Nerves of Steel: Bolstering Student Confidence in Gross Anatomy Through a Peer-to-Peer Intervention

Abstract

Introduction

Increasing confidence and performance in gross anatomy is crucial in medical education. This study identified challenging anatomical topics in a gastrointestinal (GAS) course and applied a peer-to-peer intervention to improve student confidence and performance in these areas in the following endocrine/reproductive (END) course.

Materials and Methods

Thirty gross anatomical structures from a GAS mock practical were classified into six categories. As part of the mock practical, medical students rated their confidence in each answer using a scale of 1–5. Performance and confidence were compared across the six categories, revealing two areas with significantly lower scores. In the following END course, these areas were targeted through a 1-h peer-to-peer intervention.

Results

Forty-two students participated in the GAS mock practical. Significantly lower performance was found in nerves and viscera categories. Students who attended the peer-to-peer intervention during the END course showed marked improvements in both areas on the END mock practical. Average performance for viscera increased from 31 to 68% (p < .001) and for nerves from 35 to 52% (p < .001). Average confidence for viscera increased from 2.22 to 3.32 (p < .001) and for nerves from 2.07 to 2.61 (p < .001).

Discussion

These findings align with the expected benefits of peer-to-peer interventions. However, the difficulty students faced with viscera, more so than with vasculature, was unanticipated. This unexpected outcome underscores the nuanced nature of student learning in anatomy and the importance of targeted educational interventions. Future research should explore whether students consistently struggle with nerves and visceral structures across different organ systems.

Introduction

Anatomy has traditionally been a source of stress and anxiety for medical students, owing to varying experience levels with the subject material as well as working with cadavers, often for the first time [1–4]. While a low level of stress may aid in student performance and retention of the material, high levels of stress can interfere with memory and hinder student performance [5]. Literature also suggests a somewhat weak relationship between confidence and performance [6], making it particularly important for students to develop metacognitive skills and evaluate the correlation between their confidence and competence [7].

Therefore, developing strategies to decrease stress and anxiety and increase metacognitive skills is an important goal for anatomy educators. Mock anatomy practicals and other review sessions are instructional methods that have attempted to address this goal [8]. Studies have shown that students who participate in mock practicals and other review sessions report feeling more confident than their peers who do not participate [8]. Moreover, these students outperform their peers on practical examinations, indicating that such learning opportunities could be a beneficial addition to medical school curriculums [8].

In addition to the increased stress and anxiety caused by anatomy, medical students often find certain areas of anatomy more difficult to learn than others. For example, students frequently struggle with topics including neuroanatomy, head and neck anatomy, pelvic anatomy, and anatomy of the perineum [9–11]. This problem presents an opportunity for anatomy educators to tailor learning opportunities to address these areas of decreased knowledge and confidence. Instructional modalities such as near-peer learning have been incorporated into anatomy education to aid students in their understanding of difficult anatomy topics [8, 12, 13].

Near-peer learning is being implemented more in medical education due to time constraints on senior medical education staff [14]. The proximity in age and experience of the peer instructors provides an informed perspective for the tutor to effectively engage with their students [14]. Medical students have welcomed the implementation of peer-to-peer instruction into the anatomy curriculum to address content that has not been addressed by more traditional didactic teaching methods [13–15]. Students also believe that near-peer instruction contributed significantly to their understanding of difficult anatomy topics [15, 16]. Near-peer teaching benefits those receiving the instruction and the peers leading the tutoring sessions, as it allows students to gain hands-on experience as they prepare to move into teaching roles as physicians [12, 17–19]. The additional opportunities to practice learned concepts certainly benefit students. However, the benefits of near-peer teaching extend to include increased intrinsic motivation for students, alleviating faculty teaching burden, and preparing medical students to move into future educational roles [20].

Small group instruction and discussion have also been increasingly implemented in medical schools in recent years, with consistent results of increased student achievement and attitude [21–24]. Working in small groups allows students to develop critical thinking skills, such as how to assess their level of knowledge in a certain domain, apply and articulate this knowledge to their peers, frame questions for their peers as they work together, and grapple with the gaps in their understanding of the material [21]. Having more focused instruction groups also allows more material to be covered in a shorter period and allows for students to be more actively engaged throughout the anatomy lab session [25, 26]. Students have also found that active and engaging learning events are not only beneficial but also lead to increased scores on assessments [27]. However, none of the referenced studies has assessed the impact on student confidence of a peer-to-peer intervention that identifies and addresses difficult anatomy concepts through active learning sessions.

This study aimed to identify and address topics with low student confidence in gross anatomy through a mock anatomy practical and to subsequently incorporate a peer-to-peer intervention with active, small-group learning to address the identified difficult topics. Assessment of student confidence level was deemed an important metric for this study, as many medical students have a self-perceived lack of anatomy knowledge as they enter the clinical domain [28–31]. Additionally, this provided an opportunity for students to develop metacognitive skills to ultimately improve their overall performance on anatomy practicals. Based on previous literature and faculty observation, structures of the nervous system were expected to be the areas of lowest student confidence [11].

Materials and Methods

Context

The study took place in the gross anatomy laboratory at Western Michigan University Homer Stryker M.D. School of Medicine (WMed) and included students in their second year of medical school. At the time of the study, each cohort was made up of approximately 80 medical students participating in a curriculum that included 18 months of foundational science courses followed by 2 years of core and advanced clinical clerkships. The study took place during the gastrointestinal (GAS) and endocrine/reproductive (END) courses for the second-year students. The GAS course was the third course in the second year and took place over 5 weeks with four gross anatomy labs (10 h total). The END course followed directly after and took place over 6 weeks with three gross anatomy labs (10 h total). Prior to the GAS course, second-year students had completed the anatomy components of the musculoskeletal, nervous, cardiovascular, pulmonary, and renal courses. For each anatomy lab, students were provided with pre-lab materials to prepare for the lab. During labs, students worked in groups of 5–6 to identify the structures on prosected donors with the help of 2–3 faculty members. The final grade breakdown for second-year students was 83% MCQ summative exam, 10% anatomy practical, and 7% iRAT/tRAT scores from weekly team-based learning events. While the course was pass/fail overall, students were required to pass both the summative and practical exams separately. Anatomy practical exams for both GAS and END courses consisted of 40 free response questions which included 30 questions asking students to identify a structure on a donor or model and 10 questions that required identification of structures on a radiological image. Students rotated through the 40 stations with 1 min at each station.

The study was conducted by the Anatomy Introduction and Mastery Interest Group (AIMIG), one of the student interest groups on campus, which was led by six second-year medical students. AIMIG’s goal is to inspire interest and cultivate competence of WMed students in anatomy and its applications in medicine. For first-year students, AIMIG worked alongside faculty members as an additional resource to introduce and familiarize students to their first anatomy courses. For second-year students, during each of the six system-based courses which had anatomy labs and a practical exam, including GAS and END, AIMIG set up a mock practical exam 1 week before the end of the course, when the practical exam took place. Student participation in these mock practical exams was optional and did not contribute to their course grade. The mock practical exams were formatted to replicate the practical exam with 30 structures tagged on donors and models and 10 radiological questions. Students had 1 min at each station to answer the 40 free response questions. The six AIMIG student leaders were excluded from the study.

Procedure

The first part of the study consisted of the mock practical examination during the GAS course. The 30 tagged structures included in the exam were selected from a list of structures (checklist) associated with four GAS labs. The four checklists provided the students with all of the structures that the students would be expected to identify by the end of the course and were available to the students throughout the course. Every structure on the GAS checklists was categorized into six distinct anatomical buckets: nerves, vasculature, viscera, musculoskeletal, fascia/membranes, and regions/spaces by anatomy faculty. These categories encompassed all structures and distributed the structures into roughly equally sized buckets. The AIMIG group then selected five structures from each of the buckets to create the mock practical exam. The anatomy faculty then approved the questions to ensure the structures were appropriately challenging for the mock practical exam. For each free response question, students were asked to identify the structure and rate their confidence in their identification on a scale from 1 (not confident at all) to 5 (extremely confident). To fully emulate the experience of the graded anatomy practical, each mock anatomy practical incorporated an additional 10 radiology questions pertinent to the organ system, for a total of 40 questions. However, student confidence and performance related to these radiology questions were not examined, as this was outside the scope of this investigation. An answer key was created and verified by the anatomy faculty, and mock exams were graded by AIMIG members. Any questions about specific answers were discussed within the group and with the anatomy faculty. Grading decisions were applied equally across all student answers.

The data were analyzed using multivariate analysis of variance (MANOVA) to compare the average performance and confidence of each bucket. Post hoc analysis identified two buckets—nerves and viscera—with significantly lower performance scores.

In the subsequent END course, the two identified buckets were targeted in a 1-h, optional peer-to-peer intervention conducted in two identical sessions on Monday or Wednesday before the END mock practical on Friday. The intervention was fully designed and facilitated by the AIMIG leaders and consisted of students working in groups of three or four to tag 3–5 pre-selected nervous and visceral structures on prosected donors and models at 10 stations. The teaching method employed a collaborative, iterative approach:

1. Groups were encouraged to discuss and work together to identify each structure.

2. If a group’s initial identification was incorrect, the AIMIG peer tutor would inform them without revealing the correct answer, allowing a second attempt.

3. If the second attempt was also incorrect, the AIMIG tutor would then identify the correct structure and explain effective identification techniques.

4. For correct identifications (on either the first or second attempt), the AIMIG peer tutor or a faculty member would confirm and reinforce the correct answer.

This approach fostered active learning, peer discussion, and immediate feedback, allowing students multiple opportunities to correctly identify challenging structures with guidance from their peers.

The intervention’s effectiveness was assessed using the 30 gross anatomy questions created for the mock practical in the END course. Again, there were ten radiology questions related to the endocrine and reproductive systems mixed into the mock practical which were not evaluated in this study. Students indicated whether they attended the intervention by checking a box on their mock practical exam answer sheets. Confidence data were collected for each question using the same scale, 1 (not confident at all) to 5 (extremely confident). The primary outcomes of the study were student confidence and mock practical performance. The evaluations were conducted voluntarily and according to a schedule communicated in advance to the students.

The data from the END and GAS mock practicals were analyzed using paired t-tests to determine if there were statistically significant changes in student performance and confidence across the various anatomical categories with a focus on nerves and viscera—the targets of the peer-to-peer intervention.

Results

Of the 75 students eligible (AIMIG members were excluded) to participate in the study, 42 students (56%) participated in the GAS mock practical. MANOVA revealed a significant difference in confidence across the categories, or “buckets” (F (5,5) = 9.36, p < 0.001). Post hoc analysis pinpointed significantly increased confidence in identifying vasculature, M = 2.92 (p < 0.001). Although not reaching statistical significance, student confidence was lowest in identifying nerves, M = 2.06, and viscera, M = 2.21 (Fig. 1).

Fig. 1.

Average confidence levels for each anatomical bucket in the GAS mock practical. This figure illustrates the mean confidence scores for each anatomical category. A notable increase in confidence is observed specifically in the vasculature bucket, where the difference was statistically significant (p < 0.001)

Performance mirrored confidence, with significant differences observed across the buckets (F (5,5) = 13.85, p < 0.001). Once again, post hoc analysis revealed significantly lower scores on the nerves and viscera buckets, with students scoring averages of 35% and 31%, respectively (Fig. 2).

Fig. 2.

Average performance scores for each anatomical bucket in the GAS mock practical. This figure presents the average scores, with each score graded as 1 for correct, 0 for incorrect, and 0.5 for partial credit at grader discretion. The nerves and viscera buckets displayed statistically significant lower performance compared to other categories (p < 0.001)

For the subsequent END course, 54 students (72%) attended the optional peer-to-peer intervention designed to target nerves and viscera. This intervention was followed by an END mock practical, in which 43 students (58%) participated. Forty-one students (55%) participated in both the optional peer-to-peer intervention and the END mock practical. The confidence and performance of these 41 students were analyzed to uncover any differences in confidence or performance across the different anatomical buckets after the intervention.

Significant improvements were observed on the END mock practical among students who attended the intervention. Paired t-tests revealed statistically significant increases in confidence (Fig. 3) and performance (Fig. 4) on nerves and viscera. Specifically, for viscera, the average performance and confidence increased to 68% (t(189) =  − 7.47, p < 0.001) and 3.32 (t(181) =  − 8.19, p < 0.001), respectively. Likewise, for nerves, the average performance and confidence improved to 52% (t(190) =  − 3.53, p < 0.001) and 2.61 (t(178) =  − 4.82, p < 0.001), respectively. There were some notable declines in student performance on two buckets when comparing the GAS and END mock practicals. Average performance on MSK declined from 53% on the GAS mock practical to 40% on the END mock practical (t(190) = 3.43, p < 0.001). Likewise, performance in the fascia category experienced a decrease, falling from 60% on the GAS mock practical to 32% on the END mock practical (t(190) = 6.60, p < 0.001). Interestingly, no corresponding decrease in confidence was noted in these categories. Furthermore, there was no statistically significant decrease in confidence across all anatomical buckets.

Fig. 3.

Student confidence on GAS and END mock practical exams. MANOVA shows a significant increase (p < 0.001) in student confidence in peer-to-peer intervention focus areas

Fig. 4.

Student performance on GAS and END mock practical exams. MANOVA indicates a statistically significant increase (p < 0.001) in scores on nerves and vasculature buckets and decrease on musculoskeletal and fascia buckets

Discussion

The preponderance of literature on student-led anatomy instruction in medical school traditionally focuses on near-peer teaching, in which senior students guide junior students [8, 12, 14–16]. In contrast, our research examined peer-to-peer learning, involving students receiving instruction from peers at the same level. The most effective method of including medical students in their curricular instruction remains to be determined. The improvement observed in both confidence and performance in the targeted anatomical “buckets” following our peer-peer learning intervention mirrors findings from near-peer teaching studies [8, 14]. Khatskevich et al. noted a five-percentage point increase in raw mean scores of students taking a mock anatomy practical after a peer-to-peer learning intervention led by MS-II medical students. This correlated with a statistically significant increase in comfort as reported on a 1–10 scale after the mock practical and accompanying review session [8]. Morris et al. studied the effect of peer-to-peer learning on confidence with head and neck anatomy. Among pre-clinical medical students, mean confidence on a 10-point scale increased significantly from 2.87 to 7.77 after small-group peer-to-peer learning [14].

Although a formal feedback collection process was omitted from this study design, anecdotal evidence suggests that our peer-to-peer, interactive, small group approach was well-received as an effective use of time for second-year medical students. Students affirmed that the peer-to-peer intervention and subsequent mock anatomy practical improved their anatomic knowledge and bolstered their confidence in identifying gross anatomical structures. These reflections indicate that peer-to-peer learning could be a valuable addition to effective anatomy teaching strategies. This modality could be especially beneficial in targeted interventions, as in our study, to address common areas of difficulty among students.

This study draws attention to the topic of medical student metacognition regarding appropriately rating content from well-performing anatomic buckets with high confidence and content from low-performing buckets with low confidence. Cale et al. found that medical students who completed a metacognitive practice-based learning and improvement assignment demonstrated trends in self-rated confidence and predicted performance among students who passed and those who remediated [32]. Students who passed demonstrated appropriate confidence and better predictions of their test scores, while students who needed to remediate were overconfident and inaccurate in predicting their initial test scores. Our research demonstrates additional evidence of medical student metacognitive insight. During the initial GAS block in which initial confidence scores were surveyed, students appropriately rated the two poorest performing anatomical buckets, nerves and viscera, with lower confidence scores. After the peer-to-peer intervention for the nerves and viscera buckets in the subsequent END block, students earned significantly higher scores than the previous GAS block. This increase in performance scores was mirrored in their significantly higher END confidence scores. In the four tested anatomic buckets (regions/spaces, MSK, fascia/membranes, and vasculature) without a peer-to-peer learning review, student confidence was not significantly different between GAS and END blocks. Our findings indicate that while peer-to-peer learning seems to enhance medical students’ ability to accurately gauge their proficiency in areas covered by the intervention, this effect does not extend universally. Notably, students demonstrated a similar level of confidence in fascia and MSK topics, despite markedly poorer performance in these areas compared to GAS. This suggests that the improved metacognition observed may be specifically linked to subjects directly addressed in the peer-to-peer learning sessions, rather than a general enhancement in self-assessment skills across all subjects. Alternatively, the intervention specifically focused on the nerves and viscera buckets which may have contributed to a recency bias in which students focused more on the nerves and viscera buckets to the detriment of their performance and ability to accurately rate confidence regarding fascia and MSK topics. Students could have also had a false sense of confidence when identifying structures from the fascia and MSK buckets, as pelvic anatomy has been identified as a difficult topic for students to learn [11–13].

The benefits of near-peer or peer-to-peer teaching should be carefully weighed against the inherent challenges posed by medical education. Concerns include distrust of the quality and accuracy of peer instruction, limited expertise of clinical application from pre-clinical peer instructors, and eagerness of peer instructors to share knowledge of anatomy at the expense of allowing peer learners time to think critically [12, 16]. While these difficulties may be intrinsic to peer-assisted learning, the benefits of additional learning opportunities on performance and confidence were statistically significant in this study and within the literature [8, 14]. Furthermore, 72% of eligible participants in this study attended the voluntary peer-to-peer learning intervention, demonstrating the tendency of medical students to embrace all opportunities in the prosection lab. Additional studies have shown the majority of learners find their peers “suitable” or “very suitable” as teaching facilitators [17, 24]. Lastly, near-peer teaching has proven a helpful tool in facilitating sufficient educational opportunities within courses that historically have a low faculty-to-student ratio, such as clinically oriented medical school cadaver labs [33]; therefore, we propose peer-to-peer learning as a useful adjunct to faculty-led review, rather than a replacement.

Previous studies have opted for different approaches when categorizing anatomical regions for study. For example, Kramer and Soley used regional classifications such as neuroanatomy, pelvis, perineum, omentum, and mesenteries [9]. Others classified structures by organ systems, including integumentary, skeletal, muscular, central nervous system, peripheral nervous system, digestive, male reproductive, and female reproductive [8]. Both approaches can be advantageous, depending on the context and objective of the study. These different methods of categorization offer varying levels of specificity and can serve different research objectives. In this study, we categorized anatomical structures into the following six “buckets”: vasculature, viscera, musculoskeletal, fascia/membranes, nerves, and regions/spaces, which allowed us to analyze both the students’ understanding of specific anatomical structures and their spatial relationships. This method of categorization allowed for determination of distinct subject matter within any given region with which students had lower confidence and performance.

Our findings regarding students’ confidence and performance in the nerves bucket during the GAS practical align with existing literature in the field of medical education. Previous studies have consistently reported that the nervous system is rated as one of the most challenging areas to learn by students [8, 34, 35]. This was similarly observed in our analysis of the GAS practical, where nerves represented a particularly challenging area for students. These findings emphasize the importance of targeted interventions, such as the peer-to-peer sessions used in this study, in addressing areas of lower confidence and performance in anatomical education.

Regarding students’ perceptions of their abilities in other anatomical areas, there was a distinct contrast between their confidence levels in viscera and vasculature. Prior to the GAS and END courses, students in our cohort had completed a cardiovascular course, which included an integrated anatomy component extensively covering vasculature. This prior exposure likely contributed to their heightened confidence in identifying vasculature structures during the subsequent GAS and END courses. Interestingly, despite a significant increase in confidence in the vasculature bucket during the GAS mock practical, this did not translate into a corresponding improvement in performance. On the other hand, students expressed low confidence in the viscera category. This could be attributed to lesser prior exposure and familiarity with these structures, highlighting an area that might benefit from more focused instructional efforts, such as peer-to-peer learning interventions. Additionally, although students had a dedicated block for neuroanatomy, the peripheral nerves below the diaphragm were not covered, resulting in the second-lowest confidence and performance in the GAS and END courses. This further emphasizes the impact of curriculum structure on student confidence and performance, underscoring the importance of comprehensive coverage in anatomical education. Such disparities between confidence and performance in different anatomical areas underscore the need for a nuanced approach to curriculum development, where prior learning experiences are carefully considered in designing subsequent courses and interventions.

Limitations

Our study has several strengths, as well as some notable limitations. First, the decision to use mock practical scores instead of official anatomy practical performance limited our potential to draw a correlation between peer-to-peer interventions and improvements in gross anatomy grades. However, using mock scores allowed for a more controlled environment and study design. Still, a future study with access to deidentified student grades could help us better understand if such interventions enhance academic performance in a true test environment rather than the simulated testing environment. In addition, the current study design does not control for practice effect as students had one additional structured exposure to anatomy content in the END course versus the GAS course with the peer-to-peer intervention, which could account for the increase in scores rather than the nature of the intervention itself. A future study could compare instructor-led and peer-to-peer interventions to investigate the potential benefit of peer intervention without the discrepancy in time devoted to structured exposure to material. This study was also confined to two organ system–based blocks (GAS and END), restricting the breadth of our findings. To make more definitive conclusions, future research could aim to extend this investigation across all organ systems. This would provide a comprehensive understanding of the potential impact of peer-to-peer interventions, offering a broader scope to analyze the efficacy of such teaching strategies within a systems-based curriculum. Another limitation was voluntary attendance at the mock anatomy practicals and peer-to-peer intervention sessions may have introduced a selection bias. The variation in the number of students participating in the mock practicals and the interventions might influence the reliability and generalizability of our results. However, given that the data encompasses a majority of the cohort, it still offers valuable insights into the confidence and performance of a substantial portion of the class. In addition, while the study gathered anecdotal expressions of appreciation and usefulness of the peer-to-peer intervention and mock practicals, the feedback from the cohort was not officially documented, leaving another possible metric of confidence unassessed.

Future Directions

Future research should extend to various organ system blocks, focusing on the long-term impact of peer-to-peer interventions and incorporating student feedback. Emphasizing tailored approaches, these studies should explore interventions in challenging anatomical areas identified through student feedback and examination results. Conducting longitudinal studies is crucial for assessing confidence levels across the anatomy curriculum, identifying areas that most benefit from peer-to-peer interventions. Such research will not only aid in understanding the retention of anatomy knowledge but also its application in clinical settings. Evaluating student performance on graded anatomy practicals will further highlight the effectiveness of these interventions in improving student performance, reducing test anxiety, and enhancing confidence. The findings from this study and future research will be instrumental in guiding the evolution of system-based anatomy curricula.

Conclusion

In conclusion, students initially faced significant challenges with viscera and nerves during the GAS mock practical. Nevertheless, following a peer-to-peer active learning intervention, there was a notable increase in both performance and confidence in these topics on the END mock practical. This highlights the efficacy of peer-to-peer teaching methods, particularly in complex and challenging subjects like gross anatomy. Improving confidence and performance in the gross anatomy lab may have potential long-term benefits for physician competency by building a strong foundation of anatomical knowledge. However, these findings should be approached with caution due to certain limitations, such as the lack of access to official anatomy practical grades and the voluntary nature of participation. Future studies should broaden to cover all organ system–based blocks and focus on the long-term impacts of these interventions, including the integration of formal feedback mechanisms. Such comprehensive research will enhance our understanding of the role and effectiveness of peer-to-peer teaching in anatomy education, ultimately contributing to the advancement of medical education.

Author Contribution

All authors contributed to the study conception and design. All authors contributed to material preparation, data collection, and analysis. The first draft of the manuscript was written by Tucker J. Morris, Mallory Ruvina, Carolyn E. A. Cooper, Noelle Fukuda, Hunter Berger, and Daniel F. Wagner. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Data Availability

The data supporting this study's findings are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Western Michigan University Homer Stryker M.D. School of Medicine.

Declarations

Ethics Approval

All procedures were carried out according to the protocol approved by the Institutional Review Board of Western Michigan University Homer Stryker M.D. School of Medicine (IRB# 2022–0950).

Informed Consent

Informed consent was given by all participants prior to taking part in this study.

Conflict of Interest

The authors declare no competing interests.