https://orcid.org/0009-0003-3721-6139
Figures
Abstract
The objective of this meta-analysis was to compare the effects of peer-assisted learning (PAL) and traditional teaching methods on the theoretical knowledge and practical skill education in clinical medicine by summarizing the relevant randomized controlled trial (RCT) studies reported to date. A comprehensive search was conducted across several medical literature databases, including PubMed, EMBASE, Springer, Ovid, Cochrane Library, China National Knowledge Infrastructure (CNKI), and China Biology Medicine Disc (CBMdisc). All pertinent articles, reviews, and references published from January 1970 to May 2023 were analyzed using Review Manager 5.4 software. A total of 81 RCTs were included in this analysis. The findings indicated that PAL surpassed traditional teaching methods in enhancing the transfer of theoretical knowledge and the acquisition of practical skills, especially in terms of student satisfaction and acceptance. It was also observed that, although PAL displayed advantages in certain areas, its effectiveness might not be substantial in fields demanding high levels of specialized knowledge. Furthermore, the reliability of the findings could be constrained by small sample sizes and inadequate implementation of blinding methods. Consequently, it is concluded that PAL is an effective and promising teaching method. Nonetheless, more rigorous research is required in the future to comprehensively explore the role of PAL in medical education.
Citation: Li Z, Wang Q, Wu J (2025) Effectiveness of Peer-assisted learning in medical education: A meta-analysis study. PLoS One 20(9): e0329605. https://doi.org/10.1371/journal.pone.0329605
Editor: Alexander Maniangat Luke, Ajman University, UNITED ARAB EMIRATES
Received: September 20, 2024; Accepted: July 19, 2025; Published: September 2, 2025
Copyright: © 2025 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: JW received funding from the Education and teaching reform research project of the First Affiliated hospital of Zhejiang University School of Medicine (zyjg202215), For more information about the funder, Visit https://www.zy91.com/. LY received funding from the Zhejiang Medical and Health Science and Technology Project (2023RC157) and the Natural Science Foundation of Zhejiang Province, China (QN25H040009). For more information about the funder, Visit https://kj.wsjkw.zj.gov.cn/.
Competing interests: The authors have declared that no competing interests exist.
1. Introduction
As the global population expands and ages, there is a notable rise in complex diseases, necessitating elevated standards in medical education. Consequently, clinical medical education has emerged as a critical concern [1,2]. Ensuring the quality of medical professional education and enhancing the practical capabilities of clinical medical personnel present challenging issues that warrant attention in this domain [3]. Traditional pedagogical methods are no longer adequate to address emerging medical needs, prompting leading medical colleges and universities to initiate exploratory teaching reforms. These institutions are striving to employ novel teaching methodologies and establish more comprehensive teaching models with the aim of improving teaching quality. Novel student-centered teaching concepts, including Problem-Based Learning (PBL), Case-Based Learning (CBL), and flipped classrooms, have thus arisen [4,5].
Peer-assisted learning (PAL), a venerable pedagogical approach with origins tracing back to ancient scholars like Socrates and Plato, who utilized mutual questioning and dialogue, is widely implemented today. PAL facilitates a dynamic where students assume the roles of both teachers and learners, thereby enhancing interactive learning [6,7]. Over the past decade, there has been a surge in formal PAL research interest both domestically and internationally, with the merits of PAL increasingly reflected in the growing body of published literature [8]. PAL aids students in better comprehending and applying knowledge. Studies have demonstrated that PAL can significantly enhance students’ academic performance and communication skills [9]. Furthermore, PAL serves to reduce the teaching burden on educators and represents an effective measure for resource conservation. Additionally, PAL boosts students’ confidence and initiative, fosters leadership and teamwork skills [10], and ameliorates the educational environment by encouraging cooperation and communication among students [11].
Although there is a substantial body of literature describing PAL, there is a paucity of objective evaluations of PAL within clinical medical education. Prior studies have yielded some reliable findings, particularly in the context of PAL in medical student education and nursing disciplines [12–14]. Nonetheless, potential biases in study design have not been sufficiently addressed. To the best of our knowledge, this article presents the most extensive meta-analysis of randomized controlled trial (RCT) sample sizes related to PAL in clinical medical education to date.
The purpose of this meta-analysis was to compare the effects and roles of PAL and traditional teaching methods in clinical medical education, encompassing both theoretical knowledge and practical skills, through summarizing the RCT studies of PAL reported to date. It was hypothesized that PAL would yield more favorable outcomes and enjoy greater acceptance compared to traditional teaching methods.
2. Methods
2.1. Search strategy
Following the Prima Guidelines recommended by the Cochrane Collaboration, this study searched high-quality foreign medical databases, including PubMed, EMBASE, Springer, Ovid, and the Cochrane Library, as well as Chinese medical databases, such as China National Knowledge Infrastructure (CNKI) and China Biology Medicine disc (CBMdisc). All relevant articles, reviews, and reference lists published between January 1970 and May 2023 were searched. Using the PICOS principle and combining keywords, including “medical education,” “peer-assisted learning,” “student tutor,” “clinical medicine,” etc., Boolean operators were also applied to ensure a comprehensive search.
2.2. Inclusion and exclusion criteria
The inclusion criteria are as follows:
- (1). Study population includes doctors, nurses, or students majoring in clinical medicine or nursing;
- (2). Only RCTs were included;
- (3). Intervention measures: the control group adopts traditional teaching methods, and the experimental group adopts PAL or teaching methods that include PAL;
- (4). Outcome measures: teaching results were evaluated using objective assessment indicators such as theoretical exam scores, skill assessment scores, OSCE or satisfactory scores.
The exclusion criteria are as follows:
- (1). Studies that did not adopt the aforementioned intervention measures;
- (2). Non-RCT studies;
- (3). Duplicate publications, abstracts, lectures, reviews, and case reports were also excluded.
2.3. Data extraction and quality assessment
We extracted information including publication date, first author, study design, subject information, research content, evaluation indicators, and other relevant data. RevMan software was used to evaluate the quality of the included studies. Parameters include sequence generation (selection bias), allocation concealment (selection bias), blinding (performance bias), incomplete outcome data (detection bias), selective outcome reporting (reporting bias), and “other issues”. Each item can be classified as “low risk,” “high risk,” or “unclear.” Two reviewers independently assessed the quality of these studies. Any disagreements were resolved by a third reviewer.
2.4. Statistical analysis
Statistical analysis was performed using Review Manager 5.4 software (Cochrane Collaboration, Nordic Cochrane Centre, Copenhagen, Denmark). Standardized mean difference (SMD) was used for continuous variables (as different evaluation methods were used between studies). P < 0.05 was considered statistically significant. Homogeneity was tested by Q statistic (significance level at P < 0.1) and I2 statistic (significance level at I2 > 50%). When there was no significant statistical heterogeneity, a fixed-effects model was used; otherwise, a random-effects model was used. In addition, subgroup analyses were performed on nursing majors, life support training, ultrasound training, surgical skills training, etc.
3. Results
3.1. Search results
A total of 2460 articles were identified from the database search that met the study objectives. After manual screening and removing duplicate articles, 173 articles were selected. Based on the inclusion and exclusion criteria, 81 studies were selected after reading the full text. These studies were published between 1997 and 2022, with a total of 6752 subjects, including 3412 in the experimental group and 3340 in the control group, with sample sizes ranging from 18 to 356. The literature search process was shown in Fig 1. The basic characteristics of these studies were presented in Table 1. These studies were conducted in various regions globally, including Asia, Europe, and the United States. Most studies were conducted in medical schools and clinical environments, with the majority involving clinical specialties and seven studies involving nursing majors.
3.2. Quality assessment of included studies
The quality of the included studies was evaluated. As shown in Table 1, bias assessment (according to the Cochrane Handbook for Systematic Reviews of Interventions 5.0) was conducted for the 81 RCT studies included. The entire evaluation was performed by two reviewers independently, and any disagreements were resolved by a third reviewer.
Although the included studies had high quality, due to the nature of study design and intervention measures, participants could not be well blinded in all studies, indicating concerns with regards to participant blinding bias in most literature, with 11 articles exhibiting high risk, as shown in Fig 2.
3.3. Meta-analysis results
3.3.1. Theoretical knowledge.
A total of 31 studies involved the impact of PAL on theoretical knowledge transfer, with the theoretical knowledge assessment results for the two groups being 7–95.16 points and 6–86.49 points, respectively. The results showed significant differences (SMD = 0.77, 95% CI: 0.43–1.11, P < 0.00001), favoring the PAL group. However, there was considerable heterogeneity between the two groups (I2 = 96%), which may be related to the different evaluation methods used in various studies, not all of which used multiple choice questions (MCQs) in the hundred-mark system. The results were shown in Fig 3a.
Considering that heterogeneity may be related to different evaluation methods, we conducted subgroup analysis to determine the source. When we summarized studies using 100-point scales for subgroup analysis, the results showed significant differences (SMD = 0.70, 95% CI: 0.55–0.85, P < 0.00001, I2 = 0%), favoring the PAL group. The results were shown in Fig 3b. When we summarized studies using 20-point scales for subgroup analysis, the results showed no significant differences between the two groups (P = 0.96, I2 = 0%). The results were shown in Fig 3c.
3.3.2. Procedural skill.
A total of 25 studies involved the impact of PAL on skill performance, with the skill assessment results for the two groups being 6–96.13 points and 5–84.05 points, respectively. The results showed significant differences (SMD = 1.05, 95% CI: 0.63–1.47, P < 0.00001), favoring the PAL group. However, there was considerable heterogeneity between the two groups (I2 = 96%), which may be related to the different evaluation methods used in various studies. The results were shown in Fig 4a.
Considering that heterogeneity may be related to different evaluation methods, we conducted subgroup analysis to determine the source. When we summarized studies using 100-point scales for subgroup analysis, the results showed significant differences (SMD = 0.71, 95% CI: 0.48–0.94, P < 0.00001, I2 = 28%), favoring the PAL group. The results were shown in Fig 4b. When we summarized studies using 20-point scales for subgroup analysis, the results showed significant differences (SMD = 0.30, 95% CI: 0.11–0.48, P = 0.002, I2 = 0%), favoring the PAL group. The results were shown in Fig 4c.
3.3.3. OSCE.
A total of 29 studies involved the impact of PAL on OSCE, with the OSCE assessment results for the two groups being 4−154 points and 3.4−114 points, respectively. The results showed significant differences (SMD = 0.58, 95% CI: 0.28–0.88, P = 0.0002), favoring the PAL group. However, there was considerable heterogeneity between the two groups (I2 = 94%), which may be related to the different OSCE station designs and evaluation criteria used in various studies. The results were shown in Fig 5a.
Considering that heterogeneity may be related to different evaluation methods, we conducted subgroup analysis to determine the source. When we summarized studies using 100-point scales for subgroup analysis, the results showed significant differences (SMD = 0.37, 95% CI: 0.23–0.51, P < 0.00001, I2 = 0%), favoring the PAL group. The results were shown in Fig 5b. When we summarized studies using 20-point scales for subgroup analysis, the results showed no significant differences between the two groups (P = 0.92, I2 = 0%). The results were shown in Fig 5c.
3.3.4. Satisfaction.
A total of 10 studies involved the evaluation of satisfaction of PAL, with the satisfaction assessment results for the two groups being 1.9–20.82 points and 1.5–7.48 points, respectively. The results showed significant differences (SMD = 0.39, 95% CI: 0.24–0.53, P < 0.00001, I2 = 0%), favoring the PAL group, which means in most studies, subjects were more satisfied with PAL than with traditional teaching methods. The results were shown in Fig 6.
3.3.5. Basic life support.
We further conducted subgroup analysis based on the content of the studies. There were 5 articles involving basic life support training, such as CPR and pediatric life support. The meta-analysis results showed that PAL had a significantly better teaching effect on basic life support than the control group (SMD = 1.23, 95% CI: 0.35–2.11, P = 0.006), with considerable heterogeneity (I2 = 97%). Considering that heterogeneity may be related to different evaluation methods, we conducted subgroup analysis to determine the source. The results showed that PAL did not show significant differences for theoretical knowledge teaching and OSCE, although the results appeared to favor the PAL group. However, for skill performance on basic life support, the PAL group had a significant advantage (SMD = 0.53, 95% CI: 0.25–0.80, P = 0.0002), with excellent homogeneity (I2 = 0%). The results were shown in Fig 7.
3.3.6. Ultrasound teaching.
There were 4 studies involving ultrasound teaching, such as cardiac ultrasonography and musculoskeletal ultrasonography. The meta-analysis results showed no significant difference between the two groups (SMD = −0.07, 95% CI: −0.33–0.19, P = 0.60, I2 = 55%). We further conducted subgroup analysis of these 4 studies. The results showed that there was no significant difference between the two groups in theoretical knowledge, skill performance, OSCE and satisfaction (P > 0.05). From the perspective of ultrasound teaching, PAL did not show superiority over traditional teaching methods. The results were shown in Fig 8.
3.3.7. Surgical skills.
There were 4 studies involving surgical skills teaching, such as suturing, sterile techniques, and laparoscopic techniques. The meta-analysis results showed no significant difference between the two groups (SMD = 0.01, 95% CI: −0.32–0.33, P = 0.97, I2 = 32%). Further subgroup analysis of these 4 studies showed that there was no significant difference between the two groups in terms of skill performance and OSCE (P > 0.05). From the perspective of surgical skills, PAL did not show superiority over traditional teaching methods. The results were shown in Fig 9.
3.3.8. Clinical data collection.
There were 7 studies involving clinical data collection, such as medical history taking and physical examination. The meta-analysis results showed no significant difference between the two groups (SMD = −0.11, 95% CI: −0.25–0.02, P = 0.10, I2 = 38%).
Further subgroup analysis of these 7 studies showed that there was no significant difference between the two groups in terms of theoretical knowledge, skill performance, and OSCE (P > 0.05, I2 = 0–11%). From the perspective of clinical data collection, PAL did not show superiority over traditional teaching methods.The results were shown in Fig 10.
3.3.9. Nursing education.
Three studies on nursing education were included in the meta-analysis, and the results showed that PAL had a significantly better teaching effect on nursing education than the control group (SMD = 2.39, 95% CI: 0.08–4.7, P = 0.04). Although subgroup analysis showed no significant difference between the two groups in terms of theoretical knowledge and skill performance (P > 0.05). The results were shown in Fig 11.
4. Discussion
This review meticulously analysis the impact of PAL within the realm of medical education. It compellingly demonstrates that PAL surpasses conventional teaching methodologies in disseminating theoretical knowledge and guiding practical skill acquisition. It is particularly encouraging to observe the marked preference and satisfaction among students for PAL over traditional methods, laying a robust foundation for its broader adoption. Nonetheless, in disciplines requiring advanced and specialized knowledge, the superiority of PAL is not as pronounced. In conclusion, PAL emerges as a commendable and potent educational approach, although further investigation is warranted to fully understand its applicability across the diverse spectrum of medical education.
These findings are consistent with extant literature, underscoring the importance of PAL as an active learning instrument in medical education. PAL strategies can aid students in cultivating critical competencies such as cooperation, critical exploration, and reflection [13]. Durning’s cognitive consistency hypothesis elucidates the efficacy of PAL even among peers with similar educational backgrounds [96]. The comparable baseline knowledge levels among peers may facilitate better understanding than guidance from teachers alone. Varied learning environment conditions can also influence learning effectiveness: within a peer group, students tend to be more open and less defensive, free from the fear of criticism or ridicule [57]. Furthermore, the reciprocal role-switching among peers not only augments their sense of responsibility and initiative but also refines their communication skills and teamwork abilities. Such positive social interactions contribute to enhancing students’ emotional intelligence [97]. Simultaneously, PAL can effectively stimulate students’ critical thinking: students are required not only to analyze and evaluate the viewpoints presented by their peers but also to assimilate information from diverse perspectives, fostering multifaceted thinking. Additionally, students must reflect on and summarize their learning processes and outcomes, which significantly contributes to the development of their critical thinking skills [98].
Furthermore, PAL offers advantages not only to students but also to peer tutors. As Ross famously remarked, “Teaching is learning twice” [99]. There are disparities in the learning processes of teachers and students, and by teaching others, peer tutors can facilitate more detailed and specific learning of course content, leading to long-term knowledge retention [100]. Considering the high memory demands of medical education, participation in PAL can enhance learning and augment clinical experience while teaching, thereby easing the burden of exams. Peer tutors are also required to provide learning materials to other students, which leads them to become familiar with and simplify the learning content [101]. These potential benefits undoubtedly position PAL as a valuable tool in medical education. Cohen et al. discovered that students participating in PAL generally exhibit a higher level of satisfaction with the course, as they experience a greater sense of autonomy and support during the learning process. Students not only acquire knowledge from their peers but also receive emotional support, which is relatively scarce in traditional teaching models [102,103]. This is consistent with our research findings, which indicate that the satisfaction and acceptance of PAL are significantly superior to those of traditional teaching models.
However, some literature also indicates that PAL does not exhibit a significant advantage in knowledge acquisition [45,104]. This phenomenon may be attributed to the limited professional knowledge level of peer tutors. Teaching professional theoretical and clinical scientific knowledge necessitates a higher degree of expertise, which peer tutors might not possess, potentially hindering their ability to provide in-depth explanations and diverse perspectives. Regarding specific professional clinical skills, peer tutors may not demonstrate a superior status compared to their expert peers. On the other hand, studies that show no significant differences in overall analyses often have relatively small sample sizes, which could introduce potential biases. Nevertheless, some research posits that this situation does not necessarily lead to negative outcomes. When peer tutors encounter questions or are unable to answer their peers’ inquiries, they tend to invest additional effort in studying and learning, thereby further enhancing their scores. This hypothesis is referred to as “mindful acceptance” [105]. This phenomenon could explain why, even in the absence of significant differences, the results generally tend to favor PAL.
Interestingly, this review’s subgroup analysis revealed that, in comparison to traditional teaching methodologies, PAL did not markedly enhance students’ pass rates in more specialized skill instruction, such as life support, ultrasound, surgical skills, and the like. This finding aligns with previous literature. Mundell et al. posited that cardiopulmonary resuscitation techniques within life support should be classified as advanced surgical skills, necessitating a series of professional responses and decisions in response to sudden changes in patient physiology [106]. Consequently, Zhang advocated that more intricate clinical skills demand mentors to possess ample professional knowledge and experience to conduct courses effectively, while also providing appropriate assessment of student performance and cognition [1]. Furthermore, the spontaneous assimilation of concepts and content is challenging when learning complex tasks, often necessitating a mentor’s explanation and linkage. This undoubtedly poses a challenge for peer tutors. Most studies outlining pre-service training for peer tutors are confined to limited time and knowledge within a restricted curriculum scope [107]. However, this does not negate the potential of PAL in teaching advanced skills. Peer tutors can still effectively deliver some procedures and content traditionally performed by professional tutors. Alternatively, longer and more comprehensive pre-service training may also positively impact the effects of PAL, although considerations of human and time costs must be taken into account.
In the implementation of teaching activities, “cost” is another crucial consideration. However, only a few studies analyze the cost-effectiveness of PAL. Evaluating educational outcomes and cost – effectiveness is essential to ascertain whether a teaching method is appropriate and reasonable. Economic analysis plays a significant role in decision – making regarding medical resource allocation [108]. Lemke discovered in a study on surgical suture skills training that both PAL and traditional teaching methods achieved good teaching objectives. Nevertheless, PAL can reduce teacher costs by training peer tutors. Moreover, if the “train - the - trainer model” is introduced, that is, training more future peer tutors through peer tutor training, it can further eliminate teacher costs. And it is believed that this makes better use of clinical equipment and reduces maintenance and repair costs [42]. This can be regarded as another advantage of PAL.
Compared to conventional teaching methodologies, PAL also exhibits its own set of limitations. The efficacy of PAL is, to a certain degree, contingent upon the ability levels of the peers involved. In instances where there is a substantial disparity in abilities among peers, it may prove to be difficult for students of lower abilities to derive benefits from the guidance of their higher-achieving peers. Furthermore, given that teachers typically assume the role of facilitators, the absence of systematic and structured guidance during the initial phases of PAL may leave some students uncertain about the trajectory of their learning. Additionally, owing to the diverse and interactive nature of the learning process, traditional testing and evaluation methodologies may not comprehensively capture the learning outcomes of students engaged in PAL [98]. This could potentially explain the considerable heterogeneity observed in some of the results of this study.
To further optimize the efficacy of PAL, several recommendations can be made. Firstly, it is advisable to offer training to peer tutors on essential skills, including communication, feedback techniques, and instructional guidance, prior to PAL sessions. Secondly, PAL can be integrated with conventional teaching methodologies, thus combining the professionalism and systematic approach of traditional teaching with the autonomy and adaptability inherent in PAL. Furthermore, a comprehensive evaluation of PAL should be implemented, utilizing multiple assessment methods such as self-assessment, peer assessment, and teacher assessment at the conclusion of the teaching period, as well as by analyzing students’ engagement and the quality of interactions throughout the instructional process. It is posited that PAL, as an innovative educational paradigm, is poised to emerge as a pivotal teaching strategy in future educational endeavors, thereby affording students enriched and diversified learning experiences.
5. Limitations
This review exhibits several limitations. Owing to the extensive volume of literature and the diversity of evaluation methodologies employed, the heterogeneity within the meta-analysis remains considerably high, despite endeavors to mitigate this through the selection of RCTs and subgroup analyses. Moreover, there are certain unavoidable biases, encompassing participant bias and observer bias. The behavior and reactions of participants may be swayed by expectancy effects, suggesting that the study outcomes might reflect participants’ anticipated responses rather than the actual effects of the educational interventions themselves. Furthermore, when observers are cognizant of group assignments, their recording and analytical processes may exhibit a tendency to support the hypothesis, potentially diminishing the accuracy and reliability of the data. Another limitation pertains to the absence of a standardized research design and the inability to regulate the training and quality of peer mentors. Lastly, the review solely assessed the role of PAL in medical education, without exploring its impact in other professions or disciplines. In light of these limitations, it is not possible to conclusively ascertain through simple quantitative analysis whether PAL is superior or inferior to traditional teaching methods. Instead, we can only qualitatively propose that the effectiveness of PAL is not inferior to that of traditional teaching methods and may potentially offer advantages in certain aspects.
6. Conclusion
This review provides a comprehensive summary of the efficacy of PAL within medical education, affirming that PAL surpasses conventional teaching methodologies in the realms of theoretical knowledge dissemination and procedural skill mentorship. Evidently, PAL emerges as an effective and promising educational approach. Nonetheless, further rigorous investigations are warranted in the future to comprehensively elucidate the role of PAL in medical education.
Supporting information
S2 File. Characteristics of included studies and risk of bias.
https://doi.org/10.1371/journal.pone.0329605.s002
(XLSX)
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