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Perceptions of Junior Doctors and Undergraduate Medical Students as Anatomy Teachers: Investigating Distance Along the Near-Peer Teaching Spectrum Samuel Hall,1* Jonathan Stephens,1 Teu Andrade,1 Joseph Davids,2 Matthew Powell,2 Scott Border3 1 Faculty of Medicine, University of Southampton, Southampton, United Kingdom 2 University Hospitals Southampton, NHS Foundation Trust, Southampton, United Kingdom 3 Centre for Learning Anatomical Sciences, Academic Unit of Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom

Near-peer teaching involves more experienced students acting as tutors and has been widely used in anatomy education. This approach has many advantages for the learner due to the social and cognitive congruence they share with the teacher, however, the influence of distance between the teacher and learner on these congruences has yet to be explored. The aim of this study was to compare the attitudes and perceptions of the student learner towards neuroanatomy review sessions taught by either a senior medical student or a junior doctor. The students were randomly assigned to an allocated tutor. All tutors used standardized material and had access to identical resources. The type of allocated tutor was swapped between the two teaching sessions and 99 student feedback forms were collected in total. The rating for the overall quality of the teaching session was not significantly different between the junior doctors and senior medical students (P 5 0.11). However, criteria closely relating to social and cognitive congruence such as “enjoyment of the session,” “delivery of the teaching,” and “was it a good use of time” were all rated significantly higher for the senior medical students (P < 0.05). The results of this study suggest that small increases in distance along the near-peer teaching spectrum have an impact upon the student’s perception of their learning experience. While all teachers were suitable role models it appears that junior doctors are too far removed from their own undergraduate experiences to share congruences with pre-clinical medical students. Anat Sci Educ 7: 242– C 2013 American Association of Anatomists. 247. V

Key words: teaching of neuroscience/neuroanatomy; educational methodology; effectiveness of anatomy education; undergraduate medical education

INTRODUCTION The use of near-peer teaching (NPT) in medical education has been well documented and its strength is rooted in the fact that the teacher has encountered the same learning process as the student (Bulte et al., 2007). These shared experi-

*Correspondence to: Mr. Samuel Hall, Faculty of Medicine, Mailpoint 845, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, United Kingdom. E-mail: [email protected] Received 21 January 2013; Revised 8 September 2013; Accepted 7 October 2013. Published online 29 October 2013 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1419 C 2013 American Association of Anatomists V

Anat Sci Educ 7:242–247 (2014)

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ences create a cognitive congruence which can be drawn upon during teaching sessions for teachers to provide explanations in terms that the students appreciate and understand (Lockspeiser et al., 2008; Singh, 2010). The near-peer teacher serves as a role model for the student because they see that others have progressed through the difficulties they are currently undergoing (Lockspeiser et al., 2008). As a role model the teacher shares a wealth of experiences and knowledge which are not covered in the official curriculum (Stern and Papadakis, 2006). Students feel more comfortable in admitting their ignorance on a subject to a peer rather than to a faculty member, thus allowing them to overcome specific weaknesses that might otherwise remain unaddressed (Bulte et al., 2007). Moreover, being in different years of study removes any competition, which might otherwise hinder learning (Singh, 2010; Duran et al., 2012). At the University of Southampton a

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preliminary evaluation of senior medical students teaching third year students has identified the influence of social and cognitive congruence in NPT as a significant factor in its success (Hall et al., 2013). The value of NPT in modern medical curricula lies in the changes which anatomy education has undergone in recent years. There has been a decreasing trend in the number of hours spent in anatomy education and the availability of trained anatomy staff (Heylings, 2000) which has created concern regarding current medical students’ level of anatomy knowledge (Gogalniceanu et al., 2009). In many medical schools, neuroanatomy remains a standalone course (Drake et al., 2009), but in an age of shrinking anatomy curricula many institutions, including the University of Southampton, are combining it together with the study of Head and Neck anatomy into a single course. Following a 2007 curriculum revalidation, the Head, Neck, and Neuroanatomy course at Southampton University continues to use a systemsorientated approach but with reduced contact time (approximately 15 hours of lectures combined with 12 hours of prosection based practical classes). However, these values fall short of the national average in the United Kingdom (Gogalniceanu et al., 2009) and thus NPT can potentially be used to help fill these voids (Hall et al., 2013). In anatomy, NPT in the form of student demonstrators has shown positive student responses (Lockspeiser et al., 2008; Evans and Cuffe, 2009) and successful outcomes have been evidenced for both student enjoyment (Brueckner and MacPherson, 2004) and examination performance (Nnodim, 1997). The literature identifies a wide range of other disciplines where near-peer led teaching produces the same improvement in objective examination results as expert-led teaching including musculoskeletal ultrasound (Knobe et al., 2010), interview skills (Nestel and Kidd, 2003), cardiology (Hughes et al., 2010), and clinical skills (Colaco et al., 2006; Tolsgaard et al., 2007). In addition to the benefits for the learner, NPT experience is sought after by students because of their future postgraduate responsibility to become a clinical teacher (Lachman et al., 2013). The theory of cognitive and social congruence implies that as student teachers progress through the curriculum they also increase their distance along the near-peer spectrum. Jackson and Evans (2012) propose that a slight incongruence may be beneficial in near-peer teaching although they admit that there is no evidence supporting an optimum distance. An interesting factor for consideration is whether Junior Doctors (JD) share the same level of social and cognitive congruence as Senior Medical Students (SMS) when teaching junior medical students, and more importantly what impact this could have on the learning experience. In the strictest sense, once qualified, a junior doctor is no longer near-peer to a medical student since it becomes cross level teaching (Ten Cate and Durning, 2007a). However, at the point of qualification junior doctors do not immediately transfer from apprentice to master and still have a wealth of student experience; therefore in terms of knowledge and congruence it could be argued that little has changed other than the crossing of a quantifiable threshold. The present investigation evaluates neuroanatomy teaching sessions delivered either by JD or SMS for second year medical students covering the parts of the course we felt were most difficult and required extra teaching time (cranial nerves and spinal tracts). The aim was to determine whether the increased distance along the near-peer teaching spectrum Anatomical Sciences Education

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Figure 1. A schematic detailing student participation; SMS, senior medical student; JD, junior doctor.

between SMS and JD has an impact on the social and cognitive congruences that are previously reported to benefit the student learning experience.

METHODS Experimental Procedures Two evening neuroanatomy revision sessions covering the cranial nerves and the major motor and sensory spinal tracts were delivered to second year undergraduate medical students attending the University of Southampton. Each session was scheduled approximately 2 weeks prior to their Head, Neck and Neuroanatomy course examinations. An invitation email was sent to all second year medical students (n 5 245), where 98 responded by email stating their intention of attending each session (response rate 40%). Each teaching evening (Fig. 1) consisted of eight small group tutorials lasting for 2 hours. The teachers were given strict instructions concerning content, which included precise aims and learning outcomes from the curriculum for both the cranial nerves and spinal tracts. These learning outcomes were approved by the Centre for Learning Anatomical Sciences (CLAS) within the Faculty of Medicine and enabled us to standardize the session content as well as the available resources. All teachers were briefed on these at least a week prior to the session to give adequate time for preparation. All teaching rooms were of similar size and were equipped with a white board, white board pens, a desktop computer, and a projector. The investigators provided teachers with a standard pre-prepared PowerPoint presentation along with some handouts. Although the teachers could choose not to use these resources, they were not allowed to use their own PowerPoint slides or handouts. Teachers were permitted to re-arrange the teaching space from the traditional layout (seating facing projector screen) but none chose to do so. Each session was led by either a SMS or a JD who were either currently training (or had trained) at the University of Southampton. The teachers comprised a total of five clinical year medical students (3 third-year, 1 fourth-year, and 1 fifth/ final-year) and four junior doctors (two doctors only taught one session each). The average age of the SMS teachers was 22.8 (range 20–25) and the JD teachers was 24.75 years old (range 24–26). All teachers, except for one junior doctor, 243

were male. Students were randomly assigned to groups and those who were taught by JD in the first week were then taught by SMS in the second week and vice versa. The students were not blinded to the career level of their teacher but were unaware of the purpose of the study. At the end of each session, students were invited to complete a paper based questionnaire where consent was also obtained. The questions asked students to rate their teacher on aspects of social and cognitive congruence using a five-point Likert scale ranging from very poor to excellent. The internal validity of this survey instrument was calculated using Cronbach alpha analysis returning a reliability co-efficient of 0.84.

Statistical Analysis The ratings for each feedback criteria were divided into those for SMS and JD and the groups were compared using Mann– Whitney U tests. The ratings for perceived level of knowledge before the session were subtracted from the ratings after the session and the differences for SMS and JD compared using a Mann–Whitney U test. All statistical tests were performed on GraphPad Prism, version 6 (GraphPad Software, La Jolla, CA). Ethical approval for this study was obtained from the Faculty of Medicine Ethics Committee: Ethics number 799.

RESULTS The numbers of students who attended each of our teaching sessions and who were taught by the respective teachers can be seen in Figure 1. The mean rating for the overall quality of the sessions delivered by the SMS was 4.3/5.0 compared to 4.0/5.0 for the teaching delivered by the JD, the difference between these ratings was not statistically significant (P 5 0.11; Fig. 2). Teaching by both SMS and JD improved students’ own perceived level of knowledge in the respective topics compared with ratings of their level of knowledge before the session (P < 0.0001; Fig. 3). Furthermore, the increase in perceived level of knowledge as a result of the teaching session was significantly greater for those students taught by an SMS compared to those taught by a JD (Fig. 3). The criteria relating to either social congruence (enjoyment and approachability) or cognitive congruence (use of time, delivery of teaching, and relevance of content) are also displayed in Figure 2. With the exception of relevance of content and approachability, all of these congruence criteria were scored significantly higher for the SMS teaching group compared to JD teachers (P < 0.05) (Fig. 2). We also encouraged students to comment on the teaching they had received. A total of 22 students were willing to offer us some insight into their experience. Many offered thanks and appreciation for providing the sessions, while others openly confessed to preferring the sessions lead by SMS. In general comments were directed toward improving on activities that would enhance their knowledge rather than their preferences over teaching staff.

Figure 2. Student ratings on criteria relating to social and cognitive congruence; students’ ratings are based on a five-point Likert scale ranging from 1 5 very poor to 5 5 excellent; aP < 0.05; bP < 0.01.

courses being affected the most (Drake et al., 2009) despite still receiving proportionately more time than other regional areas (Heylings, 2000). Various approaches including multidisciplinary courses and interactive e-learning packages (Svirko and Mellanby, 2008; Nowinski et al., 2009) have been adopted to minimize the impact on students’ education. However, increased time in both lectures and tutorials coupled with clearer explanations and slower repetition of teaching are still requested by those students who struggle with learning neuroanatomy (Kramer and Soley 2002). In order to meet these needs we established our own neuroanatomy NPT program and in doing so it was natural to ask who would be the most well received near-peer teachers and what effect this would have upon the student learning experience.

DISCUSSION

Figure 3.

There have been many changes to anatomy curricula in both the United Kingdom and the United States over the past few decades. Most notable is the overall reduction in time dedicated to scheduled laboratory sessions, with neuroanatomy

Student ratings on their perceived level of knowledge; students’ ratings are based on a five-point Likert scale ranging from 1 5 very poor to 5 5 excellent; aP < 0.0001; bP < 0.05.

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Congruence The main strengths of NPT are the social and cognitive congruences between the students and the teachers formed by the proximity in their stages of training (Schmidt and Moust, 1995; Lockspeiser et al., 2008). The impact of congruence on group dynamics has been demonstrated in a recent study which concluded that students have an innate tendency to form homogenous groups with those educationally equal to themselves but interact poorly with those who are more advanced (Carrell et al., 2013). The similar educational abilities and social standing of the learner and teacher allows for difficult subjects to be explained in simple language as well as creating a safe environment for students to raise questions (Bulte et al., 2007) without fear of failure (Zijdenbos et al., 2010). In theory, these benefits would be particularly useful in a subject such as neuroanatomy which is notoriously difficult to learn. Senior medical students received significantly higher ratings than JD in three of our feedback criteria (enjoyment, use of time, and delivery of teaching). Students in the study by Evans and Cuffe (2009) identified enjoyment as an important component in NPT and while an enjoyable teaching session is not confined to NPT it cannot exist without an anxiety-free environment. Therefore, we argue that the significantly higher enjoyment scores for SMS could be a reflection of a stronger social congruence and feelings of equality which removes any performance anxiety. This interpretation is supported by a previous study which demonstrated that student led-teaching creates a more relaxing tutorial atmosphere than faculty-led sessions (Kassab et al., 2005). Students value teaching that they perceive to be a good use of their time, and for many it is the most important characteristic of a teaching session (Bentley and Hill, 2009). Teaching tailored to the needs of the students, especially immediately prior to examinations, relies on a good knowledge of the course content and learning outcomes; a skill which near-peer tutors have previously demonstrated (Burke et al., 2007; Zijdenbos et al., 2010). This is likely due to their recent memories of undertaking the course themselves. All of the teachers in this study were either students at, or recent graduates from, the University of Southampton who had taken the same neuroanatomy course and so were familiar with the course learning outcomes. The significantly lower rating for the usefulness of JD’s neuroanatomy revision sessions may be due to fading of those memories with the greater passage of time. Furthermore, clinically experienced teachers may still recall learning outcomes however they often broaden the scope of their teaching by incorporating more of their own experiences (Carrell and West, 2010), something which SMSs are less equipped to do. Schmidt and Moust (1995) argued that the tutor’s ability to explain things in a comprehensible way was, in fact, a direct measure of cognitive congruence. In the current study, we have aligned their result to our delivery of teaching rating. One hypothesis is that the near-peer tutor remembers the reasoning process, and the pitfalls, associated with learning the material, whereas experts who are overly familiar with the information have become too far removed from their own learning processes (Kassab et al., 2005; Zijdenbos et al., 2010). In light of these observations it is reasonable to suggest that the SMS group outperformed the JD group because of their educational proximity which subsequently impacted upon the teacher’s performance in the classroom. This may also explain why the learners perceived their knowledge to increase more as a result of SMS teaching.

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Interestingly two of our feedback criteria showed nonsignificant differences between the two groups of teachers. First, both SMS and JD appeared equally approachable during the teaching session which is consistent with conclusions made by Tolsgaard et al. (2007). This suggests that the approachability of the teacher is independent of social congruence and is instead driven by the teacher’s own personality traits. Second, the relevance of content score did not differ significantly between the groups however this may be confounded by the standardization of the learning outcomes.

Distance Along Near-Peer Teaching Spectrum There have been several definitions proposed for what constitutes NPT including; “one or more years senior” (Ten Cate and Durning, 2007b), “one year more senior at the same level of the medical education spectrum” (Bulte, et al., 2007), or “two to five years ahead in their learning” (Evans and Cuffe, 2009). The importance of the “one plus” year gap can be found in Foster’s study which reports how the positive effect of social relationships on learning are stronger in nonfriends due to an unfamiliarity which pushes the learner out of their equilibrium (Foster, 2006). This mirrors Jackson and Evans’s concept of cognitive incongruence (Jackson and Evans, 2012). While these definitions consistently identify that the teacher must be more advanced than the learner, ambiguity remains over when the distance between teacher and student becomes too great and the term “near-peer” ceases to be applicable. The results from this study show that there is a significant drop in perceived teacher performance between the SMS and JD groups. This drop may simply be due to an increased distance between students and teachers which may be enough to impact on congruence. However, this increase in distance means that one teaching group (JD) has undergone a transition into post-graduate work which has been described as a “ravine. . .in the form of academic, social and emotional challenges” (Finlay and Fawzy, 2001). This shift in personal characteristics and development of professional identity seen in junior doctors derives from a change to a purely patient centered approach to learning and the rites of passage of their new environment (Bleakley, 2002). The newfound stress, responsibility and uncertainty around clinical practice (Brennan et al., 2010) may also separate JD from their undergraduate experiences. The new job title and social position could further impact upon the learners’ social perceptions of the teacher. If one believes that cognitive and social congruence are defining characteristics of NPT then based on these results a more accurate definition of near-peer teaching must refer to any significant transitions along the educational spectrum. A broader interpretation of NPT may be required which incorporates additional characteristics of NPT dynamics. We argue that levels of congruence between teacher and learner are likely to change along the NPT spectrum but causality may be complex and dependent on a number of further variables.

Implications for Anatomy Education Having identified a disparity between SMS and JD performance as near-peer teachers we now ask: how might this impact upon the application of NPT in medical curricula? This is particularly crucial for difficult subjects such as 245

neuroanatomy where the benefits of congruence are likely to be greatest. The overall quality of SMS teaching was not considered significantly better than JD teaching which compares well with existing studies comparing student and faculty led teaching for both perceptions (Rashid et al., 2011) and objective outcomes (Tolsgaard et al., 2007). However while junior doctors are able to teach both pre-clinical (Haubert 2011) and clinical students (Bing-You and Sproul, 1992; Rodrigues et al., 2009), nearly all anatomy teaching occurs at the preclinical level therefore it seems appropriate to recruit nearpeer teachers who relate best to these year groups.

Limitations This study has some limitations worthy of recognition. As described above the feedback criteria we tested were chosen based on previous demonstrations of their involvement in NPT however, their link with social and cognitive congruence is currently suppositional despite questionnaire items being developed from the existing literature (Lockspeiser et al., 2008; Bentley and Hill, 2009; Evans and Cuffe, 2009). Future investigations should aim to define these criteria as direct measures of congruence, possibly via statistical means. Furthermore, our criteria measured the student’s perceptions of their learning experience however we are yet to establish how our NPT sessions influence student examination performance, which would objectively validate their educational value.

CONCLUSION This study demonstrates that the distance between the tutor and the learner has an impact upon the student learning experience in a supplemental NPT program. It is likely that a quantifiable threshold such as graduation influences both how the teacher is perceived and what knowledge they can draw upon as teachers. Although SMS and JD can both produce high quality teaching sessions, our congruence indicators suggests that SMS were preferred as teachers of undergraduate neuroanatomy and therefore may also be more suitable for supplementing teaching in other areas of undergraduate education.

NOTES ON CONTRIBUTORS SAMUEL HALL, is a fifth- and final-year medical student at University of Southampton, Southampton, UK. He developed the research, advised on the teaching structure and taught the students. JONATHAN STEPHENS, is a fourth- (intercalating) year medical student at University of Southampton, Southampton, UK. He developed the teaching sessions and taught the students. TEU ANDRADE, is a fourth- (intercalating) year medical student at University of Southampton, Southampton, UK. He developed the teaching sessions and taught the students. JOSEPH DAVIDS, B.M., B.Med.Sc. (Hons), is a Foundation Year 1 Doctor at the University Hospitals Southampton NHS Foundation Trust, Southampton, UK. He taught medical students and analyzed the feedback. MATTHEW POWELL, B.M., B.Med.Sc. (Hons), is a Foundation Year 2 Doctor at the University Hospitals Southampton NHS Foundation Trust, Southampton, UK. He taught medical students and analyzed the feedback.

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SCOTT BORDER, B.Sc. (Hons), Ph.D., is a senior teaching fellow in anatomy at the Centre for Learning Anatomical Sciences, Academic Unit of Medical Education, University of Southampton, Southampton, UK. He teaches courses on nervous and locomotor systems for medical students and serves as faculty advisor for anatomy research projects in both anatomy and medical education. LITERATURE CITED Bentley BS, Hill RV. 2009. Objective and subjective assessment of reciprocal peer teaching in medical gross anatomy laboratory. Anat Sci Educ 2:143– 149. Bing-You RG, Sproul MS. 1992. Medical students’ perceptions of themselves and residents as teachers. Med Teach 14:133–138. Bleakley A. 2002. Pre-registration house officers and ward-based learning: A ‘new apprenticeship’ model. Med Educ 36:9–15. Brennan N, Corrigan O, Allard J, Archer J, Barnes R, Bleakley A, Collett T, de Bere SR. 2010. The transition from medical student to junior doctor: Today’s experiences of Tomorrow’s Doctors. Med Educ 44:449–458. Brueckner JK, MacPherson BR. 2004. Benefits from peer-teaching in the dental gross anatomy laboratory. Eur J Dent Educ 8:72–77. Bulte C, Betts A, Garner K, Durning S. 2007. Student teaching: Views of student near-peer teachers and learners. Med Teach 29:583–590. Burke J, Fayaz S, Graham K, Matthew R, Field M. 2007. Peer-assisted learning in the acquisition of clinical skills: A supplementary approach to musculoskeletal system training. Med Teach 29:577–582. Carrell SE, Sacerdote BI, West JE. 2013. From natural variation to optimal policy? The importance of endogenous peer group formation. Econometrica 81:855–882. Carrell SE, West EW. 2010. Does professor quality matter? Evidence from random assignment of students to professors. J Polit Econ 118:409–432. Colaco SM, Chou CL, Hauer KE. 2006. Near-peer teaching in a formative clinical skills examination. Med Educ 40:1129–1130. Drake RL, McBride JM, Lachman N, Pawlina W. 2009. Medical education in the anatomical sciences: the winds of change continue to blow. Anat Sci Educ 2:253–259. Dur an CE, Bahena EN, Rodrıguez Mde L, Baca GJ, Uresti AS, ElizondoOma~ na RE, L opez SG. 2012. Near-peer teaching in an anatomy course with a low faculty-to-student ratio. Anat Sci Educ 5:171–176. Evans DJ, Cuffe T. 2009. Near-peer teaching in anatomy: An approach for deeper learning. Anat Sci Educ 2:227–233. Finlay SE, Fawzy M. 2001. Becoming a doctor. Med Humanit 27:90–92. Foster G. 2006. It’s not your peers, and it’s not your friends: Some progress toward understanding the educational peer effect mechanism. J Publ Econ 90: 1455–1475. Gogalniceanu P, O’Connor EF, Raftery A. 2009. Undergraduate anatomy teaching in the UK. Ann R Coll Surg Engl 91:S102–S106. Hall S, Powell MR, Border S. 2012. An evaluation of near-peer teaching in neuroanatomy. Clin Anat 25:803. Haubert LM, Way D, DePhilip R, Tam M, Bishop J, Jones K, Moffatt-Bruce SD. 2011. Surgeons as medical school educators: An untapped resource. Anat Sci Educ 4:182–189. Heylings DJ. 2000. Anatomy 1999-2000: The curriculum, who teaches it and how? Med Educ 36:702–710. Hughes TC, Jiwaji Z, Lally K, Lloyd-Lavery A, Lota A, Dale A, Janas R, Bulstrode CJ. 2010. Advanced Cardiac Resuscitation Evaluation (ACRE): A randomised single-blind controlled trial of peer-led vs. expert-led advanced resuscitation training. Scand J Trauma Resusc Emerg Med 18:3. Jackson TA, Evans DJ. 2012. Can medical students teach? A near-peer-led teaching program for year 1 students. Adv Physiol Educ 36:192–196. Kassab S, Abu-Hijleh MF, Al-Shboul Q, Hamdy H. 2005. Student-led tutorials in problem-based learning: Educational outcomes and students’ perceptions. Med Teach 27:521–526. Knobe M, M€ unker R, Sellei RM, Holschen M, Mooij SC, Schmidt-Rohlfing B, Niethard FU, Pape HC. 2010. Peer teaching: A randomised controlled trial using student-teachers to teach musculoskeletal ultrasound. Med Educ 44:148– 155. Kramer B, Soley J. 2002. Medical student perception of problem topics in anatomy. East Afr Med J 79:408–414. Lachman N, Christensen KN, Pawlina W. 2013. Anatomy teaching assistants: Facilitating teaching skills for medical students through apprenticeship and mentoring. Med Teach 35:e919–e925. Lockspeiser TM, O’Sullivan P, Teherani A, Muller J. 2008. Understanding the experience of being taught by peers: The value of social and cognitive congruence. Adv Health Sci Educ Theory Pract 13:361–372. Nestel D, Kidd J. 2003. Peer tutoring in patient-centred interviewing skills: Experience of a project for first-year students. Med Teach 25:398– 403.

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Perceptions of junior doctors and undergraduate medical students as anatomy teachers: Investigating distance along the near-peer teaching spectrum.

Near-peer teaching involves more experienced students acting as tutors and has been widely used in anatomy education. This approach has many advantage...
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