Oriana Escobar-López 
Last year medical student
Universidad de los Andes, School of Medicine

In medical school, it is somewhat of a tradition to learn entirely new concepts from multiple disciplines in a single day. And of course, we are being assessed on these topics frequently. Sometimes, you encounter an idea you don’t get. You feel like you are the only one of your classmates who doesn’t understand, and you feel too ashamed to ask the professor a question. Before you know it, you find yourself cramming all the content the night before the test, searching on YouTube for videos that explain the subject, and even start to wonder if you honestly need to become a doctor at this point in your life. 

As medical students, we are continually facing challenges when it comes to learning, and we are regularly seeking different methods to approach new subjects in ways that can help us understand in a better and more efficient fashion. In that process, we often find ourselves lost, without knowing where to begin or which course materials are best. Professors usually try to help. Yet we sometimes feel they do not quite understand our concerns. At this point, only another student who understands the struggles, someone who recently faced the same challenges can help us get through it. There comes a time when we, the students, must not only own up to our education process but to that of our peers. This is the core of Peer-Assisted Learning (PAL). This learning methodology is not new. Ancient philosophers used to question each other as a way of discovering new truths (1). It has since been developed and implemented in several disciplines, including medical learning.

For the past decade, we have seen an explosion in the amount of literature exploring the benefits (and challenges) that come along with PAL. Many medical schools have implemented some variation of it in their programs. For instance, at our school, the Universidad de los Andes, students who excel in a subject are hired as teaching assistants, to help with the organization of the course and act as a sort of counselor for students. 

Interestingly, a variation of this approach has been implemented in our medical pharmacology and physiology courses. In our strategy, students with higher grades tutor their peers who have inadequate performance. This strategy appears to help underperforming students to improve their grades and study methods, and has been received with great enthusiasm by the students.

But what makes this so appealing? To answer that question, we must first know a bit of the theory behind PAL. Peer Assisted Learning is defined by Topping as “the acquisition or knowledge and skill through active helping and supporting among status equals as matched companions” (2), and its main traits are the shared background of tutors and tutees and the fact that tutors are not experts in teaching. These two qualities give way to a more informal setting that offers tutees the confidence to express their concerns and freely ask questions (3).

There are several benefits of PAL for both tutors and tutees, and even some for the schools. For tutors, the time and effort it takes to prepare each teaching session makes them review the material and reinforce the concepts. After all, “to teach is to learn twice” (Joseph Joubert). On top of that, it appears that teaching modifies the way a person approaches certain topics, which might lead to a better understanding (2). Tutors also develop a set of abilities, such as leadership, self-confidence, and empathy, all necessary in the medical field. Being taught by peers also brings advantages for tutees; the atmosphere is much more relaxed, which helps them overcome their fears and express their opinions with more confidence. Furthermore, tutors act as role models and this may encourage tutees to become tutors themselves as well. Finally, for schools, PAL may be seen as a cost-effective and practical strategy to tend to the necessities of a growing student body (2).

However I believe, that overall the most essential element that PAL provides is generating a culture of cooperation, solidarity and empathy among the learners. We need to start shifting the current paradigm that forces students to compete with each other as a strategy to promote learning. Collaboration between peers may bring far more advantages than competing not only in terms of personal gain but also for the entire learning community. Robert D. Putnam, an American sociologist and political scientist developed a theory centered around the importance of investing in Social Capital; “the features of social organization such as networks, norms, and social trust that facilitate coordination and cooperation for mutual benefit” (4). 

Even though Putnam developed his work in the field of civil engagement and the decline in forms of association in the United States in the last few decades, I consider that the concept of Social Capital also applies to the medical learning setting. If we create an environment in which older or more experienced students feel it is their responsibility to share what they know with others, and students who are struggling feel confident enough to ask for help, then the faculty as a whole benefit from this cooperation. 

Medical school isn´t what most people would call easy, and I have come to learn that no one is good at every single thing. And, eventually, you will come across a challenge. But that does not mean you must face it alone. More often than not, you will find someone who already went through the same experience. Peer-Assisted Learning provides a framework that allows students to connect and work in a level that offers an atmosphere of collaboration, and as we have seen, a broader culture of cooperation. Furthermore, in the future, you will no longer be a student, but you will (hopefully) become a resident and someday you will have to guide others as you once needed to be guided yourself. Perhaps if we make cooperation a habit, we wouldn´t struggle as much in an already difficult (yet rewarding, I must add) career. 

References:

1. Walberg HJ. Foreword. In: Topping K, Ehly S, editors. Hrsg. Peer-Assisted Learning. Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; 1998. p. ix–xi. 
2. Herrmann-Werner A, Gramer R, Erschens R, Nikendei C, Wosnik A, Griewatz J, et al. Peer-assisted learning (PAL) in undergraduate medical education: An overview. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen. 2017;121:74–81.
3. Loda T, Erschens R, Loenneker H, Keifenheim KE, Nikendei C, Junne F, et al. Cognitive and social congruence in peer-assisted learning – A scoping review. Plos One. 2019Sep;14(9)
4. Putnam, Robert (1995) ‘Bowling Alone: America’s Declining Social Capital’, Journal of Democracy 6. 
5. Gillinson S. Why Cooperate? A Multi-Disciplinary Study of Collective Action. Overseas Development Institute [Internet]. 2004Feb [cited 2019Oct21]; Available from: https://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/2472.pdf

The idea for this blog was suggested by Ricardo A. Pena Silva M.D., Ph.D. Professor of Physiology and Pharmacology at The Universidad de los Andes, College of Medicine, who provided guidance to Oriana in the writing of this entry. For further discussion on this topic he can be contacted at rpena@uniandes.edu.co. Twitter: @medicinart

Oriana Escobar is a last year medical student at the Universidad de los Andes School of Medicine in Bogotá, Colombia. There, she has been a teaching assistant for the course of pharmacology numerous times. She is interested in medical education and public health, as well as anesthesiology. Outside the medical setting, she enjoys reading, swimming and traveling.