Peer Assisted Study Session (PASS): Are the Millennial Leaders the Leaders of Tomorrow? A Prospective Cohort Study.

Background PASS is a peer-led structured academic mentoring program designed to provide academic assistance for new students in their transition from college to university studies and also for students struggling in certain units. This study aims to establish acquired skills by peer leaders associated with peer-led mentoring via PASS program, and to explore the role played by these acquired skills in their journey to become a successful doctor. Methods Study participants were forty selected second-year undergraduate medical students at Monash University Malaysia with commendable examination results. Validated pre-test and post-test questionnaires were administered to explore changes in the level of communication, leadership, professional, and pedagogical skills before and after participation in peer mentoring program. Qualitative analysis of focused group interviews was performed by an independent investigator to identify how the skills developed as a peer mentor may help with becoming a good doctor. Major themes were identied with the thematic-analysis approach. Results Thirty-eight students completed the pre-test and post-test questionnaires. Peer leaders reported improvement in oral and written skills for teaching; increased condence to give constructive feedback; better stress management; ecient time management; improved interpersonal skills; and enhanced problem-solving and critical thinking capabilities. Eight major themes were identied from the interview and peer leaders reported positive experience of working in diverse environments and shouldering of responsibilities. Conclusions turn may communication, leadership skills.


Background
The year was 55BC when the esteemed Roman statesman, Cicero rst coined the Latin term, 'Docere', which beautifully described the role to teach, to delight and to move. It wasn't until the thirteen centuries when the world's oldest university, i.e. the University of Bologna in medieval Europe had rst conferred a doctorate degree, which bestowed the holder the rights to teach with the title doctor. (1,2) Today's in this modern era, each and every medical doctor plays a role in teaching, be it their peers, their mentees, or their patients.
Peer Assisted Study Sessions (PASS) is a peer-led structured academic mentoring program designed to provide academic assistance for new students in their transition from college to university studies and also for students struggling in certain units. PASS is an Australian adaptation of Supplemental Instruction which was developed by Deanna Martin at University of Missouri with aim to increase students' success in di cult courses. (3) In our medical school, it is delivered by accomplished senior year medical students to junior medical students on a weekly basis after rigorous selection and training.
Friendly peer leaders are empowered with guided support to impart their knowledge and experience, and motivate mentees to do better with coursework.
Internationally, peer-led mentoring program has become a widespread phenomenon across all elds of expertise and scale of organization including the healthcare eld. (4,5) Amongst the Fortunes 500 companies, more than 70% of them are implementing peer mentoring programs. (6) Smaller institutions such as startups, on the other hand are working to provide environments where mentoring will thrive organically. (7) The structured mentoring program is currently regarded as the gold standard in mentoring because the mentor is rst trained to mentor which then results in improvement of their mentoring knowledge, skills, and demeanors at mentoring. (8,9) At present, literatures on intricacies of relational dynamic between mentor and mentee, the performance of mentor evaluation, and satisfaction of mentee are in abundance. (10,11) The raison d'etre for this burgeoning phenomenon is perhaps due to the positive outcomes from multiple studies associated with peer mentoring. Studies have reported positive experience amongst former peer leaders, positive feedback from mentees, opportunities for development of leadership skills, increased sense of engagement in the community, and the unique traits of the new generation of workforce which demand changes in doctrine for their training (12-14).
Current literature on experience of peer leaders are focused on measuring three key components of mentoring which are role-modelling, psychosocial support, and vocational support. (15) Results from these studies have been overwhelmingly positive. Another common theme being researched on is the intricacies of relational dynamics between mentor and mentees in a peer-led mentoring program. Many a time, mentees reported di culties regarding several aspects of relational challenges which often are communication and interpersonal in nature. Some examples include di culties in confronting hurdles and managing expectations of mentor. (10) In the current era, doctors are expected to be an effective communicator with good interpersonal skills to navigate through the complexity of the healthcare system and patient-doctor relationship. Living up to the Latin root word, docere, a doctor in this ever-changing world is also expected to be a good teacher and mentor (16,17). However, there is inadequate data on the association of skills gained as a peer mentor and its relevance to their future practice as a medical professional.
This study aims to establish the skill set acquired by peer leaders during the peer mentoring and to explore how these skills will be helpful in their journey to become a successful medical practitioner.

Setting
The study was done at Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia over a period of two years from 2018 to 2019.

Characteristics of Study Participants
Study participants were undergraduate second-year pre-clinical medical students who were selected through an interview for their excellent communication and interpersonal skills, and have achieved excellent results in all course-related examinations with a ranking of upper third quartile in their cohort of students. This study is approved by the Monash University Humans Research Ethics Committee, Approval No. 17004.

Description of Materials
The pre-test questionnaire is a validated (Cronbach's a 0.876) self-report measured on a 5-point Likert scale and included 12 items with focus on establishing the baseline level of communication skill and pedagogical skill (see Additional File 1); the post-test questionnaire is a validated (Cronbach's a 0.797) self-report measured on a 5-point Likert scale and included 12 items with focus on establishing the postintervention level of communication skill and pedagogical skill (see Additional File 2).
Both questionnaires utilized a 5-point Likert scale to measure agreement of the participant for each item, i.e. 5 is strongly agree, 4 is agree, 3 is neutral, 2 is disagree and 1 is strongly disagree. In addition to the questions related to their communicationskills and pedagogical skill, both questionnaires also collected demographic information (age and gender).

Study Processes, Interventions, and Comparisons
This study utilized a mixed-study approach, i.e. quantitative survey and focus group discussion to achieve the objectives. Prior to the training, participants were asked to complete a pre-test questionnaire. Following which, the two-day PASS leaders training is conducted by a certi ed trainer-supervisor for PASS program. The training is focused on essential elements of PASS program, i.e. planning for a PASS session, facilitating a PASS session, and handling administrative work as a PASS or peer leader. On completion of the training, peer leaders in pairs are then assigned to their respective groups of juniors for one semester. After 12 weeks, the leaders were asked to complete a post-test questionnaire. One year later, a follow-up interview was done when the leaders were in their third year of their study which is also their rst year in clinical setting.

Statistical Analysis
Demographic data and responses to quantitative questions are presented as means and proportions. The normality test is performed using Shapiro-Wilk Test. A paired T-test is used to compare between items in post-test and pre-test group. Statistical analysis is performed by using IBM SPSS Version 22. The general level of signi cance is xed at 0.05. Qualitative data was analyzed by using thematic-analysis approach to search for salient points of common experiences. First, a recorded interview was done which was transcribed and fed into an analytical software, i.e. NViVo 12.6.0. Relevant quotes were highlighted and grouped into a suitable thematic category. Next, multiple thematic categories which described a speci c version of similar experience were combined to create a more inclusive thematic category. Additionally, subcategories that stood on their own but described another theme were then created. Finally, thematic categories were checked to ensure all quotes contained within them t well into their assigned categories.

Informant Sampling and Respondent Demographics
Of the 40 peer leaders who were sent questionnaires, 38 responded. Informant characteristics are summarized in Table 1. Sixteen of the participants were male (40.0%), twenty-three were female (57.5%) and one participant did not identify the gender (2.5%). The mean age was 20.9 years old. 15 peer leaders who consented to participate in focus group discussion were interviewed a year later.

Results of Qualitative Analysis
The comments and stories related by student leaders in the structured interview were categorized into themes pertaining to how PASS program helps with preparing to become a successful medical practitioner. Two major themes were identi ed which are personal growth and professional growth.

Personal Growth
Four sub-themes consisting of individual skills development were identi ed. These skills are communication skills, leadership skills, learning skills, and pedagogical skills.
Communication Skills.The majority of peer leaders identi ed the ability to connect and reciprocate with peers and students as an essential skill to conduct a successful PASS session which is pivotal to become a successful doctor. These skills consisted of rapport building with students and peers, giving and receiving constructive feedback, responding to non-verbal cues, and setting expectations .
An enthusiastic female medical undergraduate on the topic of building rapport stated: It de nitely helps us because we now know how to build rapport with our peers; in clinical practice we build rapport with our patients. This will enable us to get the information across quickly.
Another male medical undergraduate remarked on giving feedback: I tend to be nice to a person when giving feedback. I learnt via PASS that giving good feedback, a frank one is important. That is more bene cial. When it comes to clinical practice, I would need to be truthful and critical with my patient.
An exuberant female medical undergraduate commented on setting expectation: In order to create the most effective learning environment, I would need to know what their needs and expectations are....I had to put myself in their shoes. This is important when it comes to understanding a patient, hence the importance for patient-doctor relationship.
Leadership. Peer leaders identi ed good leadership as the key to stewarding the teaching session successfully. Maturity and con dence in interacting with students are the two important parts of good leadership.
A male medical undergraduate who identi ed as an introvert remarked on instilling con dence as a key to good leadership: I feel that it is important to be con dent and also to portray con dence when it comes to patient practice. This is true when handling the juniors, we need to portray con dence with the juniors so that we can instill con dence for them to have active discussion with them.
A female medical undergraduate remarked on maturity as part of the process of being a leader: When I started, I was shy and ashamed at times when I didn't know the answers for certain things… But after some time, I realized that learning is not a one-way learning process. While teaching, I was learning too of what I didn't know... So, I will nd the answer and share with the rest of them.
Learning. Peer leaders described three keys to learning which are resourcefulness, active learning and collaborative learning.
A dedicated male medical undergraduate who was in charge of the peer leaders for PASS program commented on resourcefulness: It does tickle our brain on how to answer those questions posed by our juniors from a different perspective. It requires us to stay updated with the latest resources. In future, we will do the same in the management of our patients too.
A committed female medical undergraduate who assisted the head of peers for PASS program remarked on collaborative learning: PASS does help us a lot because during PASS, we can discuss things we don't understand with our juniors.
Pedagogical. Peer leaders identi ed two important attributes from the experience of teaching junior students through which are the prerequisite to successful active learning teaching session. These attributes are creativity and critical thinking which were honed further via participation in PASS program.
A tech-savvy male medical undergraduate remarked: We learned that we have to make our session more interactive, e.g. via active discussion and participation such as Kahoot.
A bright female medical undergraduate rea rms her challenging experience to hone critical thinking skills for PASS remarked: It does really help me in improving my critical skills because we conduct the session from different perspectives. It re ects back on my clinical practice where it helps me to think holistically as a patienttreat the patient vs treat the disease.

Professional Growth
Four sub-themes were identi ed.
Administrative. Peer leaders identi ed skills gained from administrative duties of being a peer leader as one of the k eys to success as a doctor as well and would increase the threshold to burn out in future. These skills include managing schedule by coordinating timing between students and tutors to organize a teaching session, and juggling between responsibilities both as a student-teacher and a peer.
A bright male medical undergraduate peer leader noted on administrative duties as a peer leaders: Management skill is something we have gained, and I feel that it will allow us to manage ourselves better hence not to burn out.
Experience. Experience is an important aspect of PASS program. Peer leaders reported experience in con ict resolution, opportunities for learning and observing different presentation style, complexity of teamwork and challenges of working with diversity amongst the top experience of being a peer leader .
A vibrant female medical undergraduate who is also a highly-decorated scholar reported: By teaching our juniors, I feel that it does help me with my presentation skills. This is because presentation is a big part of being a medical student, and a doctor. During a continuing medical education session or a medical conference, we would need to do a presentation and read up on the topic as well. This is what I have experienced while being a peer leader.
Another bright and enthusiastic gender non-binary student identi ed teamwork as an important experience of being a peer leader: I think it has made us realize that to sharing responsibilities amongst the peer leaders is important.
An international male medical undergraduate noted on working with diversity: I have to communicate with my juniors as well who are of differentbackgrounds and culture, thus PASS program helps me in this aspect.
Responsibility. Peer leaders identi ed fouraspects of being a responsible peer leader which will shape a good character of a responsible doctor which are to do adequate preparation, honoring commitment, honesty as the best policy and lifelong learning.
An exuberant female medical undergraduate reported: "Not only that we have to prepare for discussion, but we have to also be responsible and answerable to what we are going to tell our juniors because we cannot just blurt out everything. " Another male medical undergraduate noted: We wanted to do quality work and committed to our juniors' learning. It mase us responsible Time Management. Peer leaders reported three essential skills related to time management which have been acquired and honed through participation in PASS program. These skills are prioritizing tasks, punctuality, and having a work-life balance.
A female medical undergraduate commented on prioritizing of tasks: We learned how to manage our time effectively and to weigh the priority of the topics to focus on for our juniors and our own revision.
Another male medical undergraduate spoke of punctuality: Our juniors taught us to be on time. I feel that it is an important trait as a successful doctor.
And a female medical undergraduate further added: With PASS, we have to manage our time well to ensure we get up to date with our tasks and that everyone is on track as well. This would make an important and good trait of a doctor.

Discussion
In our study, peer mentoring experience contributed to the development of skills and attributes that are considered essential to becoming a good doctor. The acquired skills from participation in peer mentoring program are consistent with the core clinical competencies of a good doctor, i.e. competent interpersonal and communication skills which result in effective bilateral exchange of information between doctor and patient; practicing professional attributes and demeanors such as empathy, compassion, calmness, attentiveness, adaptability, passion, con dence, and humility. (17) Findings from our study are consistent with ndings from previous studies concerning peer leaders in medical education. These studies found that with participation in peer-led mentoring program, peer leaders are more organized and better at time management; they are ready to negotiate challenges and utilize resources to support their work; they feel driven from healthy peer pressures of being with crème de la crème pool of peer leaders; their learning and pedagogical skills are enhanced; they feel more inclusive in the community and contempt with their contribution at mentoring their juniors. (18)(19)(20) We did not nd signi cant differences after peer mentoring experience in written and oral communication skills as well as interaction and collaboration skills amongst our peer leaders. It could be because of the fact that our cohort of peer leaders were chosen for the program based on their strong communication and interpersonal skills.
Arguably, population of medical students and junior doctors in years to come would largely be made up of millennials. Such a generational shift would require a colossal shift in the doctrine for their training as well. (21,22) Millennials are known for being con dent, narcissistic, collective minded, and diverse in thinking.(23) They value personalized learning experience, mentoring by seniors, working in team and incorporation of technology in their work. (24) In order to cater to their unique learning needs and personality traits, the learning approach should work around their values.
In PASS, our peer leaders who are entirely made up of the millennial's generation are empowered with a clear set of responsibilities and skills needed to conduct a teaching session through our structured peer mentoring program. They are given the freedom to plan and conduct session amongst themselves which provide a room for them to breathe amidst their own tight schedule at medical school. Topics of choice for each session are mutually decided and agreed to be bene cial for their own learnings and the mentees as well. This form of active learning with clearly de ned structure is proven effective.(25) The opportunities to teach, engage and contribute back to their community are also aligned with the values and attributes of millennials. Many studies have cited these values to be the deciding factor for many millennial peer leaders to join such a program in spite of their tight schedule. (20) There are limitations to our study. First, our study relies exclusively on self-report measure by peer leaders of their own experience. There is no measure of peer leader's performance from the perspective of their mentees. Second, our peer leaders are only representative of a single centre and their experiences are not re ective of the experience of peer leaders from other centres where there are variations on the doctrine of the peer-led mentoring session as well as its bene ts and drawbacks. Third, we made the assumption that for data with sample size less than 200, there is no signi cant difference between parametric and non-parametric analysis based on literature. Forth, there is no intergenerational interaction in our peer mentoring program. Our PASS leaders and their mentees are both millennials, andthus there is no intergenerational interaction between mentor and mentee which could result in different experiences.
Lastly, our population of peer leaders consist exclusively of undergraduate medical students -had postgraduates students included as well, the opinions may be different.
Future research in this eld of peer-led mentoring should include diverse populations of undergraduate and post-graduate medical students from multiple centres to get the bigger picture of their experience as peer leaders. Feedbacks from mentees regarding their peer leader's performance throughout the PASS program should also be analyzed and compared against self-report measure by peer leaders themselves as this will allow for self-report bias to be eliminated from the nal study. Postgraduate medical students should also be included in the pool of peer leaders to increase the diversity of the study population.

Conclusion
Our study has shed light on acquired skills and attributes associated with peer-led mentoring and how peer leaders perceived these qualities to be useful in their journey as a future doctor. We conclude that peer-led mentoring provides good opportunity for medical students to shoulder responsibilities as a leader and experience managing of their peers and juniors which in turn enhance their communication, interpersonal, pedagogical and leadership skills. These qualities are in concordance with the requirement of future medical workforce which amongst others require healthcare workers with the right skills to provide the right care, in the right place, at the right time, and with competent leadership skills, communication skills and the ability to work within a team. (26) List Of Abbreviations