also essential as it can help the individual see where changes may be needed or learn what is seen positively [9]. For receiving feedback to be effective, the individual needs to learn to listen to the feedback and consciously think about how to implement what they heard [9]. In both cases, providing and receiving constructive feedback are core pieces of professional development. As such, it is important for individuals to learn about feedback processes, including the role that the student and teacher play [12]. As part of the program, TAs are taught how to give and receive feedback through a variety of exercises.

Giving Feedback

There are identified teaching sessions within the curriculum where TAs are strategically placed to provide them with opportunities to develop the skill of giving feedback. One example of how we teach TAs to give feedback is through the standardized patient program. TAs are trained to be standardized patients.

“An SP is a person trained to portray a patient scenario, or an actual patient using their own history and physical exam findings, for the instruction, assessment, or practice of communication and/or examining skills of a health care provider. In the medical sciences, SPs are used to provide a safe and supportive environment conducive to learning. SPs can serve as practice models or participate in sophisticated assessment and feedback of one’s abilities or services.” (Gayle Gliva-McConvey, Director, Theresa A. Thomas Professional Skills Center, Eastern Virginia Medical School).

At NJMS, a robust standardized patient program is integrated throughout the medical school curriculum. They are vital to the medical school curriculum by allowing students a safe environment to practice interviewing skills and physical examination techniques and receive feedback to improve their skills. The integration of TAs into the standardized patient program allows the TAs to be in the patient and learner’s shoes, which provides a richer appreciation of the importance of medical education.

For the Clinical Skills track, TAs are required to be a standardized patient 4 times during the academic year. They are provided with an illness script or serve as a patient for students to practice physical examination techniques.

For the Anatomy track, TAs are required to be standardized patients for ultrasound sessions 2 times during the academic year. Pre-clerkship students obtain different ultrasound images from the standardized patients. TAs provide feedback to pre-clerkship students on their ultrasound techniques and answer history questions based on an illness script.

TAs also learn to give feedback through their role as a facilitator in small group sessions.

Receiving Feedback

Receiving feedback is an integral part of the program that involves the TAs, pre-clerkship students, faculty, and program directors. TAs receive feedback as an ongoing process to demystify the process and to provide constructive feedback to reinforce positive behaviors and correct negative ones by developing a plan.

TAs are encouraged to use the following framework when receiving feedback:

• Self-reflection on their teaching skills.

• Receive feedback with an open mind.

• Anticipate emotions with feedback.

• Clarify confusing feedback.

• Develop a plan that can be implemented.

• Always be proactive.

There are three ways that the TAs receive feedback.

• TAs receive feedback from students for their facilitator skills after the activity has ended. The feedback is anonymous, similar to the faculty evaluation forms. There is also an open comment text box for constructive written feedback.

• TAs meet with their faculty mentor to discuss areas of strength and improvement in their teaching. This allows the TAs to reflect on their teaching and explore ways to improve throughout the year and into their careers.

• TAs receive feedback from the program directors for a holistic review of their teaching skills and develop a plan before graduating from medical school.

Lessons Learned

The Teaching Assistant in the Medical Education Program has been incredibly successful at Rutgers New Jersey Medical School. There has been a growing interest from students who want to participate in a formal teaching program, leading to an expansion of this program to accommodate more students. An experienced coordinator is critical to the program to ensure that (1) expectations are communicated to the TAs and faculty and (2) all requirements for each track are met. The program also requires a large number of faculty to meet with the TAs throughout the year to provide continued support and feedback. It is estimated that each faculty member needs 1–2 h of preparation time per month to appropriately mentor and support the TAs. The faculty members assigned to the TAs are the same doctoring course small group facilitators, which aided in recruitment. While mentorship of the TAs is an additional responsibility, faculty have noted feeling privileged to witness a pre-clerkship student mature into the TA role. The time invested by faculty yields an ease of burden to faculty in grading oral and written presentations as well as help in facilitation of physical examination and other small group sessions. Thus, the benefits truly outweigh the additional time commitment, making the teaching assistants a great resource for teaching students, especially for institutions with difficulty recruiting faculty to teach.

Some feedback themes from TAs after participating in the program included:

● Appreciated the process of curriculum development and implementation: TAs had a deeper understanding of why decisions were made and how things were implemented.

Student Quotes

• “Exposure to curriculum development is both individually useful and a strong resume builder that I’ve discussed multiple times in interviews.”

• “I liked learning how to write learning objectives using Bloom’s taxonomy.”

• “I learned how to teach it in an order that feels most efficient to me, which some of the students seemed to appreciate. I was surprised by how hard it still is to percuss- like everything it takes practice.”

• “Understanding and getting experience working with medical education in particular which will make me more informed about what it is like should I choose to do that in the future.”

● Respected the assessment process: TAs realized how much work and thought went into writing exam questions and vignettes.

Student Quotes

• “The multiple-choice questions were most challenging when generating appropriate “distractor” answers and making sure the questions had enough info to make one answer categorically most correct.”

• “Writing questions ultimately reinforced my knowledge on the subject assigned and I am confident I could provide more questions of a high quality in the future.”

• “Preparing and grading the anatomy practical with the anatomy faculty was very informative. It showed me how much work goes into orchestrating an anatomy exam.”

● Improved self-confidence: TAs were motivated to review content because they knew they were responsible for teaching it to the pre-clerkship students.

Student Quotes

• “Revisiting previous material and developing the mastery to teach it to students has been useful as well as gratifying.”

• “Writing learning objectives was the most difficult part. It forced me to think about concepts that I previously learned in a different way (from the perspective of an educator) and to ask myself what learning point I am really trying to get across to students with a given question.”

• “The physical exam session was a strong reminder for me of some of the more targeted and rarely utilized exam techniques and encouraged me to review and solidify my own skills.”

● Built a sense of community: TAs appreciated being part of a community where they felt supported. TAs also commented that they established new relationships as a result of the experience.

Student Quotes

• “The most useful experiences of the TA program so far have been attending the clinical session and interacting with the 1st/2nd years. Speaking to them and hearing their perspectives/concerns/ideas gives me insight into them as students as well as their retention of medical curricula.”

• I have really enjoyed getting to know the M1/M2s and spending more time with the people in my class. In 4th year, we don’t see each other in the hospital as much anymore, so having opportunities to hang out and work alongside each other is so fun.

• “Dr. G is an incredible source of help. He is always available to provide feedback, and that allows us to have more confidence in our project.”

● Strengthened communication skills: TAs felt that they were more empathic and compassionate because of this experience, reflecting on always thinking about how the patients are feeling when they treat them. Walking in the learner’s shoes also allowed them to reflect on what they liked from their education and what they felt could be improved on. TAs recognized that facilitation was hard, and more practice was required. As a result of the experience, TAs were more likely to participate in teaching sessions not associated with the program.

Student Quotes

• “Working with students and seeing what examples/explanations help them understand concepts better.”

• “The most useful part of this program was being an SP and thinking of different ways to deliver feedback.”

• “Participating in small-group physical exam sessions with faculty is very helpful for us to develop the skills required to lead those sessions as future attendings. As someone who is interested in a career in medical education, having the opportunity to learn from faculty, teach students, and receive feedback from faculty on how to improve is a valuable experience.”

• “I really enjoy acting as the SP during TOSCE sessions because I feel like I relate to the students and can give them advice based on my own experience.”

• “The most useful component of the TA program so far has been learning how to provide constructive and valuable feedback.”

Conclusion

As medical school curricula continue to evolve with an increased focus to create bold innovations that train physicians to treat patients, we must not lose sight of the importance of providing the students with a traditional framework that they can build on to take the steps to be innovative educators. Traditional teaching assistant programs lay the foundations for excellence in teaching and provide students with the skills they need to be future educators.

With a growing demand for medical educators, early exposure on how to teach is critical in helping students recognize early on if it is a career they wish to pursue. Although the medical school curriculum provides many informal ways to teach, developing and implementing a structured program provides students with the necessary skills and support needed to hone their skills. The Rutgers NJMS Teaching Assistant in Medical Education program has expanded from the traditional near peer teaching method to a systematic approach of curricular design, assessment, and communication skills. In addition, it promotes lifelong learning since the students will be able to transfer the framework they acquired into aspects of their professional development. It also reinforces the importance of being part of a community which is critical for students who are interested in the role of a medical educator. While this paper summarized the components of the program, additional data is needed from the TAs and pre-clerkship students to fully measure the effect it has on the learning process. This data, once collected, can further guide the evolution of the TA program and its application at other institutions. In summary, a successful TA program requires investment in resources and the benefits can be seen in real time (e.g., teacher learner ratio), as well as long term (e.g., development of future medical educators).

Author Contributions

S.C. initially helped create the Teaching Assistants in Medical Education program. S.C. and C.T serve as co-directors for the Clinical Skills Track and J.G. and G.H. serve as co-directors for the Anatomy Track. J.G. and S.C. primarily wrote the original draft, with G.H. and C.T. reviewing, editing, and adding additional contributions. All authors have read and approved the manuscript.

Funding

No funding was obtained for this study.

Data Availability

Not applicable.

Declarations

Ethics Approval and Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Competing Interests

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.