literature review medical education

Writing an effective literature review

Part II: Citation technique

• The Writer’s Craft
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• Published: 02 March 2018
• Volume 7 , pages 133–135, ( 2018 )

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Avoid common mistakes on your manuscript.

In the Writer’s Craft section we offer simple tips to improve your writing in one of three areas: Energy, Clarity and Persuasiveness. Each entry focuses on a key writing feature or strategy, illustrates how it commonly goes wrong, teaches the grammatical underpinnings necessary to understand it and offers suggestions to wield it effectively. We encourage readers to share comments on or suggestions for this section on Twitter, using the hashtag: #how’syourwriting?

This Writer’s Craft instalment is the second in a two-part series that offers strategies for effectively presenting the literature review section of a research manuscript. This piece argues that citation is not just a technical practice but also a rhetorical one, and offers writers an expanded vocabulary for using citation to maximal effect.

Many writers think of citation as the formal system we use to avoid plagiarism and acknowledge others’ work. But citation is a much more nuanced practice than this. Not only does citation allow us to represent the source of knowledge, but it also allows us to position ourselves in relation to that knowledge, and to place that knowledge in relation to other knowledge . In short, citation is how we artfully tell the story of what the field knows, how it came to that knowledge, and where we stand in relation to it as we write the literature review section to frame our own work. Seen this way, citation is a sophisticated task, requiring in-depth knowledge of the literature in a domain.

Citation is more than just referencing; it is how we represent the social construction of knowledge in a field. A citation strategy is any indication in the text about the source and nature of knowledge. Consider the following passage, in which all citation strategies are italicized:

Despite years of effort to teach and enforce positive professional norms and standards, many reports of challenges to medical professionalism continue to appear, both in the medical and education literature and, often in reaction, in the lay press . 1,2,3,4,5 Examples of professional lapses dot the health care landscape: regulations are thwarted, records are falsified, patients are ignored, colleagues are berated. 2,4,6 The medical profession has articulated its sense of what professionalism is in a number of important position statements . 7,8 These statements tend to be built upon abstracted principles and values, such as the taxonomy presented in the American Board of Internal Medicine’s (ABIM’s) Project Professionalism : altruism, accountability, excellence, duty, honour, integrity, and respect for others. 7 (From Ginsburg et al., The anatomy of a professional lapse [ 1 ])

In this passage, citation as referencing (in the form of Vancouver format superscript numbers) is used to acknowledge the source of knowledge. There are more than just references in this passage, however. Citation strategies also include statements that characterize the density of that knowledge (‘many reports’), its temporal patterns (‘continue to appear’), its diverse origins (‘both in the medical and education literature’), its social nature (‘often in reaction’), and its social import (‘important position statements’). Citation does more than just acknowledge the source of something you’ve read. It is how you represent the social nature of knowledge as coming from somewhere, being debated and developed, and having impact on the world [ 2 ]. If we remove all these citation strategies, the passage sounds at best like common sense or, at worst, like unsubstantiated personal opinion:

Despite years of effort to teach and enforce positive professional norms and standards, challenges to medical professionalism continue. Examples of professional lapses dot the health care landscape: regulations are thwarted, records are falsified, patients are ignored, colleagues are berated. Professionalism is a set of principles and values: altruism, accountability, excellence, duty, honour, integrity, and respect for others.

But perhaps you’ve been told that your literature review should be ‘objective’—that you should simply present what is known without taking a stance on it. This is largely untrue, for two reasons. The first involves the distinction between summary and critical summary. A summary is a neutral description of material, but a good literature review contains very little pure summary because, as we review, we must also judge the quality, source and reliability of the knowledge claims we are presenting [ 3 ]. To do this, we engage in critical summary, not only summarizing existing knowledge but offering a stance on it.

The second reason is that, even when we’re aiming for simple summary, a completely neutral presentation of knowledge claims is very difficult to achieve. We take a stance in ways we hardly even notice. Consider how the verb in each of these statements adds a flavour of stance to what is otherwise a summary of a knowledge claim in the field:

Anderson describes how the assessment is overly time-consuming for use in the Emergency Department. Anderson discovered that the assessment was overly time-consuming for use in the Emergency Department. Anderson claims that the assessment is overly time-consuming for use in the Emergency Department.

The first verb, ‘describes’, is neutral: it is not possible to ascertain the writer’s stance on the knowledge Anderson has contributed to the field. The second verb, ‘discovered’, expresses an affiliation or positive stance in the writer, while the third verb, ‘claims’, distances the writer from Anderson’s work. Even these brief summary sentences contain a flavour of critical summary. This is not a flaw; in fact, it is an important method of portraying existing knowledge as a conversation in which the writer is positioning herself and her work. But it should be done consciously and strategically. Tab.  1 offers examples to help writers think about how the verbs in their literature review position them in relation to existing knowledge in the field. Meaning is subject to context and these examples should only be taken as a guide: e. g., ‘suggests’ can be used to signal neutrality or distancing.

Most of us have favourite verbs that we default to almost unconsciously when we are writing—reports, argues, describes, studies, explains, asserts—but these verbs are not interchangeable. They each inscribe a slightly different stance towards the knowledge—not only the writer’s stance, but also the stance of the researcher who created the knowledge. It is critical to get the original stance right in your critical summary. Nothing irritates me more than seeing my stance mispresented in someone else’s literature review. For example, if I wrote a paragraph offering tentative reflections on a new idea, I don’t want to see that summarized in someone’s literature review as ‘Lingard argues’, when more accurate would be ‘Lingard suggests’ or ‘Lingard explored’.

Writers need to extend their library of citation verbs to allow themselves to accurately and persuasively position knowledge claims published by authors in their field. You can find many online resources to help extend your vocabulary: Tab.  2 , adapted from one such online source [ 4 ], provides some suggestions. Tables like these should be thought of as tools, not rules—keep in mind that words have flexible meanings depending on context and purpose. This is why one word, such as suggest or conclude , can appear in more than one list.

Knowledge is a social construction and it accumulates as researchers debate, extend and refine one another’s contributions. To avoid your literature review reading like a laundry list of disconnected ‘facts’, reporting verbs are an important resource. Tab.  3 offers a selection of verbs organized to reflect different relationships among authors in the field of knowledge being reviewed.

Finally, although we have focused on citation verbs in this article, adverbs (e. g., similarly, consequently) and prepositional phrases (e. g., by contrast, in addition) are also important for expressing similar, contrasting or responding relations among knowledge claims and their authors in the field being reviewed.

In summary, an effective literature review not only summarizes existing knowledge, it also critically presents that knowledge to depict an evolving conversation and understanding in a particular domain of study. As writers we need to know when we are summarizing and when we are critically summarizing—summary alone makes for a literature review that reads like a laundry list of undigested ‘facts-in-the-world’. Finally, writers need to attend to the subtle power of citation verbs to position themselves and the authors they are citing in relation to the knowledge being reviewed. Broadening our catalogue of ‘go-to’ verbs is an important step in enlivening and strengthening our writing.

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Thanks to Mark Goldszmidt for his feedback on an early version of this manuscript.

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Lingard, L. Writing an effective literature review. Perspect Med Educ 7 , 133–135 (2018). https://doi.org/10.1007/s40037-018-0407-z

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Original Research

State-of-the-art literature review methodology: a six-step approach for knowledge synthesis.

• Erin S. Barry
• Jerusalem Merkebu
• Lara Varpio

Introduction Researchers and practitioners rely on literature reviews to synthesize large bodies of knowledge. Many types of literature reviews have been developed, each targeting a specific purpose. However, these syntheses are hampered if the review type’s paradigmatic roots, methods, and markers of rigor are only vaguely understood. One literature review type whose methodology has yet to be elucidated is the state-of-the-art (SotA) review. If medical educators are to harness SotA reviews to generate knowledge syntheses, we must understand and articulate the paradigmatic roots of, and methods for, conducting SotA reviews.

Methods We reviewed 940 articles published between 2014–2021 labeled as SotA reviews. We (a) identified all SotA methods-related resources, (b) examined the foundational principles and techniques underpinning the reviews, and (c) combined our findings to inductively analyze and articulate the philosophical foundations, process steps, and markers of rigor.

Results In the 940 articles reviewed, nearly all manuscripts (98%) lacked citations for how to conduct a SotA review. The term “state of the art” was used in 4 different ways. Analysis revealed that SotA articles are grounded in relativism and subjectivism.

Discussion This article provides a 6-step approach for conducting SotA reviews. SotA reviews offer an interpretive synthesis that describes: This is where we are now. This is how we got here. This is where we could be going. This chronologically rooted narrative synthesis provides a methodology for reviewing large bodies of literature to explore why and how our current knowledge has developed and to offer new research directions.

• State-of-the-art literature review
• Literature review
• Literature review methodology

Literature reviews play a foundational role in scientific research; they support knowledge advancement by collecting, describing, analyzing, and integrating large bodies of information and data [ 1 , 2 ]. Indeed, as Snyder [ 3 ] argues, all scientific disciplines require literature reviews grounded in a methodology that is accurate and clearly reported. Many types of literature reviews have been developed, each with a unique purpose, distinct methods, and distinguishing characteristics of quality and rigor [ 4 , 5 ].

Each review type offers valuable insights if rigorously conducted [ 3 , 6 ]. Problematically, this is not consistently the case, and the consequences can be dire. Medical education’s policy makers and institutional leaders rely on knowledge syntheses to inform decision making [ 7 ]. Medical education curricula are shaped by these syntheses. Our accreditation standards are informed by these integrations. Our patient care is guided by these knowledge consolidations [ 8 ]. Clearly, it is important for knowledge syntheses to be held to the highest standards of rigor. And yet, that standard is not always maintained. Sometimes scholars fail to meet the review’s specified standards of rigor; other times the markers of rigor have never been explicitly articulated. While we can do little about the former, we can address the latter. One popular literature review type whose methodology has yet to be fully described, vetted, and justified is the state-of-the-art (SotA) review.

While many types of literature reviews amalgamate bodies of literature, SotA reviews offer something unique. By looking across the historical development of a body of knowledge, SotA reviews delves into questions like: Why did our knowledge evolve in this way? What other directions might our investigations have taken? What turning points in our thinking should we revisit to gain new insights? A SotA review—a form of narrative knowledge synthesis [ 5 , 9 ]—acknowledges that history reflects a series of decisions and then asks what different decisions might have been made.

SotA reviews are frequently used in many fields including the biomedical sciences [ 10 , 11 ], medicine [ 12 – 14 ], and engineering [ 15 , 16 ]. However, SotA reviews are rarely seen in medical education; indeed, a bibliometrics analysis of literature reviews published in 14 core medical education journals between 1999 and 2019 reported only 5 SotA reviews out of the 963 knowledge syntheses identified [ 17 ]. This is not to say that SotA reviews are absent; we suggest that they are often unlabeled. For instance, Schuwirth and van der Vleuten’s article “A history of assessment in medical education” [ 14 ] offers a temporally organized overview of the field’s evolving thinking about assessment. Similarly, McGaghie et al. published a chronologically structured review of simulation-based medical education research that “reviews and critically evaluates historical and contemporary research on simulation-based medical education” [ 18 , p. 50]. SotA reviews certainly have a place in medical education, even if that place is not explicitly signaled.

This lack of labeling is problematic since it conceals the purpose of, and work involved in, the SotA review synthesis. In a SotA review, the author(s) collects and analyzes the historical development of a field’s knowledge about a phenomenon, deconstructs how that understanding evolved, questions why it unfolded in specific ways, and posits new directions for research. Senior medical education scholars use SotA reviews to share their insights based on decades of work on a topic [ 14 , 18 ]; their junior counterparts use them to critique that history and propose new directions [ 19 ]. And yet, SotA reviews are generally not explicitly signaled in medical education. We suggest that at least two factors contribute to this problem. First, it may be that medical education scholars have yet to fully grasp the unique contributions SotA reviews provide. Second, the methodology and methods of SotA reviews are poorly reported making this form of knowledge synthesis appear to lack rigor. Both factors are rooted in the same foundational problem: insufficient clarity about SotA reviews. In this study, we describe SotA review methodology so that medical educators can explicitly use this form of knowledge synthesis to further advance the field.

We developed a four-step research design to meet this goal, illustrated in Fig.  1 .

Four-step research design process used for developing a State-of-the-Art literature review methodology

Step 1: Collect SotA articles

To build our initial corpus of articles reporting SotA reviews, we searched PubMed using the strategy (″state of the art review″[ti] OR ″state of the art review*″) and limiting our search to English articles published between 2014 and 2021. We strategically focused on PubMed, which includes MEDLINE, and is considered the National Library of Medicine’s premier database of biomedical literature and indexes health professions education and practice literature [ 20 ]. We limited our search to 2014–2021 to capture modern use of SotA reviews. Of the 960 articles identified, nine were excluded because they were duplicates, erratum, or corrigendum records; full text copies were unavailable for 11 records. All articles identified ( n  = 940) constituted the corpus for analysis.

Step 2: Compile all methods-related resources

EB, JM, or LV independently reviewed the 940 full-text articles to identify all references to resources that explained, informed, described, or otherwise supported the methods used for conducting the SotA review. Articles that met our criteria were obtained for analysis.

To ensure comprehensive retrieval, we also searched Scopus and Web of Science. Additionally, to find resources not indexed by these academic databases, we searched Google (see Electronic Supplementary Material [ESM] for the search strategies used for each database). EB also reviewed the first 50 items retrieved from each search looking for additional relevant resources. None were identified. Via these strategies, nine articles were identified and added to the collection of methods-related resources for analysis.

Step 3: Extract data for analysis

In Step 3, we extracted three kinds of information from the 940 articles papers identified in Step 1. First, descriptive data on each article were compiled (i.e., year of publication and the academic domain targeted by the journal). Second, each article was examined and excerpts collected about how the term state-of-the-art review was used (i.e., as a label for a methodology in-and-of itself; as an adjective qualifying another type of literature review; as a term included in the paper’s title only; or in some other way). Finally, we extracted excerpts describing: the purposes and/or aims of the SotA review; the methodology informing and methods processes used to carry out the SotA review; outcomes of analyses; and markers of rigor for the SotA review.

Two researchers (EB and JM) coded 69 articles and an interrater reliability of 94.2% was achieved. Any discrepancies were discussed. Given the high interrater reliability, the two authors split the remaining articles and coded independently.

Step 4: Construct the SotA review methodology

The methods-related resources identified in Step 2 and the data extractions from Step 3 were inductively analyzed by LV and EB to identify statements and research processes that revealed the ontology (i.e., the nature of reality that was reflected) and the epistemology (i.e., the nature of knowledge) underpinning the descriptions of the reviews. These authors studied these data to determine if the synthesis adhered to an objectivist or a subjectivist orientation, and to synthesize the purposes realized in these papers.

To confirm these interpretations, LV and EB compared their ontology, epistemology, and purpose determinations against two expectations commonly required of objectivist synthesis methods (e.g., systematic reviews): an exhaustive search strategy and an appraisal of the quality of the research data. These expectations were considered indicators of a realist ontology and objectivist epistemology [ 21 ] (i.e., that a single correct understanding of the topic can be sought through objective data collection {e.g., systematic reviews [ 22 ]}). Conversely, the inverse of these expectations were considered indicators of a relativist ontology and subjectivist epistemology [ 21 ] (i.e., that no single correct understanding of the topic is available; there are multiple valid understandings that can be generated and so a subjective interpretation of the literature is sought {e.g., narrative reviews [ 9 ]}).

Once these interpretations were confirmed, LV and EB reviewed and consolidated the methods steps described in these data. Markers of rigor were then developed that aligned with the ontology, epistemology, and methods of SotA reviews.

Of the 940 articles identified in Step 1, 98% ( n  = 923) lacked citations or other references to resources that explained, informed, or otherwise supported the SotA review process. Of the 17 articles that included supporting information, 16 cited Grant and Booth’s description [ 4 ] consisting of five sentences describing the overall purpose of SotA reviews, three sentences noting perceived strengths, and four sentences articulating perceived weaknesses. This resource provides no guidance on how to conduct a SotA review methodology nor markers of rigor. The one article not referencing Grant and Booth used “an adapted comparative effectiveness research search strategy that was adapted by a health sciences librarian” [ 23 , p. 381]. One website citation was listed in support of this strategy; however, the page was no longer available in summer 2021. We determined that the corpus was uninformed by a cardinal resource or a publicly available methodology description.

In Step 2 we identified nine resources [ 4 , 5 , 24 – 28 ]; none described the methodology and/or processes of carrying out SotA reviews. Nor did they offer explicit descriptions of the ontology or epistemology underpinning SotA reviews. Instead, these resources provided short overview statements (none longer than one paragraph) about the review type [ 4 , 5 , 24 – 28 ]. Thus, we determined that, to date, there are no available methodology papers describing how to conduct a SotA review.

Step 3 revealed that “state of the art” was used in 4 different ways across the 940 articles (see Fig.  2 for the frequency with which each was used). In 71% ( n  = 665 articles), the phrase was used only in the title, abstract, and/or purpose statement of the article; the phrase did not appear elsewhere in the paper and no SotA methodology was discussed. Nine percent ( n  = 84) used the phrase as an adjective to qualify another literature review type and so relied entirely on the methodology of a different knowledge synthesis approach (e.g., “a state of the art systematic review [ 29 ]”). In 5% ( n  = 52) of the articles, the phrase was not used anywhere within the article; instead, “state of the art” was the type of article within a journal. In the remaining 15% ( n  = 139), the phrase denoted a specific methodology (see ESM for all methodology articles). Via Step 4’s inductive analysis, the following foundational principles of SotA reviews were developed: (1) the ontology, (2) epistemology, and (3) purpose of SotA reviews.

Four ways the term “state of the art” is used in the corpus and how frequently each is used

Ontology of SotA reviews: Relativism

SotA reviews rest on four propositions:

• The literature addressing a phenomenon offers multiple perspectives on that topic (i.e., different groups of researchers may hold differing opinions and/or interpretations of data about a phenomenon).
• The reality of the phenomenon itself cannot be completely perceived or understood (i.e., due to limitations [e.g., the capabilities of current technologies, a research team’s disciplinary orientation] we can only perceive a limited part of the phenomenon).
• The reality of the phenomenon is a subjective and inter-subjective construction (i.e., what we understand about a phenomenon is built by individuals and so their individual subjectivities shape that understanding).
• The context in which the review was conducted informs the review (e.g., a SotA review of literature about gender identity and sexual function will be synthesized differently by researchers in the domain of gender studies than by scholars working in sex reassignment surgery).

As these propositions suggest, SotA scholars bring their experiences, expectations, research purposes, and social (including academic) orientations to bear on the synthesis work. In other words, a SotA review synthesizes the literature based on a specific orientation to the topic being addressed. For instance, a SotA review written by senior scholars who are experts in the field of medical education may reflect on the turning points that have shaped the way our field has evolved the modern practices of learner assessment, noting how the nature of the problem of assessment has moved: it was first a measurement problem, then a problem that embraced human judgment but needed assessment expertise, and now a whole system problem that is to be addressed from an integrated—not a reductionist—perspective [ 12 ]. However, if other scholars were to examine this same history from a technological orientation, learner assessment could be framed as historically constricted by the media available through which to conduct assessment, pointing to how artificial intelligence is laying the foundation for the next wave of assessment in medical education [ 30 ].

Given these foundational propositions, SotA reviews are steeped in a relativist ontology—i.e., reality is socially and experientially informed and constructed, and so no single objective truth exists. Researchers’ interpretations reflect their conceptualization of the literature—a conceptualization that could change over time and that could conflict with the understandings of others.

Epistemology of SotA reviews: Subjectivism

SotA reviews embrace subjectivism. The knowledge generated through the review is value-dependent, growing out of the subjective interpretations of the researcher(s) who conducted the synthesis. The SotA review generates an interpretation of the data that is informed by the expertise, experiences, and social contexts of the researcher(s). Furthermore, the knowledge developed through SotA reviews is shaped by the historical point in time when the review was conducted. SotA reviews are thus steeped in the perspective that knowledge is shaped by individuals and their community, and is a synthesis that will change over time.

Purpose of SotA reviews

SotA reviews create a subjectively informed summary of modern thinking about a topic. As a chronologically ordered synthesis, SotA reviews describe the history of turning points in researchers’ understanding of a phenomenon to contextualize a description of modern scientific thinking on the topic. The review presents an argument about how the literature could be interpreted; it is not a definitive statement about how the literature should or must be interpreted. A SotA review explores: the pivotal points shaping the historical development of a topic, the factors that informed those changes in understanding, and the ways of thinking about and studying the topic that could inform the generation of further insights. In other words, the purpose of SotA reviews is to create a three-part argument: This is where we are now in our understanding of this topic. This is how we got here. This is where we could go next.

The SotA methodology

Based on study findings and analyses, we constructed a six-stage SotA review methodology. This six-stage approach is summarized and guiding questions are offered in Tab.  1 .

The six-stage approach to conducting a State-of-the-Art review

Stage 1: Determine initial research question and field of inquiry

In Stage 1, the researcher(s) creates an initial description of the topic to be summarized and so must determine what field of knowledge (and/or practice) the search will address. Knowledge developed through the SotA review process is shaped by the context informing it; thus, knowing the domain in which the review will be conducted is part of the review’s foundational work.

Stage 2: Determine timeframe

This stage involves determining the period of time that will be defined as SotA for the topic being summarized. The researcher(s) should engage in a broad-scope overview of the literature, reading across the range of literature available to develop insights into the historical development of knowledge on the topic, including the turning points that shape the current ways of thinking about a topic. Understanding the full body of literature is required to decide the dates or events that demarcate the timeframe of now in the first of the SotA’s three-part argument: where we are now . Stage 2 is complete when the researcher(s) can explicitly justify why a specific year or event is the right moment to mark the beginning of state-of-the-art thinking about the topic being summarized.

Stage 3: Finalize research question(s) to reflect timeframe

Based on the insights developed in Stage 2, the researcher(s) will likely need to revise their initial description of the topic to be summarized. The formal research question(s) framing the SotA review are finalized in Stage 3. The revised description of the topic, the research question(s), and the justification for the timeline start year must be reported in the review article. These are markers of rigor and prerequisites for moving to Stage 4.

Stage 4: Develop search strategy to find relevant articles

In Stage 4, the researcher(s) develops a search strategy to identify the literature that will be included in the SotA review. The researcher(s) needs to determine which literature databases contain articles from the domain of interest. Because the review describes how we got here , the review must include literature that predates the state-of-the-art timeframe, determined in Stage 2, to offer this historical perspective.

Developing the search strategy will be an iterative process of testing and revising the search strategy to enable the researcher(s) to capture the breadth of literature required to meet the SotA review purposes. A librarian should be consulted since their expertise can expedite the search processes and ensure that relevant resources are identified. The search strategy must be reported (e.g., in the manuscript itself or in a supplemental file) so that others may replicate the process if they so choose (e.g., to construct a different SotA review [and possible different interpretations] of the same literature). This too is a marker of rigor for SotA reviews: the search strategies informing the identification of literature must be reported.

Stage 5: Analyses

The literature analysis undertaken will reflect the subjective insights of the researcher(s); however, the foundational premises of inductive research should inform the analysis process. Therefore, the researcher(s) should begin by reading the articles in the corpus to become familiar with the literature. This familiarization work includes: noting similarities across articles, observing ways-of-thinking that have shaped current understandings of the topic, remarking on assumptions underpinning changes in understandings, identifying important decision points in the evolution of understanding, and taking notice of gaps and assumptions in current knowledge.

The researcher(s) can then generate premises for the state-of-the-art understanding of the history that gave rise to modern thinking, of the current body of knowledge, and of potential future directions for research. In this stage of the analysis, the researcher(s) should document the articles that support or contradict their premises, noting any collections of authors or schools of thinking that have dominated the literature, searching for marginalized points of view, and studying the factors that contributed to the dominance of particular ways of thinking. The researcher(s) should also observe historical decision points that could be revisited. Theory can be incorporated at this stage to help shape insights and understandings. It should be highlighted that not all corpus articles will be used in the SotA review; instead, the researcher(s) will sample across the corpus to construct a timeline that represents the seminal moments of the historical development of knowledge.

Next, the researcher(s) should verify the thoroughness and strength of their interpretations. To do this, the researcher(s) can select different articles included in the corpus and examine if those articles reflect the premises the researcher(s) set out. The researcher(s) may also seek out contradictory interpretations in the literature to be sure their summary refutes these positions. The goal of this verification work is not to engage in a triangulation process to ensure objectivity; instead, this process helps the researcher(s) ensure the interpretations made in the SotA review represent the articles being synthesized and respond to the interpretations offered by others. This is another marker of rigor for SotA reviews: the authors should engage in and report how they considered and accounted for differing interpretations of the literature, and how they verified the thoroughness of their interpretations.

Stage 6: Reflexivity

Given the relativist subjectivism of a SotA review, it is important that the manuscript offer insights into the subjectivity of the researcher(s). This reflexivity description should articulate how the subjectivity of the researcher(s) informed interpretations of the data. These reflections will also influence the suggested directions offered in the last part of the SotA three-part argument: where we could go next. This is the last marker of rigor for SotA reviews: researcher reflexivity must be considered and reported.

SotA reviews have much to offer our field since they provide information on the historical progression of medical education’s understanding of a topic, the turning points that guided that understanding, and the potential next directions for future research. Those future directions may question the soundness of turning points and prior decisions, and thereby offer new paths of investigation. Since we were unable to find a description of the SotA review methodology, we inductively developed a description of the methodology—including its paradigmatic roots, the processes to be followed, and the markers of rigor—so that scholars can harness the unique affordances of this type of knowledge synthesis.

Given their chronology- and turning point-based orientation, SotA reviews are inherently different from other types of knowledge synthesis. For example, systematic reviews focus on specific research questions that are narrow in scope [ 32 , 33 ]; in contrast, SotA reviews present a broader historical overview of knowledge development and the decisions that gave rise to our modern understandings. Scoping reviews focus on mapping the present state of knowledge about a phenomenon including, for example, the data that are currently available, the nature of that data, and the gaps in knowledge [ 34 , 35 ]; conversely, SotA reviews offer interpretations of the historical progression of knowledge relating to a phenomenon centered on significant shifts that occurred during that history. SotA reviews focus on the turning points in the history of knowledge development to suggest how different decisions could give rise to new insights. Critical reviews draw on literature outside of the domain of focus to see if external literature can offer new ways of thinking about the phenomenon of interest (e.g., drawing on insights from insects’ swarm intelligence to better understand healthcare team adaptation [ 36 ]). SotA reviews focus on one domain’s body of literature to construct a timeline of knowledge development, demarcating where we are now, demonstrating how this understanding came to be via different turning points, and offering new research directions. Certainly, SotA reviews offer a unique kind of knowledge synthesis.

Our six-stage process for conducting these reviews reflects the subjectivist relativism that underpins the methodology. It aligns with the requirements proposed by others [ 24 – 27 ], what has been written about SotA reviews [ 4 , 5 ], and the current body of published SotA reviews. In contrast to existing guidance [ 4 , 5 , 20 – 23 ], our description offers a detailed reporting of the ontology, epistemology, and methodology processes for conducting the SotA review.

This explicit methodology description is essential since many academic journals list SotA reviews as an accepted type of literature review. For instance, Educational Research Review [ 24 ], the American Academy of Pediatrics [ 25 ], and Thorax all lists SotA reviews as one of the types of knowledge syntheses they accept [ 27 ]. However, while SotA reviews are valued by academia, guidelines or specific methodology descriptions for researchers to follow when conducting this type of knowledge synthesis are conspicuously absent. If academics in general, and medical education more specifically, are to take advantage of the insights that SotA reviews can offer, we need to rigorously engage in this synthesis work; to do that, we need clear descriptions of the methodology underpinning this review. This article offers such a description. We hope that more medical educators will conduct SotA reviews to generate insights that will contribute to further advancing our field’s research and scholarship.

Acknowledgments

Acknowledgements.

We thank Rhonda Allard for her help with the literature review and compiling all available articles. We also want to thank the PME editors who offered excellent development and refinement suggestions that greatly improved this manuscript.

Conflict of interest

E.S. Barry, J. Merkebu and L. Varpio declare that they have no competing interests.

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Supplementary Information

For information regarding the search strategy to develop the corpus and search strategy for confirming capture of any available State of the Art review methodology descriptions. Additionally, a list of the methodology articles found through the search strategy/corpus is included

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A necessary skill for any doctor

What causes disease, which drug is best, does this patient need surgery, and what is the prognosis? Although experience helps in answering these questions, ultimately they are best answered by evidence based medicine. But how do you assess the evidence? As a medical student, and throughout your career as a doctor, critical appraisal of published literature is an important skill to develop and refine. At medical school you will repeatedly appraise published literature and write literature reviews. These activities are commonly part of a special study module, research project for an intercalated degree, or another type of essay based assignment.

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Literature reviews are most commonly performed to help answer a particular question. While you are at medical school, there will usually be some choice regarding the area you are going to review.

Once you have identified a subject area for review, the next step is to formulate a specific research question. This is arguably the most important step because a clear question needs to be defined from the outset, which you aim to answer by doing the review. The clearer the question, the more likely it is that the answer will be clear too. It is important to have discussions with your supervisor when formulating a research question as his or her input will be invaluable. The research question must be objective and concise because it is easier to search through the evidence with a clear question. The question also needs to be feasible. What is the point in having a question for which no published evidence exists? Your supervisor’s input will ensure you are not trying to answer an unrealistic question. Finally, is the research question clinically important? There are many research questions that may be answered, but not all of them will …

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Artificial Intelligence in Anatomy Teaching and Learning: A Literature Review

Pandurangam, Gayathri; Gurajala, Swathi; Nagajyothi, Dandu 1

Assistant Professor, Department of Respiratory Care, College of Applied Medical Sciences in Jubail, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

1 Associate Professor, Department of Anatomy, Government Medical College Suryapet, KNRUHS, Warangal, Telangana, India

Address for correspondence: Dr. Gayathri Pandurangam, Department of Respiratory Care, College of Applied Medical Sciences in Jubail, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. E-mail: [email protected]

Medical anatomy is an essential preclinical course for medical undergraduates and provides a fundamental basis for various medical and surgical specializations. Frequently, students encounter difficulties when it comes to studying and comprehending the subject matter. Several pedagogical strategies have been devised and utilized throughout the years to enhance the process of teaching and learning in the field of anatomy. Artificial intelligence (AI) is now transforming anatomy education by utilizing modern technologies such as virtual reality, augmented reality, machine learning, and AI-powered evaluation tools. Recent research explored the AI in anatomy teaching, emphasizing its advantages and constraints. This review provides a thorough overview of the latest developments in the use of AI in anatomical education. It explores how AI-powered technologies can improve the educational experience for anatomy students, including personalized learning, automated grading, and intelligent tutoring systems, and examines the effects of these technologies on student engagement, learning outcomes, and teaching methods.

I NTRODUCTION

Artificial intelligence (AI) is a groundbreaking technology that can impact multiple domains, including medical education. [ 1 , 2 ] Recently, there has been significant interest in integrating AI into educational environments, as educators and academics explore the potential of advanced technology to enhance teaching and learning. [ 3 ]

Multiple studies have investigated the impact of AI on improving the efficiency and efficacy of education systems. [ 4 ] The integration of AI into education is becoming more prevalent, providing significant advantages across all levels and fields of study. AI technologies, such as intelligent tutoring systems (ITS), personalized learning platforms, and automated assessment tools, improve the learning process by offering customized instruction and instant feedback. [ 5 ]

Technology is being incorporated into the health sciences and medical education curricula to improve student involvement. Podcasts and screencasts, which are multimedia tools, are utilized to enhance educational achievements. Additionally, there is a trend toward problem-based learning, which places emphasis on student-directed methodologies. Virtual reality (VR) and augmented reality (AR) are utilized to develop immersive educational settings, especially in areas such as anatomy, where they improve comprehension of intricate spatial connections. [ 6 ]

Nevertheless, there is still a need for more investigation into the implementation of AI tools in medical education, particularly in the domain of anatomy instruction and learning. [ 7 ] Historically, the teaching of anatomy has primarily utilized cadaver dissections, textbooks, and static photographs. Although these methods have proven to be effective, they have certain limitations, particularly in terms of accessibility. This issue has been more pronounced during the COVID-19 pandemic, as in-person learning has been restricted. Conventional techniques, such as dissecting cadavers, became restricted, necessitating the development of alternate educational methods. AI technologies such as VR, AR, and machine learning (ML) provide innovative solutions to these difficulties, revolutionizing postpandemic anatomy teaching. [ 8 , 9 ]

AI-driven technologies and methodologies have the potential to revolutionize anatomy teaching by offering customized learning paths, adaptive testing, and sophisticated visual aids. [ 7 ] This literature review seeks to analyze the present status of AI integration in anatomy education, exploring the possible advantages and obstacles, as well as the prospects for incorporating AI-based technologies into the medical school curriculum. It will look at how these technologies improve educational outcomes and reshape teaching methods in anatomy education and learning.

M ATERIALS AND M ETHODS

This literature review used multiple reliable sources, such as PubMed, Google Scholar, Scopus, and Web of Science, to locate pertinent research on the utilization of AI tools in anatomy education. The search parameters encompassed terms such as “AI in anatomy education,” “virtual reality in anatomy learning,” and “3D visualization in anatomy.” The inclusion criteria were peer-reviewed studies published from 2016 to 2023, which particularly examined the usefulness of AI applications in anatomy teaching and were written in English. The exclusion criteria were articles not peer-reviewed, opinion letters, and publications not focusing on anatomy or medical education.

The search approach entailed doing initial keyword searches, which were further refined using inclusion and exclusion criteria. The relevance of titles and abstracts was assessed, and full-text publications were obtained for thorough analysis. The data regarding the specific AI tool, its application, advantages, and constraints were extracted and organized into categories. The studies’ methodological quality was evaluated using a standardized checklist, and the findings were summarized through narrative synthesis. This technique offered a thorough analysis of the present situation and identified trends and gaps in the application of AI in anatomy instruction.

L ITERATURE R EVIEW

Artificial intelligence technologies in anatomy education.

The integration of AI in anatomy education has given rise to a range of innovative applications and tools that can enhance the teaching and learning process. A study by Abdellatif et al . analyzes how AI might improve anatomy education, teaching, and assessment. It emphasizes the necessity for new techniques to increase student knowledge and recall of anatomy due to its complexity and breadth. The study underlines AI’s ability to store, analyze, and use massive amounts of data to personalize learning, improve accessibility, and boost engagement through interactive lessons and VR. [ 10 ]

Adaptive learning platforms

Adaptive learning platforms leverage AI methods to customize the learning journey for every student, considering their unique requirements, level of expertise, preferred learning methods, emotional states, and personality traits. Through the development of precise student profiles, these platforms offer personalized study materials and educational approaches to enhance student achievement and contentment in anatomy education. The insights gained from analyzing students’ attributes are effectively utilized to create adaptive learning environments that address individual needs, thereby enriching the anatomy learning experience. The overview of AI techniques used for adaptive educational systems in e-learning shows that these technologies can mimic human thinking and decision-making, reducing uncertainty and improving learning-teaching. [ 11 ]

Virtual reality and augmented reality

VR and AR are being investigated as complementary anatomy instruction aids. These technologies enable three-dimensional (3D) imaging and interactivity of anatomical structures that cadaveric dissection is unable to do. [ 12 ] Research suggests that incorporating VR and AR into anatomy teaching can enhance spatial awareness, information retention, and student engagement. [ 13 , 14 ]

VR and AR are leading AI anatomy education applications. Students can examine anatomical structures in dynamic and interesting 3D representations using these immersive technologies. VR and AR help comprehend spatial interactions between anatomical structures, which is challenging with traditional methods, according to Moro et al . [ 15 ] A study by Ekstrand et al . demonstrated that VR-based anatomy training boosted student retention and engagement more than traditional techniques. [ 16 ]

Sinou et al . used surveys and interviews to assess VR and AR’s effectiveness in teaching anatomy. Medical students’ perspectives and faculty insights were gathered. Participants from multiple universities engaged in VR/AR courses, providing curricular feedback. Results indicated higher engagement, better anatomy understanding, and improved information retention. Educators positively viewed VR/AR for enhancing teaching and interactive learning. The study highlighted the technologies’ potential to transform medical education, especially during the COVID-19 pandemic. [ 17 ]

Karbasi et al . found that VR, AR, and instructional games enhance medical students’ understanding of complex anatomy, offering dynamic alternatives when cadavers are scarce. These technologies bridge theoretical knowledge and practical application, transforming anatomical instruction and adapting to evolving medical education. [ 18 ]

ChatGPT’s impact on anatomy education

Talan and Kalınkara examined how ChatGPT can improve anatomy student learning. It compares ChatGPT’s performance with Turkish state university anatomy students to demonstrate AI’s rapid advancement. The study employed a comparative examination of ChatGPT and students’ performance in a multiple-choice anatomy test. ChatGPT outperformed pupils, showing that it could improve educational experiences and help instructors create more dynamic and adaptive learning environments. [ 19 ]

ChatGPT and other AI chatbots have garnered attention in education, notably in anatomy teaching and learning. These advanced language models could change how students learn and apply anatomy and how instructors teach. [ 20 ] ChatGPT may help anatomy education, according to research. ChatGPT could help students understand basic anatomical concepts such as bodily structure names, locations, and functions. Students can learn more, get fast feedback, and practice memory by chatting with the chatbot.

ChatGPT’s adaptability goes beyond student learning. Teachers can improve their methods with this technology. ChatGPT can help teachers create lecture slides, instructional tools, and assessment activities, easing the curriculum design process and letting them focus on more individualized student interactions. ChatGPT and other AI-powered technologies have great potential, but integrating them into anatomy instruction requires careful planning and implementation. Academic dishonesty and the chatbot’s accuracy and reliability have sparked concerns. [ 21-24 ]

Three-dimensional visualization platforms

Students struggle to perceive and understand human anatomy’s complex structures and relationships. Computer and interface technologies have enabled the creation of 3D computerized models of anatomical structures for visualization, manipulation, and interaction in virtual 3D settings to solve this issue. These digital representations simplify difficult spatial learning of the human body and improve student comprehension. [ 25 ]

There is little empirical information to guide the development and integration of effective anatomy computer models. Researchers want to construct dynamic, interactive 3D models to increase student learning. [ 25 ]

A dynamic head-and-neck model with adjustable displays and interactive control is an example. Computer tomography scans of a human corpse were used to build this highly accurate and lifelike anatomy model. [ 25 ] This approach was used to create and evaluate computer models to improve student learning of complicated anatomical components. [ 26 ]

More broadly, other researchers have investigated interactive, 3D digital models for anatomy and medical education. Photogrammetry, computed tomography and surface scanning, and computer modeling were used to create these models, each with pros and cons. Researchers have investigated virtual learning environments, websites, interactive portable document format (PDFs), VR and AR, bespoke programs, and 3D printing to distribute these 3D models. Student engagement with models improves learning results; therefore, each method’s interactivity is important. [ 26 ]

Anatomage table: A virtual dissection tool

The anatomage table, a cutting-edge virtual dissection tool, has transformed anatomy education in medical schools, universities, and health-care facilities worldwide. Students and professionals can examine the human body in unprecedented depth on this interactive 3D platform using powerful AI technologies. [ 18 ]

The anatomage table has advanced anatomy education. Historically, medical students learned about the body from textbooks, two-dimensional graphics, and cadaver dissection The anatomage table provides a more interactive and immersive learning experience with fully digitalized, life-size 3D human body models. [ 13 , 14 , 27 , 28 ]

Academic institutions have adopted this technology for its many benefits. Research indicates that the anatomage table promotes students’ comprehension of complicated structures, spatial awareness, and excitement for the subject. [ 14 , 27 , 28 ] Most medical students at Saud Islamic University were satisfied with utilizing the anatomage table for learning anatomy, indicating its ability to supplement traditional teaching techniques. [ 13 ]

Beyond simple anatomical visualization, the anatomage table has additional features. Users can imitate surgery, dissect the body, and separate structures. This allows trainees to practice and improve their skills without the hazards of cadaveric dissection. The anatomage table’s uses go beyond medical education. Used in veterinary medicine, comparative anatomy, and physical anthropology, it is useful in many fields. [ 29 ]

Intelligent tutoring systems in anatomy

Anatomy education has focused on ITSs since they provide a tailored and adaptive learning experience for each learner. These computer-based systems can adjust education to the learner’s psychological state to help them gain domain-specific knowledge and cognitive and metacognitive skills. [ 29 ]

ITSs improve learning results, as proven in the literature. ITS systems can improve student learning and accomplishment, as shown by a meta-analysis that found ITS students consistently outperformed non-ITS students. The study also explored how instructional material, learner characteristics, and system architecture affect ITS efficacy, giving useful insights for technology development and refinement. [ 29 ]

Smart Tutor, for instance, combines personalization and intelligent coaching in continuous education. The system adapts its instructional tactics based on learners’ answers, which reveal their conceptual knowledge. Why2-Atlas, another intelligent system, analyzes students’ physics explanations using several techniques to study syntactic learning. [ 30 ]

Artificial intelligence-powered image analysis in histology

AI and ML have transformed several industries, including medical imaging analysis. In particular, deep learning has shown promise in digital pathology and hematopathology. [ 31-34 ]

Whole-slide imaging technologies enable digital pathology, which gives high-resolution, data-dense pictures for AI-based disease diagnosis, categorization, and quantification. These computer-aided diagnostics methods may exceed microscopy, giving pathologists a significant tool for diagnostic accuracy and efficiency. [ 32 , 34 ]

Historical obstacles in medical imaging AI research include a lack of huge, well-annotated datasets and computer capacity. However, as digital pathology data accumulate and graphical processing units improve, AI’s skills in this sector have grown. [ 31 , 32 ]

Deep learning-based systems can detect and classify hematological cancers such as diffuse large B-cell lymphoma. A highly accurate deep learning framework using several convolutional neural networks can categorize pathologic pictures using fewer datasets. [ 35 ]

Chatbots and virtual assistants in anatomy

Recently, chatbots and virtual assistants have become popular in anatomy teaching due to advances in AI and natural language processing (NLP). IBM Watson Tutor and Ada are two popular learning systems that improve student learning and give individualized guidance.

IBM Watson Tutor uses AI to answer students’ queries and explain anatomical concepts. This interactive application uses tests, flashcards, and review sessions to help students discover their strengths and weaknesses and receive fast feedback on anatomical knowledge. Ada, an AI-powered health companion app, uses simulated patient encounters to teach clinical anatomy in a more engaging and immersive way. [ 36 , 37 ]

Several research have examined the benefits of AI-driven tutors and virtual aides in anatomy instruction. Students can get tailored guidance, answer questions, and learn complex anatomical concepts with chatbots. Implementing these tools can also help students with low teacher-to-student ratios get the aid they need. [ 9 ]

Chatbots and virtual assistants in anatomy instruction create technical issues that must be addressed. Using interactive quizzes and flashcards to reinforce anatomical knowledge is constrained by ChatGPT, a popular language model. Furthermore, developing AI-powered tools involves a solid understanding of the subject matter and the capacity to create compelling and successful learning experiences. [ 38 ]

Natural language processing tools in anatomy

• BioDigital Human uses AI and NLP to provide interactive 3D visualizations and simulations of the human body. [ 37 ]
• AnatomyZone utilizes AI and NLP to deliver detailed anatomical content and interactive quizzes. [ 37 ]

NLP is commonly used in health-care systems to extract useful information from narrative texts for data-driven decision-making. During the COVID-19 pandemic, NLP-powered AI technologies like Health Map and COBWEB have tracked patient requests and detected incidents, aiding illness identification, medicine research, and infection control. Health care is changing as NLP and AI are used to forecast patient readmissions, optimize clinician staffing, and analyze medical pictures and scans. [ 39 ]

NLP and deep learning have been investigated for medical image analysis, particularly for neurology, cardiology, and orthopedics diagnoses. [ 33 ] Recently developed deep learning technologies have allowed AI algorithms to analyze brain scans for neurological disorders, cardiac images for cardiovascular diseases, and skeletal images for orthopedic conditions with high accuracy, efficiency, and scalability. [ 33 , 39 ]

Artificial intelligence-driven assessment and feedback tools

AI is widely used in anatomy teaching, especially for assessments and feedback. AI-powered solutions could transform writing evaluation by providing more objective and fast grading while letting teachers focus on relevant feedback and student development. [ 40 ]

Several AI-based anatomy writing assessment experiments have shown promise. These systems may automatically grade student writing, identify areas for growth, and provide individualized feedback to improve skills. AI-powered evaluation tools can also examine multiple student data sets to provide individualized comments based on academic standing and qualities. [ 41 ]

AI systems in anatomy teaching should be implemented cautiously. These systems’ biases must be addressed and mitigated. Student adaptation to AI system feedback and education may require help, which may be best integrated with human teacher input. [ 42 ] AI in anatomy assessment and feedback has the potential to disrupt existing methods, but it must be deployed carefully and with safeguards to ensure equal and successful student outcomes. [ 43 ]

Integrating technology with traditional cadaveric teaching in anatomy education

Zargaran et al . found that medical students prefer cadaveric anatomy education despite the accessibility and standardization offered by technology. A structured review revealed students use smartphones and apps but emphasized the importance of cadaveric instruction. [ 42 ] Wickramasinghe et al .’s strengths, weaknesses, opportunities, and threats analysis highlighted digital anatomy’s strengths in visualization and participatory learning and its weaknesses in costs and technical issues. Both studies suggest a balanced approach, integrating technology with traditional methods, to enhance medical education and adapt to diverse learning styles. [ 43 ]

C HALLENGES

Training and resources.

Medical colleges have acknowledged the increasing significance of AI literacy among prospective health-care practitioners. Surveys indicate that both students and faculty are enthusiastic about integrating AI technologies into the curriculum, recognizing the vital role of teachers in spearheading these initiatives. In order to successfully integrate AI-based anatomy instruction, it is advisable to use a cooperative and interdisciplinary strategy that involves teams of educators. [ 44 ]

Introducing AI into the premedical curriculum at the undergraduate level is an essential initial measure, as it may acquaint future doctors with core principles in data science, ML, and leadership. As students advance in their medical education, it is important for the curriculum to continually develop, including AI-related knowledge and abilities throughout the program. [ 45 ]

The widespread recognition of the potential utility of AI in health care is contingent upon the quality of clinician education and the seamless integration of these technologies into workflow. Despite the emergence of specialist training possibilities like the Radiological Society of North America’s imaging AI degree, medical institutions have not fully incorporated AI into their curriculum. [ 46 ]

Ensuring accuracy and reliability

A key obstacle in implementing AI tools is ensuring their long-term correctness and dependability. AI systems, when trained on extensive data, can experience performance variations due to alterations in the underlying data, shifts in user behavior, or the introduction of new use cases. [ 47 ] Regular and continuous evaluation and monitoring of AI systems are essential to identify and resolve these difficulties, guaranteeing that the tools maintain their intended performance and provide precise and dependable outcomes.

Addressing ethical concerns

The implementation of AI in crucial sectors, such as education and health care, also gives rise to ethical considerations. The presence of algorithmic bias and the lack of transparency in AI decision-making processes provide the potential for perpetuating inequities and impacting assessment outcomes or health-care decisions. In order to instill confidence in these AI tools, it is essential to implement transparency and accountability measures. This will guarantee that the creation and implementation of AI systems prioritize the well-being and requirements of the general public, rather than solely focusing on maximizing profits. [ 47 ]

A study by Gill S analyzes how AI might improve anatomy education, teaching, and assessment. It emphasizes the necessity for new techniques to increase student knowledge and recall of anatomy due to its complexity and breadth. However, heavy expenses, faculty training, and AI algorithm biases were noted. AI tools improve anatomy education, but they should be used in conjunction with traditional approaches to accommodate varied learning styles, according to the report. [ 22 ] The incorporation of AI in anatomy teaching is difficult despite promising advances. High expenses of emerging AI technologies can deter educational institutions. Students and educators need substantial training to use these devices. AI-driven tool dependability and accuracy remain concerns. To ensure ethical and effective AI usage in education, continued research is recommended to overcome these difficulties. AI tools improve anatomy education, but they should be used in conjunction with traditional approaches to accommodate varied learning styles. [ 42 , 48 ]

Limitations of this study

In this study, we tried to summarize the most recent technological developments in the field of anatomy teaching and learning. In order to remain relevant, medical education must eventually integrate AI. However, it is equally crucial to provide proper education of the “AI Systems.” It is crucial to educate future medical practitioners on AI technology and its ethical concerns in order to establish a health-care system that differs from current medical practices.

C ONCLUSION

AI is revolutionizing anatomy education with new tools and methods that improve learning and teaching. For AI to be sustainable in anatomy teaching, cost, training, and reliability must be addressed. Research and collaboration between educators, technologists, and politicians are needed to maximize AI’s potential in this field.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

R EFERENCES

Artificial intelligence; anatomy teaching; augmented reality; digital technology; machine learning; medical education; virtual reality

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• Published: 27 September 2024

Narrative Medicine: theory, clinical practice and education - a scoping review

• Ilaria Palla 1 ,
• Giuseppe Turchetti 1 &
• Stefania Polvani 2 , 3  

BMC Health Services Research volume  24 , Article number:  1116 ( 2024 ) Cite this article

Metrics details

The origin of Narrative Medicine dates back to more than 20 years ago at an international level. Narrative Medicine is not an alternative to evidence-based medicine, however these two approaches are integrated. Narrative Medicine is a methodology based on specific communication skills where storytelling is a fundamental tool to acquire, understand and integrate several points of view related to persons involving in the disease and in the healthcare process. Narrative Medicine, henceforth NM, represents a union between disease and illness between the doctor’s clinical knowledge and the patient’s experience. According to Byron Good, “we cannot have direct access to the experience of others’ illness , not even through in-depth investigations: one of the ways in which we can learn more from the experience of others is to listen to the stories of what has happened to other people.” Several studies have been published on NM; however, to the best of our knowledge, no scoping review of the literature has been performed.

This paper aims to map and synthetize studies on NM according to theory, clinical practice and education/training.

The scoping review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist. A search was conducted in PubMed, APA PsycNet and Jstor. Two authors independently assessed the eligibility and methodological quality of the studies and extracted the data. This review refers to the period from 1998 to 2022.

A total of 843 abstracts were identified of which 274 papers were selected based on the title/abstract. A total of 152 papers in full text were evaluated and 76 were included in the review. Papers were classified according to three issues:

✘ Nineteen studies focused on the definition and concept of NM (Theoretical).

✘ Thirty-eight papers focused on the collection of stories, projects and case reports (Clinical practice).

✘ Nineteen papers focused on the implementation of the Narrative Medicine approach in the education and training of medical doctors (Education and training).

Conclusions

This scoping review presents an overview of the state of the art of the Narrative Medicine. It collect studies performed mainly in Italy and in the United States as these are the countries developing the Narrative Medicine approach in three identified areas, theoretical, clinical practice and education and training. This scoping review will help to promote the power of Narrative Medicine in all three areas supporting the development of methods to evaluate and to measure the Narrative Medicine approach using key performance indicators.

Peer Review reports

Introduction

The role and involvement of patients in healthcare have changed, as has their relationship with healthcare professionals. The patient is no longer a passive subject but part of the healthcare process. Over the years, many approaches to patients’ involvement in healthcare have been developed in the literature, with significant differences in terms of concept and significance.

NM represents a focus on the patient’s needs and the empowerment of their active participation in the healthcare process.

Narrative Medicine enables patients to share their stories with healthcare professionals so that the latter can gain the necessary skills to recognize, interpret and relate to patients [ 1 ]. Stories of illness have an important impact on patients and their caregivers, healthcare professionals and organisational systems [ 2 ].

Trisha Greenhalgh, an academic in primary healthcare who trained as a General Practitioner, and Brian Hurwitz, an Emeritus Professor of Medicine and The Arts at King’s College (London) [ 3 , 4 ], affirmed that the core clinical skills in terms of listening, questioning, outlining, collecting, explaining and interpreting can provide a way of navigating among the very different worlds of patients and health professionals. These tasks need to be performed well because they can affect disease outcomes from the patient’s perspective and the scientific aspects of diagnosis and treatment.

In 2013, Rita Charon, a general internist and professor at Columbia University (New York), and Brian Hurwitz promoted “a narrative future for healthcare” , the first global conference on Narrative Based Medicine (NBM). The global conference took place in London in June 2013, where experts in humanities, social sciences and professionals interested in shaping a narrative future for healthcare discussed several topics, such as increasing the visibility of narrative-based concepts and methods; developing strategies that can influence traditional clinical institutions; spreading appreciation for the role of creativity in caring for the sick; articulating the risks of narrative practices in health care; providing a space for Narrative Medicine in the context of other fields, including personalized medicine; and sharing goals for training, research, and clinical care. The conference was the first important opportunity to share different points of view and perspectives at the global level involving several stakeholders with different backgrounds [ 5 ].

In the early 2000s, the first Italian experience of Narrative Medicine occurred in Florence with NaMe, a project endorsed by the Local Health Authority aimed at diffusing the culture of patient-centered medicine and integrating strategies to improve doctor‒patient communication in clinical practice [ 6 ]. This project was inspired by the articles of Hurwitz and Greenhalgh [ 3 , 4 ]. In addition, significant input was derived from Arthur Kleinman [ 7 ] and Byron Good [ 8 ], psychiatrists and anthropologists who studied medicine as a cultural system, as a set of symbolic meanings involving the story of the sick person. Health and illness represent the subjective experience of the person.

Kleinmann [ 7 ] defines three dimensions to explain the illness using three different significances:

✘ Disease: “only as an alteration in biological structure or functioning” .

✘ Illness: the subjective experience of suffering and discomfort.

✘ Sickness: the social representation.

Narrative Medicine can be used in several areas such as prevention, diagnosis, treatment, and rehabilitation; adherence to treatment; organization of the care team; awareness of the professional role and the emotional world by health and social workers; prevention of the burnout of professionals and caregivers; promotion and implementation of Patient Care Pathways (PCPs); and prevention of legal disputes and defensive medicine.

The Italian guidelines established by the National Institute of Health in 2015 [ 9 ] represent a fundamental step in the process of diffusion and implementation of Narrative Medicine in Italy and currently represents the only document. The guidelines define Narrative Medicine as an intervention methodology based on specific communication skills. Storytelling is a fundamental instrument for acquiring, understanding and integrating the different perspectives of those involved in the disease and in the healthcare process. Storytelling represents a moment of contact between a healthcare professional and the patient’s world. The story told involves people, those who narrate and those who listen. Telling stories is a way of transferring knowledge and experience, connecting, reflecting and feeling emotions.

In the last few years, several studies have been carried out with different objectives and perspectives, but no literature review on Medicine Narrative has been performed. We founded the study of Rui et al. [ 10 ] performing a bibliometric analysis of the literature on medical narratives published from 2011 to 2021 showing that the field of narrative medicine is dominated by a few countries. Respect to 736 studies included in the review, 48% (369) are performed in US and 98 papers in Italy.

The objective of scoping review was to map and synthetize studies on NM according to theory, clinical practice and education/training, three settings where NM was developed.

The research questions formulated: (1) What is Narrative Medicine?; (2) How is Narrative Medicine implemented in clinical practice?; (3) What is the role of Narrative Medicine in education and training for medical doctors?

The study protocol follows the PRISMA-ScR checklist (PRISMA extension for Scoping Reviews) but it is not registered (Additional file 1).

We included peer-reviewed papers published from 1998 to December 2022 written in Italian or in English. We excluded papers written in other languages. We included articles according to one of these issues: studies on theory of Narrative Medicine, on clinical practice or education/training of Narrative Medicine. We excluded books, case reports, reviews. To identify potentially relevant studies, the following databases were searched from 1998 to December 2022: PubMed, APA PsycNet and Jstor. The search strategy can be founded in Additional file 2. A data charting form was developed by two reviewers to define which variables can be extracted. The reviewers independently charted the data and discussed the results. We grouped the studies by type of application related to the Narrative Medicine and summarized objective, methods and reflections/conclusions. The scoping review maps the evidence on Narrative Medicine according one of the three fields of diffusion and implementation (Fig.  1 ). Furthermore, the studies classified in “theoretical field “are grouped in subcategories to explain in best way the concepts and permit a clearer and more streamlined reading.

Categories of Narrative Medicine

Review process

After removing duplicates, 843 abstracts from PubMed, Jstor and APA PsycNet were screened. A total of 274 papers were screened based on the abstracts, of which 122 were excluded. A total of 152 full texts were evaluated, and 76 were included in the review (Fig.  2 ).

PRISMA Flow-chart

The studies included were classified into the three fields where the Narrative Medicine is implemented:

✘ Theoretical studies: 19.

✘ Clinical Practice: 38.

✘ Education and training: 19.

The scoping review did not present the results of papers included but the main objectives and the methods used as the aim of the scoping review was to map the studies performed in terms of theory, clinical practice and education/training. We have tried to organize the studies published so far, making it increasingly clear how Narrative Medicine has developed.

Theoretical studies

This section presents the 19 selected theoretical studies grouped into subcategories (Additional file 3).

Narrative Medicine: advantages

In this section, we present seven papers that highlight the benefits of narrative medicine.

Of the seven papers considered, four were performed by Rita Charon emphasizing the value of Narrative Medicine in four different contexts. In the first [ 11 ], the study by Goupy et al. evaluated a Narrative Medicine elective course at the Paris-Descartes School of Medicine. In the second [ 12 ], Charon rewrote a patient’s family illness to demonstrate how medicine that respects the narrative dimension of illness and care can improve the care of individual patients, their colleagues and effective medical practice. The third paper [ 13 ] describes a visit to the Rothko Room at the Tate Modern in London as a pretext to emphasize how for narrative medicine, creativity is at the heart of health care and that the care of the sick is a work of art.

In the fourth [ 14 ], Charon provides the elements of narrative theory through a careful reading of the form and content of an excerpt from a medical record. This is part of an audio-recorded interview with a medical student and a reflection on a short section of a modernist novel to show how to determine the significance of patients’ situations.

According to Abettan [ 15 ], Narrative Medicine can play a key role in the reform of current medical practice, although to date, there has been little focus on how and why it can deliver results and be cost-effective.

Cenci [ 16 ] underlines that the existential objective of the patient is fundamental to know the person’s life project and how they would like to live their future years.

Zaharias [ 17 ], whose main sources are Charon and Launer, has published three articles on NM as a valid approach that, if practiced more widely by general practitioners, could significantly benefit both patients and doctors. If the patient’s condition is central, the NM shifts the doctor’s focus from the need to solve the problem to the need to understand. Consequently, the patient‒physician relationship is strengthened, and patients’ needs and concerns are addressed more effectively and with better results.

Narrative Medicine: the role of digital technologies

This section includes 3 papers on the role of digital technologies in Narrative Medicine. Digital narrative medicine is diffusing in care relationship as presents an opportunity for the patient and the clinician. The patient has more time to reflect on his/her needs and communicate in best way with the healthcare professionals. The clinician can access to more information as quantitative and qualitative information and data provided by the patient. These information represent an instrument for the clinician to personalize the care and respond to patient’s unmet needs.

The use of digital technologies, particularly the digital health storymap tool described by Cenci [ 16 ], for obtaining a multidisciplinary understanding of the patient’s medical history facilitates communication between the patient and caregiver. According to Charon [ 18 ], the relentless specialization and technologization of medicine damages the therapeutic importance of recognizing the context of patients’ lives and witnessing their suffering.

Rosti [ 19 ] affirms that e-health technologies will build new bridges and permit professionals to have more time to use narrative techniques with patients.

The increased use of digital technologies could reduce the opportunity for narrative contact but provide a starting point for discussion through the use of electronically transmitted patient pain diaries.

Narrative Medicine: integration with evidence-based medicine

Greenhalgh’s [ 20 ] and Rosti’s [ 19 ] studies address one of the most significant issues, the integration of Narrative Medicine with Evidence Based Medicine. Narrative Medicine is not an alternative to Evidence Based Medicine, they coexist and can complement each other in clinical practice.

Greenhalgh’s work [ 20 ] clearly shows how NM and EBM can be integrated. EBM requires an interpretative paradigm in which the patient experiences the disease in a unique and contextual way and the clinician can draw on all aspects of the evidence and thus arrive at an integrated clinical judgement.

Rosti [ 19 ] believes that even “evidence-based” physicians sustain the importance of competence and clinical judgement. Clinicians also need to rely on patients’ narratives to integrate more objective clinical results. Clinical methods are not without their limitations, which Narrative Medicine can help to overcome. Lederman [ 21 ] enphatises the importance of social sciences to analyze the stories and to improve the care.

Narrative-based Medicine: insidious

Three papers in this section focus on the possible risks of the Narrative Medicine approach. It is needing a more awareness on role of Narrative Medicine as a robust methodology.

The study by Kalitzus [ 22 ] shows how a narrative approach in medicine will be successful only if it has a positive effect on daily clinical practice instead of merely increasing existing problems.

Complex narratives on diseases published in biographies or collected by social scientists are useful only for training and research purposes. NM requires time and effort and cannot be considered the only important issue in medicine. According to Abettan [ 15 ], Narrative Medicine can make the treatment more personalised for each patient, but it is not the only way.

Zaharias [ 17 ] affirms that Narrative Medicine is often described simplistically as listening to the patient’s story, whereas it is much more common and requires special communication skills. Perhaps for these reasons, and despite its advantages, NM is not as widely practiced as it could be. Narrative skills are an integral part of practice and learning them takes time. As the author also states, “the healing power of storytelling is repeatedly attested to while evidence of effectiveness is scarce”. Lanphier [ 23 ] underlines the need to explain the term "narrative medicine" to avoid misunderstandings and to analyze the use of narrative as a tool.

Narrative Medicine: training

Liao et al. [ 24 ] presented a study aimed at helping students improve their relationships with patients by listening to them. These results, similar to those described by Charon [ 25 ], suggest that Narrative Medicine is worth recommending in academic training. The essay by O’Mahony [ 26 ] aims to provoke a debate on how and what the medical humanities should teach. Narratology and narrative medicine are linked to empathy.

Narrative Medicine: clinician-patient communication

Papers included within this category focus on the relationship between the clinician and patient, which is important in the healthcare context.

American healthcare institutions recognize the use of the Narrative Medicine approach to develop quality patient care. As a gastroenterologist at a health centre in Minnesota (US), Rian [ 27 ] concluded that the practice of Narrative Medicine should not be kept on the fringes of medicine as a hobby or ancillary treatment for the benefit of the patients but should be considered key to the healthcare process. Improving doctor‒patient communication merits more attention.

According to Rosti [ 19 ], NM can be seen as a tool to promote better communication. Although time constraints are often mentioned as an obstacle, the time needed to listen to patients is not excessive, and all healthcare professionals should consider giving patients more freedom from time constraints during consultations by encouraging them to talk about their experiences. The use of NM may also be associated with better diagnosis and treatment of pain.

Zaharias [ 28 ] underlines that communication skills are crucial. General practitioners can further develop the strong communication skills they already possess by practicing NM through neutrality, circular questions and hypotheses, and reflective skills.

Narrative Medicine: bioethics in qualitative research

The use of qualitative research in bioethics and narrative approaches to conducting and analysing qualitative interviews are becoming increasingly widespread. As Roest [ 29 ] states, this approach enables more “diagnostic thinking”. It is about promoting listening skills and the careful reading of people and healthcare practices, as well as quality criteria for the ethical evaluation of research and training.

• Clinical practice

In this classification, we included case studies performed in clinical care. We focused on methods used to guide the patients’ stories or narratives written by healthcare professionals. We analysed how Narrative Medicine has been implemented in clinical healthcare practice.

The studies included (38) were performed in the following countries: Italy (28), USA (4), Australia (1), Canada (1), China (1), Colombia (1), Norway (1), and several European countries (1) (Table  1 ). The main methods used were semi-structured interviews that guided the patient’s and physician’s narration [ 30 , 31 , 32 , 33 ], narrative diaries written by patients [ 34 ], and paper parallel charts (an instrument to integrate the patients’ stories in clinical practice) written by clinicians [ 34 , 35 , 36 ].

The studies underlined the usefulness of narrative medicine not only in qualitative research but also in integration with quantitative analysis. Gargiulo et al. [ 45 ] highlighted the importance of integrating narrative medicine and evidence-based approaches to improve therapeutic effectiveness and organizational pathways. Cappuccio et al. [ 36 ] affirmed that narrative medicine can be effective in supporting clinicians in their relationships with patients and caregivers.

Narrative Medicine is an important instrument for patients, caregivers and healthcare professionals [ 63 ]. Suter et al. [ 60 ] affirmed that patients’ stories can help other patients with similar experiences. The studies performed by Cercato [ 39 , 40 ] and Zocher [ 67 ] highlighted the role of digital diaries in the care process from the perspective of healthcare professionals and patients. Sansone et al. [ 55 ] highlighted that the use of diaries in the intensive care unit is helpful in facilitating communication between healthcare professionals and the family.

Education and training

This section includes studies on the role of Narrative Medicine in the education and training of medical students and healthcare professionals. The studies discuss the experiences, roles and programmes of the Narrative Medicine programme in education and training. Nineteen studies were carried out, 10 of which were in the USA (Table  2 ). Only two studies were carried out in Europe, 4 in Taiwan, 1 in Canada, 1 in Iran and 1 in Israel. Seven studies focused on the role of narrative medicine for healthcare professionals [ 68 , 69 , 70 , 71 , 72 , 73 , 74 ], and 11 were aimed at medical students from different disciplines. All studies underlined the positive role of Narrative Medicine in training. Chou et al. [ 75 ] affirmed that the new model of narrative medicine training, “community-based participatory narrative medicine”, which focuses on shared narrative work between healthcare trainees and patients, facilitates the formation of therapeutic patient-clinician relationships but also creates new opportunities to evaluate those relationships. Darayazadeh et al. [ 70 ] underlined the effectiveness of Narrative Medicine in improving students’ reflections and empathy with patients. Additionally, Lam et al. [ 76 ] highlighted that Narrative Medicine could be a useful tool for improving clinical empathy skills. The studies used different approaches to implement the Narrative Medicine method. Arntfield et al. [ 77 ] proposed three tools at different steps of the study (survey, focus group and open-ended questions). Chou et al. [ 75 ] asked participants to write a personal narrative. DasGupta and Charon [ 78 ] used a reflective writing exercise to analyse personal experiences of illness.

In this scoping review we identified 76 studies addressing dissemination and implementation of Narrative Medicine across three settings between 1998 and 2022. The studies performed by Hurwitz [ 3 ] and Greenhalgh [ 4 ] provide a path towards the Narrative Medicine affirm that sickness episodes are important milestones in patient life stories. Not only we live through storytelling, but often, with our doctor or nurse as a witness, we get sick, we improve, we get worse, we are stable and finally we also die through the story. affirms that the stories are often evocative and memorable. They are image rich, action packed and laden with emotions. Most people recall them better than they recall lists, graphs or numbers. Stories can convey important elements of nuance, including mood, tone and urgency. We learn through stories because the story form allows our existing schemas to be modified in the light of emerging experiential knowledge. The stories can capture tacit knowledge: in healthcare organizations they can bridge the gap between explicit, codified and formal knowledge (job descriptions, guidelines and protocols) and informal, not codified knowledge (knowing how to get things done in a particular organization or team, sometimes referred to as knowing the ropes). The “story” is the focal point in the studies related to the clinical practice as these discuss about the patient’s experience, illness story thought tools as questionnaires, narrative diary, chart parallels. The patient is an expert patient able to interact with the healthcare professionals, he/she had not a passive role; the patient is part of the process with the other involved stakeholders. Also, the Italian guidelines on Narrative Medicine [ 9 ] considers the storytelling as a fundamental instrument to acquire, understand and integrate several points of view related to persons involving in the disease and in the healthcare process. Storytelling represents the interaction between a healthcare professional and the patient’s world. According to this perspective, it is useful to educate in Narrative Medicine the healthcare professionals from the University to provide instruments to communicate and interact with their patients. Charon [ 11 ] emphasizes the role of training in narrative skills as an important tool permitting to physicians and medical students to improve their care. Charon [ 24 ] underlines that narrative training permits to explore the clinician’s attention to patients and to establish a relationship with patients, colleagues, and the self. The study of Liao [ 22 ] underlines that Narrative Medicine is worth recommending for healthcare education as resource for interdisciplinary collaboration among students from different discipline.

John Launer in The Art of Medicine. Narrative medicine , narrative practice , and the creation of meaning (2023) [ 87 ] affirm that Narrative Medicine could be complemented by the skills and pedagogy of narrative practice. In addition to the creation and study of words on the page, learners could bring their spoken accounts of their experiences at work and interview each other using narrative practice techniques. He also affirms that narrative practice and narrative medicine could both do more to build alliances with advocacy groups.

We have performed a picture of Narrative Medicine from its origin to today hoping that it will help to promote the power of Narrative Medicine in all three areas becoming increasingly integrated.

Strengths and limitations

The scoping review does not present the results of studies included but objectives, methodology and conclusions/suggestions as it aims to map the evidence related to the Narrative Medicine using a classification defined for the review. This classification had permit to make even clearer the “world” of Narrative Medicine and present a mapping.

English- and Italian-language articles were included because, as seen from the preceding pages, most of the studies were carried out in the United States and Italy.

This could be a limitation, as we may have excluded papers written in other languages. However, the United States and Italy are the countries where Narrative Medicine has developed the most.

The scoping review presents an overview of the literature considering three settings in which Narrative Medicine has emerged from its origins until today highlighting evidence in terms of theory, clinical practice, and education. Currently, a methodology to “measure” Narrative Medicine with indicators, a method assessing the effectiveness and promoting a greater diffusion of Narrative Medicine using objective and measurable indicators, is not available. Furthermore, the literature analysis doesn’t show an integration across three settings. We hope that the review will be a first step towards future projects in which it will be possible to measure Narrative Medicine according to an integrated approach between clinical practice and education/training.

Availability of data and materials

Availability of data and materials: All data generated or analysed during this study are included in this published article.

Abbreviations

• Narrative Medicine

Narrative-Based Medicine

Evidence-Based Medicine

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I.P. and S.P. carried out the scoping review, conceived the study, data collection process and drafted the manuscript. G.T. participated in the coordination of the study. All authors read, reviewed and approved the final manuscript.

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Palla, I., Turchetti, G. & Polvani, S. Narrative Medicine: theory, clinical practice and education - a scoping review. BMC Health Serv Res 24 , 1116 (2024). https://doi.org/10.1186/s12913-024-11530-x

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Effective supervision in clinical practice settings: a literature review

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• 1 Department of Medical Education, University of Sheffield, Northern General Hospital, Sheffield, UK.
• PMID: 11012933
• DOI: 10.1046/j.1365-2923.2000.00758.x

Context: Clinical supervision has a vital role in postgraduate and, to some extent, undergraduate medical education. However it is probably the least investigated, discussed and developed aspect of clinical education. This large-scale, interdisciplinary review of literature addressing supervision is the first from a medical education perspective.

Purpose: To review the literature on effective supervision in practice settings in order to identify what is known about effective supervision.

Content: The empirical basis of the literature is discussed and the literature reviewed to identify understandings and definitions of supervision and its purpose; theoretical models of supervision; availability, structure and content of supervision; effective supervision; skills and qualities of effective supervisors; and supervisor training and its effectiveness.

Conclusions: The evidence only partially answers our original questions and suggests others. The supervision relationship is probably the single most important factor for the effectiveness of supervision, more important than the supervisory methods used. Feedback is essential and must be clear. It is important that the trainee has some control over and input into the supervisory process. Finding sufficient time for supervision can be a problem. Trainee behaviours and attitudes towards supervision require more investigation; some behaviours are detrimental both to patient care and learning. Current supervisory practice in medicine has very little empirical or theoretical basis. This review demonstrates the need for more structured and methodologically sound programmes of research into supervision in practice settings so that detailed models of effective supervision can be developed and thereby inform practice.

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Facilitating Active Collaborative Learning in Medical Education; a Literature Review of Peer Instruction Method

Adegbenro omotuyi john fakoya.

1 Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, LA, USA

Mariana Ndrio

2 University of Medicine and Health Sciences, Basseterre, St. Kitts and Nevis

Kevin J McCarthy

The call for educational reform by the Carnegie Foundation for the Advancement of Teaching marked a pivotal juncture in the trajectory of medical education in the United States. The call underscored the imperative for educational restructuring to equip forthcoming physicians with the requisite skills to engage in lifelong learning. Among the several active teaching methods is the Peer Instruction (PI), a brainchild of Eric Mazur, empowering students to steer their own education and wield knowledge adeptly into real-world scenarios. In this review paper, we delve into the core elements of PI which involves the combination of four dynamic pedagogical approaches which are: Just-in-Time Teaching, ConcepTest, Audience Response System, and Think-Pair-Share technique. PIs effectiveness notwithstanding, it is not exempt from limitations such as its flexible implementation, lengthy time, the level of expertise required for instructional design, among others. While Peer Instruction has become increasingly popular among educators across other disciplines, with proven educational benefits with positive outcomes, PIs footprint in gradate and postgraduate medical education remains inchoate, evidenced by a paucity of scholarly references. This underscores a crucial gap - despite its proven potency in fueling engagement and learning, PI still lacks formal recognition and acknowledgement as a distinct instructional method in medical education. Within these boundaries, the promise of heightened education and amplified engagement beckons further exploration of PI as a medical educational model, warranting more consideration and research.

Introduction

In the past, traditional medical education has primarily relied on in-person classroom lectures and textbooks to convey information to students. While the educational character of all other science fields over the years appeared to transition from passive to more active means of teaching steadily, medical education seemed more rigid and reluctant to adopt such changes. The 2010 publication of “Educating Physicians: A Call for Reform of Medical School and Residency” 1 was very important in the history of United States medical education. 2 This report highlighted the need for educational reform to prepare future physicians with the required skills to engage in lifelong learning. 1 , 2 As a result, medical education implemented several changes to facilitate a learner-centered approach and promote active engagement and collaborative learning for students. Several medical curricula started adopting active learning methods, such as case-based learning, team-based learning, problem-based learning, and Peer-Instruction, which enabled students to take an active role in their learning process and encouraged them to apply their knowledge to real-world situations by enhancing their critical thinking, problem-solving, and clinical reasoning skills. 2

One collaborative and active educational approach has been the Peer-Instruction (PI) method which has been employed with great success in the fields of science, technology, engineering, and mathematics (STEM) for several decades. 2–4 PI involves students working in small groups to engage with course material through active discussion and collaboration, focusing on peer-to-peer teaching and learning. This method has been shown to increase student engagement, participation, and knowledge retention and is a popular choice for instructors looking to promote active understanding. 2–4

Despite its proven efficacy in STEM fields, PI has been underutilized in medical education, as evidenced by the limited body of research on this matter. 2 Incorporating PI in medical education could significantly enhance the learning experience for medical students, potentially leading to better outcomes for both students and patients. With the increasing recognition of the importance of active learning in medical education, there is a growing interest in exploring the potential of PI to enhance the learning experience for medical students. In this review, we explore the “PI” method and its potential application to graduate and post-graduate medical education.

With the background knowledge that Mazur conceptualized Peer Instruction in 1997. For the first part of the paper, studies that investigated the use of peer instruction in STEM college courses were included. Using PubMed database from 1997 to 2023, we inserted the keywords “peer instruction” plus “STEM” this yielded a total of 65 papers. For the second part of the paper, we included studies that investigated the use of peer instruction in medical education. Using the keywords “peer instruction” plus “medical education”, further filtered by article types to include books and documents, classical article, meta-analysis, randomized control trial, review, and systematic review, this yielded a total of 486 papers. These papers were then screened to exclude studies that did not follow the Mazur format of Peer Instruction; studies on Peer Assisted Learning (PAL), Peer teaching, Near-peer teaching, and Peer tutoring were all excluded. Similar search and filter were applied to Google Scholar database. In all, we selected a total of 44 most suitable literature for this study.

What is Peer Instruction?

Peer Instruction (PI) was first conceptualized by Eric Mazur, a physicist at Harvard University in 1991, who applied it as a method of teaching and learning to his undergraduate physics classes. PI’s framework was based on the instructor posing conceptual questions (also referred to as ConcepTests) with discrete multiple-choice options and allowing students to think and record their answers individually, using an Audience Response System (ARS) or “clickers” as they are often called. Afterward, students engaged in discussions with their peers, explaining their reasoning, before voting again (also called Think-Pair-Share). The instructor then led a discussion of the correct answer, often seeking input from the class ( Figure 1 ). 2 , 5–7

The seven steps of the Peer Instruction Workflow. Audience Response System (ARS).

Mazur created Peer Instruction intending to address the deficiencies in students’ conceptual understanding that arise from passive learning experiences and an overreliance on traditional teaching models that prioritize the transmission of information. He believed that students needed to be more actively engaged in learning to develop a deeper understanding of the material. 5 By encouraging students to work together to solve problems and discuss concepts, Mazur aimed to create a more interactive and collaborative learning experience that would allow students to develop their critical thinking and problem-solving skills. Ultimately, Mazur’s approach was designed to help students become more effective learners, better equipped to apply their knowledge in real-world situations. 5 , 7 , 8

Popularization of Peer Instruction in STEM

To determine the efficacy of Peer Instruction, Dr. Mazur designed and administered various standardized tests in his physics course that assessed students’ conceptual understanding. Results from his first standardized test showed an improvement in scores between the start of the physics class and two months after the class began when Peer Instruction was used. 5 Furthermore, the increase in scores on these tests was more significant than the traditional teaching methods, such as lectures, were used. A second standardized examination incorporating conceptual and computational questions again showed improvement in the average scores achieved by students taught using Peer Instruction compared with those prepared using traditional methods. The results from these two standardized examinations, combined with results from the same final examinations given by Dr. Mazur in 1985 using conventional teaching and in 1991 using Peer Instruction, indicated that Peer Instruction not only enhanced students’ conceptual knowledge of physics but also provided them with better problem-solving abilities. 5 A longitudinal review by Crouch and Mazur, conducted ten years after the introduction of the Peer Instruction (PI) method to Harvard Physics classes, found that student performance, as measured by standardized assessments, improved compared with previous versions using the traditional didactic methods (TDL). 8 A global survey by Fagen evaluated users’ experiences with Peer Instruction (PI). The results showed that most PI courses surveyed resulted in higher learning gains than traditional teaching methods and were consistent with interactive engagement. Additionally, over 80% of the instructors surveyed (more than 300) considered their use of PI successful. Furthermore, 90% of those surveyed who used the method planned to continue or expand their use of PI. 9

Since its introduction, Peer Instruction (PI) has been the subject of numerous studies by education researchers, who have examined its effectiveness, implementation, and outlooks of both instructors and students. 2 Overall, an extensive literature review conducted by Vickey indicated that replacing traditional didactic lectures (TDL) with a Peer Instruction-based classroom has been found to enhance students’ conceptual understanding, enhance qualitative and non-qualitative problem-solving skills, decrease student dropout rates, lower failure rates, and improve students’ attitudes towards their classmates, instructors, and course. 2 Moreover, several recent studies have showcased how PI, when compared with TDL is significantly greater in improving attendance and enhancing student engagement. 4 , 6–8

Pedagogical Elements in Peer Instruction Design

According to Knight et al, PI combines several pedagogical elements that are known to improve learning. 4 Peer instruction is a dynamic form of cooperative learning which has been found to raise student achievement, motivation, and positive attitudes toward science. 10 Furthermore, PI provides opportunities for students to explain their reasoning and engage in argumentation, which helps integrate new information with existing knowledge and improves mental models. 11 More specifically, Peer Instruction’s successful implementation and positive results stem from its clever combination of four active learning methods: (a) Just-in-Time Teaching, (b) ConcepTest, (c) Audience Response System, (d) Think-Pair-Share technique.

Just-in-Time Teaching (JiTT)

Just-in-Time Teaching (JiTT) is a teaching and learning approach to foster an active learning environment during class. It was initially conceptualized by Gregor Novak and his team, who believed in creating a feedback loop between web-based learning materials and the classroom environment that could ultimately allow students to come prepared, motivated, and engaged in class. 12

In JiTT, instructors use the Internet to upload course materials and pre-class reading in the form of Web-based Warm Up assignments, while students use these resources online to prepare for each class. The instructors then can leverage the student responses to identify areas of understanding and misunderstanding and adjust the lessons so that students can receive specific “just-in-time” feedback on those particular areas. JiTT empowers students to take more responsibility for learning the content outside of class in a more engaging and modern way than the conventional method of pre-class assigned textbook reading, optimizes class time for focused and impactful content explanations, and increases opportunities for interaction and discussion. 12

According to Watkins and Mazur, PI is most successful when combined with Just-in-Time Teaching (JiTT), 5 summarized in Figure 2 . JiTT prepares students for PI takes place and provides feedback to the instructor, enabling them to craft PI questions that address students’ specific difficulties. Independently, both JiTT and PI offer valuable learning feedback to students at various stages - JiTT operates asynchronously outside of class, while PI provides immediate feedback during class. Combining these methods allows students and instructors to monitor learning progress in real-time, amplifying the benefits of the feedback. 13

Just-in-Time Methodology; pre-class, during class, and post-class steps.

ConcepTests

Conceptual questions, or Concept Tests (ConcepTests), are crucial to the Peer Instruction (PI) method. These tests evaluate students’ understanding of the key concepts taught and serve as a formative assessment tool for instructors to identify areas that require additional instruction. Unlike traditional STEM questions, ConcepTests can be answered based solely on the knowledge of relevant concepts without complex numerical calculations. The questions are usually multiple-choice and are easy to administer during in-class discussions with the help of an audience response system. 5

However, ConcepTests are flexible and can be modified by instructors to meet the classroom’s needs. The format and content of these tests can vary, such as being based on applications, case studies, or procedures. Alternatively, they may consist of logistical, recall, or algorithmic questions rather than conceptual ones. The format of the questions can also vary. At the same time, multiple-choice with one best answer is typical; other forms such as multiple true-false and free-response questions, or questions that encourage drawing, can also provide benefits. 4 , 14

The goal of administering ConcepTests before and after group work is to enhance student engagement and learning. Research shows that ConcepTests in PI increase student learning, critical thinking, problem-solving skills, motivation, and attention compared with traditional lecture-based teaching methods. 4 , 5 Additionally, these tests provide immediate feedback on learning and allow students to track their progress over time. 4 , 5 Moreover, ConcepTests results can shape the instruction session’s course. For example, according to researchers, ConcepTests with an initial correct response rate of 35% to 70% lead to the highest degree of engagement and most effective small-group discussions. If less than 35% of students answer correctly, the question may be too difficult, while more than 70% of correct response suggests that the instructor can move on to the next topic (See Figure 3 ). 4 , 5

Example of how Concept Test results can be applied in Peer Instruction.

The outcomes of Peer Instruction largely depend on how well the Concept Tests is formulated. After the popularization of Concept Tests by Eric Mazur, and their widespread use in various subjects, studies have provided clear guidelines to instructors for efficient design of the ConcepTests for their Peer Instruction as shown in Figure 3 . According to Knight and Zingaro, the questions should be engaging and challenging enough to provoke discussion. 15 , 16 The difficulty of the questions is only partially determined by the level of cognitive activity required to answer them. Sometimes, questions that need lower-order cognitive skills can generate robust peer discussions as much as those that require higher-order skills. 15 Furthermore, questions that address misconceptions can be especially beneficial, 17 as they expose students to a commonly held incorrect idea and allow them to understand why it is wrong.

Audience Response System

An audience response system (ARS) is a technology-based tool used across educational facilities since the 1960s and has become an integral part of the Peer Instruction method. 5 The audience response system allows the educator to pose multiple choice or true/false questions to the students, who then respond using handheld devices (known as “clickers”) or, nowadays, more commonly used smartphone applications. The answers are then collected via the system and displayed in real-time on a screen, usually depicted as a histogram, providing immediate feedback to the students and the educator. In Peer Instruction, ARS assesses student understanding and engages them in learning. 5 By offering all students the chance to participate and respond to questions while allowing them to view the results of their peers’ answers, ARS promotes active learning and helps to facilitate discussion and debate among the students. 6 ARS has also been found to enhance student class attendance. 6 , 18 At the same time, for educators, the higher-technology response systems allow for the analysis of student responses and progress, which can inform future teaching and assessment planning based on patterns of answer choices and can aid educators in adjusting their teaching method accordingly. 6 , 7 , 19

Other methods, such as raising hands or using response cards to record student answers, have also been used along with Peer Instruction, with some researchers arguing that the method by which students indicate their answers is not of great importance as long as they actively generate and commit to a response. 20 However, it is worth considering the benefits of higher-technology response systems, such as clickers and web-based response systems, in that they offer increased anonymity when students respond compared with using hand signals or flashcards. This encourages all students to participate, even the most introverted and hesitant students, without feeling self-conscious about choosing the wrong answer. 7

Throughout the literature, there have been numerous instances of ARS usage in STEM classroom settings, with both students and instructors endorsing positive attitudes toward clickers; however, the impact of clickers on student learning has been less transparent and warrants further research. 6 , 19 , 21 Some early studies failed to show significant improvements in education when clickers were used merely as a stimulus-response learning method and were not combined with active-learning methods. 22 However, recent studies have shown positive effects on student learning when using clickers with active learning strategies like peer instruction. 6 While some studies comparing the effects of clickers on student learning have been mixed, with some showing no result, other studies have reported a positive impact on student learning. 19 However, it is not easy to compare these studies due to various confounding factors such as class size, course level, instructors, levels of clicker use, and even the effects of outside events. 4 , 19

Regardless of the outcome, research has shown that clickers can enhance active learning and improve learning outcomes when used in conjunction with other active learning strategies. 6 , 19 Over the past few years, ARS, with or without Peer Instruction, has become increasingly popular in medical schools, as evidenced by recent research publications. While various studies have assessed student and educator attitudes towards ARS and its positive impact on student engagement, its direct effect on learning and knowledge retention outcomes has yielded mixed results. 23 , 24 For instance, in a comparative study involving 294 third-year medical students who were taught clinical microbiology, the effectiveness of clickers were evaluated in six teaching sessions, with three using clickers and three without. After the sessions, students completed an online quiz related to the session and a questionnaire about their attitudes toward the clickers. The results indicated that students had a positive attitude towards clickers. More than half agreed that teaching sessions with clickers were more engaging and agreed that clickers made important concepts more memorable. However, the grades of the online quizzes were slightly lower after sessions where clickers were used, with no significant difference in the grades of students who engaged completely with the process. 23

Similarly, in a separate study comparing the examination scores in a second-year medical school Pulmonology class when ARS was used, Stoddard and Piquet found that although ARS use may correlate with an improved educational experience, there was no measurable increase in learning. 24 Other studies, however, have reported a distinct improvement in learning outcomes. A study conducted at the University of Valencia (Spain) between 2016 and 2019, aiming to evaluate the impact of clicker quizzes administered at the end of a physiology course on students’ academic performance, showed a moderate increase in academic performance due to the intervention. Specifically, although the percentage of failed students remained the same, there was a change in the distribution of scores among the students who passed, with an increase in the number of students receiving a B score (7–8.9/10 points) by approximately 20%, and a corresponding decrease in the number of students obtaining a C score (5–6.9/10 points). 25

Alexander et al, 2009 aimed to assess the usability and predictive value of an ARS as a knowledge assessment tool in a medical curriculum. 26 The study collected data over three years (2006–2008) from first-year didactic blocks in Genetics/Histology and Anatomy/Radiology, with 42–50 students per class. During each block, students answered multiple-choice questions using the ARS, and students’ ARS performances were then recorded and compared with their final examination performances. 26 The study found a statistically significant positive correlation between ARS and final examination scores in all didactic blocks (all P < 0.0001). Students and faculty agreed that ARS was easy to use and a reliable tool for real-time feedback that improved their performance and participation. 26

Similarly, in a study conducted by Nosek et al, an Audience Response System (ARS) was used during a Hematology/Oncology course for 148 2nd-year medical students. 27 Examination scores of participants who used the ARS were compared with those who did not. The mean exam score was 81.9% for non-participants and 85.8% for students who used the ARS at least once. The mean score increased progressively to 94.4% for students who used the system the most. 27 The use of ARS in postgraduate medical education has also gained popularity in the last decade, with overall positive outcomes recorded in research literature in various residency programs. For example, in a plastic surgery residency program, a qualitative and quantitative study aimed to compare the outcomes of ARS testing with traditional pencil-paper testing, with results indicating that the ARS format led to statistically significantly higher scores (85% with ARS compared with 75% without ARS). 28 However, the disadvantages included start-up clicker costs and lead-time preparation. 28 Similarly, in a two-year study by Hettinger et al, psychiatry residents attended 12 90-min review sessions with Psychiatry Residency In-Training Examination (PRITE) questions and an ARS to provide immediate feedback and a stimulus for discussion. 29 Overall performance improved significantly (p= 0.0068) on PRITE testing when ARS was used compared with pre-ARS scores. 29

While ARS can be an effective tool for engaging students in undergraduate and postgraduate medical education, its use also has several drawbacks. One of the most significant drawbacks is the time and effort instructors require to prepare the questions and integrate the system into their lecture format. 6 Without proper preparation, ARS can lead to student dissatisfaction and reduced motivation. 6 Another potential drawback is the cost associated with implementing ARS, which may be a deterrent for institutions or students. 30 Technical malfunctions can also be a challenge, as ARS operates on a wireless platform susceptible to software glitches or mechanical issues with the clickers. 30 Additionally, reducing lecture time to allow for questions can be problematic for some instructors who may need to adjust their lecture format to accommodate ARS, potentially leading to omitting important lecture material. 18

Think-Pair-Share (TPS)

The Think-pair-share (TPS) is a collaborative teaching approach initially introduced by Professor Frank Lyman of the University of Maryland in 1981 and widely incorporated into the Peer Instruction method. 5 In this method, students are first given a question or a problem to think about individually. Then, they are paired with a classmate and asked to discuss their thoughts and compare their answers. Finally, the pairs share their answers and reasoning with the rest of the class. This technique encourages active learning and helps students to understand and retain the material better by engaging with their peers and hearing diverse perspectives. 31 It also allows the educator to assess the understanding of the students and address any misconceptions they may have. 31 Combining individual reflection, small group discussion, and whole-class participation, the Think-Pair-Share technique effectively facilitates learning in a Peer Instruction setting. 5

A study by Cortright et al, 2005 found that using a variation of Think-Pair-Share in exercise physiology classes along with Peer Instruction improved students’ ability to solve new problems. 32 The results showed that students who used PI with TPS had higher rates of answering questions correctly (59%) and answering new problems correctly (47%) compared with students who did not use PI with TPS. 32 Another study assessing the effectiveness of TPS when applied in an associate degree nursing curriculum showed that using TPS improved student engagement and created better outcomes on proficiency assessments. Also, the collaborative nature of the technique encouraged students to prepare more for class and build confidence in their knowledge. 33 A more recent study from the Department of Biochemistry and Molecular Biology at McGovern Medical School in Texas showed that incorporating active learning in a flipped classroom setting, along with the use of TPS, was viewed as an effective teaching method by medical students, with students reporting improvement in their performance on clicker questions, as well as an increase in engagement and participation. 34 These studies have shown that the TPS approach can be easily applied to various areas of study and offers a valuable alternative to traditional, passive lecture-based teaching.

Drawbacks of Peer Instruction

Although Peer Instruction (PI) is a highly effective active learning method, it also has its limitations. One key challenge is that its flexible implementation can lead to variations in classroom norms, which can affect student learning outcomes. 4 Furthermore, PI can be time-consuming, requiring students to engage in discussions that take away from lecture time, making it challenging to implement in large classes or when there is a limited amount of time for a particular topic. 2 , 4 , 9 In a survey of instructors who used PI, 10% reported skepticism from colleagues about the benefits of student discussions. In comparison, 9% struggled to cover a sufficient amount of course material in the limited class time available.

In some cases, instructors had to reduce the amount of material covered, which is not always feasible. 9 Another potential challenge is the requirement for instructors to design practical questions and facilitate group discussions, which requires a certain level of expertise in instructional design and pedagogy, as well as time. 2 , 4 , 8 , 9 According to Fagen’s survey, 13% of instructors cited the time and energy required to develop ConcepTests as a barrier to using PI. 9

Moreover, PI requires students to have a certain level of pre-existing knowledge, as they need to engage in meaningful discussions with their peers. 5 , 8 , 9 If students are not appropriately prepared for the peer discussion sessions, it can hinder the quality of the discussions and affect the outcome of PI. Also, during discussion sessions, students are free to discuss often without any group supervision, which might give space for students to discuss topics not necessarily centered around the concepts and topics instructors intend. 4

At the same time, while PI encourages exposure to new ideas, it can also potentially increase shared misconceptions, especially among students who feel less confident in the classroom. 4 This is why the Audience Response System session is particularly of great importance due to its ability to give real-time feedback. However, the costs of implementing an ARS and the requirement for instructors and students alike to be tech-savvy could also be considered drawbacks.

In addition, PI can be hampered by students’ resistance to the method, with 7% of students surveyed by Fagen reporting such resistance. 9 As most students are accustomed to passive learning, some may feel uncomfortable participating in discussions or initially consider the discussions a waste of time. As a result, it can hinder the effectiveness of the Peer Instruction method.

Despite these limitations, PI can still be an invaluable tool for promoting student engagement and active learning in the classroom. While it may not uniformly improve students’ course grades, PI has been shown to improve students’ reasoning and argumentation skills, which are essential components of learning in any discipline. 4 , 6 By recognizing and addressing these challenges, instructors can leverage PI’s potential to create more engaging and meaningful learning experiences for their students.

Applying Peer Instruction in Medical School Curricula

Although PI has shown significant benefits and positive outcomes in STEM classrooms, only a few research articles have reported its use in medical school courses. 2 The few studies, however, that have examined the use of PI in graduate and postgraduate medical education have yielded consistently positive results, indicating its potential as a powerful tool for enhancing medical education. Studies by Rao and DiCarlo, Trout et al, Versteeg et al, Marina-Gonzalez et al, Passeri and Mazur showed promising results, as summarized in Table 1 . 35–39

Research Studies in the Application of Peer-Instruction in Medical Schools

Rao et al at Wayne State School of Medicine in Michigan found that using the Peer-Instruction (PI) method in a respiratory section of a medical physiology class improved students’ understanding and ability to integrate material. 35 The study consisted of 256 first-year medical students, and the PI technique was used for ten classes. The class was divided into short presentations (12–20 min each) followed by a one-question, multiple-choice quiz on the topics covered in the presentations. Students were given 1 min to think and to record their first answer using a “clicker” and another minute to discuss answers with their classmates. The percentage of correct answers before the discussion was 73.1 ± 11.6%. After the discussion, the percentage of correct answers increased to 99.8 ± 0.24%. This study suggested that PI could be an effective teaching strategy for large classes and increase students’ attention and appeal to a more significant number of students. 35

Trout et al conducted a study using a modified version of Peer Instruction (PI) in a medical school pharmacology course. 36 In this study, they removed the mini-lecture component of the traditional PI method and did not award credit for participation in the session. Instead, lectures were placed online, and readings were assigned. Attendance was not mandatory, and questions and answers were posted online for student review. Examination scores and performance of those who attended with those who did not participate in the PI sessions were compared. The results showed that students who had attended at least one PI session achieved a statistically significant improvement of 8.2% in their examination scores compared with those who had not participated in any PI sessions (82.1% versus 73.9%). The improvement in examination performance was maintained, even as attendance diminished as the sessions progressed. Furthermore, most students who attended the sessions were found not to come from the upper quartile, indicating that the gain in examination performance was not solely attributed to the academic caliber of students attending. 36

In a study conducted by Versteeg et al in a medical physiology class in the Netherlands, the effectiveness of Peer Instruction (PI) in optimizing comprehension of physiological concepts was rigorously examined. 37 First-year medical students (n = 317) were randomly assigned to either PI or Self-Explanation (SE), an active learning technique, and were then given a set of near and far transfer questions to assess their understanding. The study results revealed that both PI and SE groups significantly improved their post-test scores, with PI outperforming SE by 35% compared to 23%. Furthermore, the study found that both methods showed higher transfer scores than the control group, with a tendency for higher near transfer scores for PI, indicating that PI is an effective method for improving comprehension of physiological concepts. 37

Dr. Marina-Gonzalez and Professors Hernandez-Guerra and Quintero led a joint study across two universities, Universidad de La Laguna in Spain (ULL) and University College of London in England (UCL), to compare the impact of Peer Instruction on academic performance between beginner and advanced undergraduate biomedical/medical students. 38 At UCL, the study used the Cardiovascular and respiratory function in health and disease (CRF) module, which was already delivered using the flipped classroom approach. On the other hand, at ULL, the Diseases of the Digestive System (DDS) module was traditionally offered in a big lecture-based classroom.

The study found that Peer Instruction significantly enhanced the learning experience of all students. The study revealed that Peer Instruction enhances in-class problem-solving skills and produces similar academic benefits to those obtained with small group flipped classroom sessions but with the added benefit of facilitating these results in large classes. Moreover, at ULL, students achieved a higher number of correct answers and averaged scores with the Peer Instruction module compared with the traditional lecture module. Nevertheless, year one students at UCL expressed discomfort in being asked to teach each other rather than have a professor teach them, while year four students at ULL showed higher student satisfaction, implying that more mature students are better prepared for this academic environment. 38

Passeri and Mazuri (2019) implemented Peer Instruction (PI) in a review session for three medical school pre-clinical subjects in Brazil. They found that students who used PI retained more basic science knowledge on an examination given six months later compared with students who received individual feedback from the instructor. 39 For their study, 226 medical students were invited to participate; 125 were in the control group and received individual feedback from the professor, while 101 students were in the study group and participated in an immediate intervention after the regular examination with a feedback session using the PI method. After the session, the students were given a post-feedback examination (PFE) to identify any changes in their answers compared with the regular examination before feedback. Six months later, a diagnostic examination (DE) was given to identify whether the students retained the concepts covered in the previous examinations. 39 The results showed that the PI group performed better in both examinations than the control group, with retention of basic science knowledge increasing by 15%. The students who received immediate feedback via the PI method had the opportunity to discuss their misconceptions, leading to the highest number of correct answers and demonstrating that when PI is applied in the assessment feedback, it can improve the retention of basic science knowledge. 39

Applying Peer Instruction in Postgraduate Medical Training

By incorporating peer instruction in postgraduate medical training, healthcare professionals can build upon their prior knowledge and expand their understanding of complex medical concepts. Studies have shown that peer instruction can improve students’ critical thinking and problem-solving skills, 31–34 which can lead to better patient outcomes. Additionally, peer instruction can increase motivation and engagement among medical professionals, as it provides them with immediate feedback on their learning progress and allows for self-reflection. However, there is a need for further research to determine the effectiveness of peer instruction in specific medical specialties and to explore the best practices for implementation in postgraduate medical education programs.

One study conducted at Northwestern University Feinberg School of Medicine aimed to showcase the effectiveness of Peer Instruction (PI) and Just-in-Time Teaching (JiTT) as an instructional mode of education for the core curriculum of a residency program. The study was conducted in 2010–2011 with 31 core curriculum sessions taught by 22 faculty members to 31 preliminary and categorical residents. The JiTT/PI strategy involved residents completing web-based study questions before the weekly topic sessions and faculty tailoring the session content based on the residents’ learning needs. During the sessions, residents answered multiple-choice questions using clickers and engaged in PI. The study found that 70% of resident respondents felt that JiTT/PI helped in the learning of key points, and 90% of faculty respondents reported positive perceptions of the strategy. Resident engagement time for JiTT/PI sessions was higher compared with prior lecture-based sessions, and more review session MCQ responses were correct for residents who attended corresponding JiTT/PI sessions. The study concluded that JiTT/PI is an effective approach for meaningful and active learning in core curriculum sessions, increasing learner participation, retention, and learner-centered time. 40

With limited clinical time for residents and high clinical demands on faculty, it is essential to use education methods that maximize engagement and learning during residency didactics. The PI method offers an effective solution, allowing residents to participate in active and meaningful learning while maximizing the value of face-to-face time with faculty.

Applying Peer Instruction in Interprofessional Medical Education

Interprofessional Education (IPE) in medicine refers to educational programs and initiatives that bring together healthcare professionals from different disciplines to work collaboratively, share knowledge, and enhance patient care. 41 IPE emphasizes the importance of interdisciplinary collaboration, understanding the role and responsibilities of each profession, and developing teamwork and communication skills. 42 By working together, healthcare professionals can share their unique perspectives and learn from one another, which can improve patient outcomes and increase the overall quality of healthcare delivery. 42 IPE programs can take various forms, such as joint classes, simulation exercises, and clinical rotations, and are designed to prepare healthcare professionals to work effectively as a team in the complex and rapidly evolving healthcare landscape. 41 , 42 The integration of Interprofessional Education (IPE) into healthcare curricula globally has led many medical educators to focus on finding and implementing effective teaching methods to achieve the core competencies of IPE. 43

Bucheit et al argued that the Peer Instruction Method could be an ideal fit for Interprofessional Education (IPE). The research explored the application of Peer Instruction method in a family residency program to provide interprofessional education (IPE) during didactic sessions. Pharmacy and medical students were recruited for a session that was based on learners’ answers to 80 questions submitted two weeks previously. The session was facilitated by one family medicine resident, one physician, and one pharmacy faculty member, who tried to distribute the learners evenly into interdisciplinary teams. During the session, the learners answered questions using “clickers” before and after group discussions and had the opportunity to express their viewpoints. The session resulted in changes in learner perceptions towards IPE, as shown by surveys before and after the session. These changes reflected the learning community as a whole rather than being profession-specific. The article concluded that the Peer Instruction Method could be effectively used in didactic sessions for family medicine residency programs, provided the scheduling and choice of topics are carefully considered. 44

Despite the growing recognition of the importance of Interprofessional Education (IPE) in modern medical education, there is still a need for further research to understand fully the potential benefits and limitations of Peer Instruction method for IPE. While the above study demonstrated positive results from incorporating Peer Instruction into IPE programs, there is still much to be learned about the best ways to effectively integrate this method into a diverse range of IPE curricula. This includes understanding the role that Peer Instruction can play in facilitating interdisciplinary collaboration and communication and promoting the development of core IPE competencies such as teamwork and patient-centered care. By exploring the benefits and challenges of Peer Instruction in IPE, medical educators can make informed decisions about the most effective educational methods to use and work towards ensuring that future healthcare professionals are equipped with the interprofessional skills they need to provide high-quality patient care.

Limitations in Peer Instruction Research in Medical School Settings

While Peer Instruction has become increasingly popular among educators across various disciplines, its application in medical education has not been extensively researched. 2 , 6 , 8 , 9 In 2015, Vickrey et al, in a literature review, estimated that only 4% of research articles referred to the application of PI in a medical classroom. 2 Similarly, the authors recent PubMed search for research articles on Peer Instruction application in medical schools with year parameters from 2015–2023 generated only a few results, with many results referring to Peer-assisted learning (PAL) instead of Peer Instruction (PI).

It is evident that despite its well-established framework and effectiveness in promoting student engagement and learning outcomes, there is a lack of formal recognition and acknowledgment of PI as a distinct instructional method. As a result, many instructors may implement different combinations of the PI components without necessarily referring to it by its official name. This ambiguity makes finding and reviewing research articles on PI difficult, with some arguing that any active learning method that uses an ARS and Concept Tests could be considered a form of PI. While this argument has some validity, it is essential to note that PI is more than just a combination of these two components. PI is a pedagogical approach that involves a specific set of principles and practices, including peer discussion, promoting student autonomy, and aligning assessment with learning objectives. Therefore, while there may be an overlap between PI and other active learning methods, it is important to recognize the unique features and benefits of PI as a distinct pedagogical approach. 2 , 6 , 8 , 9

Another reason for the scarcity of research articles on PI in medical education, in part, could be due to the traditional emphasis on individual learning in medical education, which often prioritizes direct instruction over collaborative, multistep education methods. As a result, medical educators may be more inclined to rely on traditional teaching techniques such as lectures and case studies, which may not lend themselves as readily to the PI format. Moreover, the highly structured nature of medical education, with its focus on specific learning outcomes and competencies, can create challenges for the implementation and research of PI. For example, the emphasis on standardized testing and certification requirements in medical education may lead instructors to prioritize the coverage of a large volume of material, leaving less time for the extended periods of discussion and reflection central to PI. Despite these limitations, the potential benefits to student learning and engagement suggest that Peer Instruction is a pedagogical approach that warrants further attention and research.

The application of the Peer Instruction method in medical schools has shown promising results in enhancing students’ engagement and learning outcomes. The technique encourages students to participate in their learning process actively, promotes critical thinking, and fosters collaborative learning. The research findings indicate that the peer instruction method positively impacts students’ academic performance, confidence, and satisfaction with the learning experience. The peer instruction method has the potential to transform traditional teaching approaches and improve the quality of medical education. Therefore, medical schools should consider incorporating the peer instruction method in their educational strategies to enhance their students’ learning experience. Finally, further research is needed to explore the long-term effects of the technique and its effectiveness in different medical disciplines.

Funding Statement

Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA supported this project financially. KJM supported in part by NIH Grant NIDDK RO1DK111958.

The authors declare no conflict of interest.