Enhancing stress physiology learning in MBBS students through peer-assisted and case-based learning: A mixed-methods study

Problem statement

Traditional learning methods often emphasise theory, but there is a gaping need for interactive, student-centred approaches that promote deeper understanding, better retention and practical application. Given the theoretical nature of conventional approaches and the emotional complexity of stress responses, it is important to explore more dynamic and interactive teaching strategies.

Review of existing literature

Peer-assisted learning (PAL) is a student-centred approach where peers, typically more senior students, facilitate learning for their juniors. This method not only reinforces learners’ understanding of the concepts but also enhances facilitators’ understanding. The mutual exchange of knowledge and perspectives encourages a deeper grasp of complex topics and builds confidence in both groups. Research indicates that PAL fosters active engagement, improves communication skills and cultivates a supportive learning environment. It allows for:

1. Enhanced conceptual understanding: Students often feel more comfortable discussing doubts with peers, leading to clearer explanations

2. Skill development: Facilitators refine their teaching, leadership and communication skills

3. Increased motivation: Peer learning instils a sense of accountability and motivates students to perform better^[1-4]

4. Case-based learning (CBL) is another technique which contextualises learning by presenting real-life case scenarios, allowing students to apply theoretical knowledge to practical situations. CBL is widely appreciated for its capacity to bring the patient to the classroom, diminishing the void between textbooks and medical practice. When combined, PAL and CBL have the potential to foster a deeper understanding of complex topics such as stress physiology- promoting active learning, independent thinking, collaboration and decision-making^[5-7]

Alignment with national medical commission (NMC) guidelines

The NMC of India has mandated a shift to Competency-Based Medical Education (CBME), emphasising the development of Indian Medical Graduates who are lifelong learners, critical thinkers and skilled communicators. CBME encourages self-directed learning, early clinical exposure and integration of basic sciences with clinical reasoning. The use of PAL and CBL directly aligns with these CBME goals by facilitating collaborative learning, enhancing motivation and promoting the application of theoretical knowledge to real-life contexts.

Study purpose

In medical education, where students often experience chronic stress due to academic pressures, the application of these methodologies becomes even more relevant. By involving students in discussions around stress responses through real-world cases, this study aims to bridge the gap between theoretical knowledge and practical understanding, while also exploring how stress impacts learning performance. The primary objective of this study is to evaluate the effectiveness of an integrated PAL and CBL session in enhancing understanding of stress physiology amongst Phase I MBBS students, using both quantitative (knowledge gain through validated MCQs) and qualitative (student feedback) assessments. We have included parameters to assess changes in both quantitative aspects, in terms of knowledge gain and qualitative aspects using student feedback. The inclusion of pre- and post-tests with validated MCQs will allow us to measure the improvement in knowledge after the PAL and CBL session, ensuring the assessment is both reliable and valid.

Study design and ethical consideration

The study employed a cross-sectional interventional design, utilising a PAL approach combined with CBL to assess knowledge gain in the topic of stress physiology amongst Phase I MBBS students.

Participants and setting

A total of 200 Phase I MBBS students participated in the study. All students completed both the pre- and post-intervention assessments. The mean age of participants was 18.7 ± 0.6 years. Of these, 112 were female and 88 were male.

Facilitator selection and training

Two Phase III MBBS students served as peer facilitators. They were selected based on academic performance and demonstrated teaching aptitude. To ensure standardisation, the facilitators underwent a structured orientation session conducted by faculty members, where they were briefed on learning objectives, facilitation techniques, case content and group dynamics.

Development of teaching materials and questionnaire

The teaching session was built around a case scenario titled ‘The Exam Panic’, designed to illustrate acute physiological and psychological responses to stress. The case-based discussion was structured into six sections:

1. Symptoms of stress: Exploring physiological changes during stress

2. Mechanism of stress response: Focusing on body systems and the hypothalamic–pituitary–adrenal axis

3. Stress and glucose-sparing action: Hormonal regulation to ensure glucose availability

4. Hormones in stress: Roles of cortisol, adrenaline and noradrenaline

5. Impact on performance: Effects of stress on memory and performance

6. Management: Strategies for managing acute stress.

Multiple-choice questions (MCQ) validation and item analysis

Initially, 20 multiple-choice questions (MCQs) were developed to assess knowledge before and after the intervention and were aligned with Bloom’s taxonomy. Following expert validation using the Delphi method, pilot testing, and item analysis, 12 MCQs that met acceptable psychometric criteria were retained for the final pre- and post-test assessments. The final questionnaire comprised five recall-based items, four application-level items, and three analysis-level items. The questionnaire was reviewed by a panel of five subject matter experts using the Delphi method,^[8] with two rounds conducted to refine the items. Consensus was defined as ≥80% agreement on relevance, clarity, and alignment with learning objectives. The validated questionnaire was piloted on 20 Phase II MBBS students (not included in the main study), and feedback was used to improve clarity and difficulty. Item analysis was performed on the final 12 MCQs using the difficulty index (acceptable range: 30–70%), discrimination index (acceptable if ≥0.25), and distractor efficiency (≥75%) [Supplementary Material].^[9]

Implementation of PAL-CBL intervention

Students were divided into 20 small groups of 10 students each. Each group was led by a peer facilitator, guided by faculty observers to ensure consistency and adherence to case flow. A pre-test was conducted using the validated MCQs to assess baseline knowledge. Afterwards, the peer facilitators led their groups through the six-section case discussion, encouraging active participation and peer interaction. Following the session, a post-test using the same MCQs was administered.

Feedback and qualitative evaluation

Immediately after the post-test, students completed a feedback form comprising both Likert-scale questions and open-ended responses to assess perceptions of content clarity, facilitator effectiveness and overall experience. A 24-h window was provided for students to submit further questions through WhatsApp. A total of 16 students utilised this option, and all doubts were addressed on the same day [Figure 1].

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Figure 1:

Study protocol.

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Statistical analysis

Quantitative data were analysed using the Statistical Package for the Social Sciences version 25.0. The mean and standard deviation of pre- and post-test scores were calculated to summarise students’ performance. To test the assumption of normality, the Shapiro–Wilk test was applied to the difference in scores between pre- and post-tests. The test yielded a P > 0.05, indicating that the data were normally distributed. As the normality assumption was met, a paired t-test was employed to assess the statistical significance of knowledge improvement following the PAL-CBL session. A P < 0.05 was considered statistically significant. In addition, McNemar’s test was used for item-wise comparison of correct responses before and after the session, while a Chi-square test was applied to examine the overall distribution of correct and incorrect responses. To determine the magnitude of the intervention’s impact, Cohen’s d was calculated, with values interpreted as follows: d > 0.8 (large effect), 0.5–0.8 (moderate effect) and <0.5 (small effect). Qualitative data from open-ended feedback responses were analysed using thematic analysis. Two independent coders reviewed the responses and categorised them into key themes and subthemes to ensure reliability and minimise bias.

Pre-and post-test knowledge assessment

A total of 200 Phase I MBBS students participated in the pre-test, and 189 completed both pre- and post-tests. The data from 11 students who missed the post-test were excluded from the final analysis.

The mean number of correct responses per student increased significantly from 164.5 (82.6%) in the pre-test to 195.92 (98.4%) in the post-test. Correspondingly, the mean number of incorrect responses declined from 34.5 (17.4%) to 3.08 (1.6%). The x-axis represents the test phase (pre-test vs. post-test), while the y-axis denotes the average number of responses. Bars are categorised into correct and incorrect responses. Error bars represent the standard deviation to show response variability [Graph 1].

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Graph 1:

Pre- versus post-test accuracy in stress physiology knowledge amongst MBBS phase I students.

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Statistical analysis showed a highly significant difference between pre- and post-test scores (χ² = 28.7, P < 0.005). However, given the matched nature of the data, McNemar’s test was also conducted for item-wise comparison and confirmed statistically significant improvements (P < 0.05 for all items). The Shapiro–Wilk test confirmed normal distribution of the difference in scores (P > 0.05), validating the use of paired t-test, which also showed significant knowledge gain (P < 0.001). The effect size (Cohen’s d) was calculated at 1.21, indicating a large effect of the intervention on learning outcomes.

Table 1 summarises pre- and post-test domain-based performance. The questionnaire comprised 12 validated MCQs aligned with Bloom’s taxonomy: Five recall-based questions, four application-based questions and three analytical questions. These covered topics including hormone pathways, physiological mechanisms and clinical correlations. Overall, the improvement was consistent across all Bloom’s levels, with a marked increase in application and analytical questions, suggesting enhanced conceptual understanding post-session. Recall-based knowledge was already high at baseline but still improved post-session, confirming reinforcement of foundational knowledge. Application-based questions also improved substantially, indicating better clinical reasoning and conceptual application. Analytical skills showed the greatest improvement, reflecting a better understanding of higher-order thinking concepts after the session.

Feedback analysis (quantitative)

Out of 189 students who completed the post-test, 100% responded to the feedback questionnaire. Results are summarised in Table 2.

Feedback analysis (qualitative themes)

Qualitative responses were analysed using thematic analysis and are presented in Table 3. One student shared a challenge with examination-time stress and found the session helpful in learning how to stay focused during critical periods. The overwhelmingly positive student feedback and facilitator reflections underscore the effectiveness of PAL-CBL in promoting engagement, practical application of knowledge and emotional resonance, particularly in a topic like stress physiology.

Peer facilitator reflections

Informal reflections were gathered from the peer facilitator post-session. Facilitators reported that the experience enhanced their subject mastery, improved confidence, leadership and communication skills and required deep engagement with the content to anticipate peer questions. Explaining concepts to our juniors made me revisit the material with greater depth. It also improved how I communicate under pressure — Peer Facilitator.

These reflections align with literature indicating that peer teaching enhances metacognitive development and reinforces learning amongst facilitators.

Overview of key findings

This study aimed to evaluate the effectiveness of an integrated PAL and CBL session in enhancing the understanding of stress physiology amongst MBBS Phase I students. The findings revealed a statistically significant improvement in knowledge scores post-intervention, with all MCQs showing item-wise gains (P < 0.05, McNemar’s test) and a large overall effect size (Cohen’s d > 0.8). This affirms the utility of interactive, student-centred strategies in foundational physiology teaching.

Effectiveness of PBL-CBL model

PAL has gained traction in medical education due to its flexibility and learner-centred approach. Numerous studies affirm its efficacy in both clinical and pre-clinical domains, often showing comparable or superior outcomes to faculty-led models.^[10-16] PAL also promotes communication, confidence and metacognitive growth in peer tutors.^[17,18] However, some concerns remain regarding variability in peer facilitator quality, underscoring the importance of structured training.^[19,20]

In this study, the vertical peer model, where senior students led discussions, proved highly effective. Student feedback supported this, with 97.3% (n = 184) reporting improved understanding and 95.2% (n = 180) appreciating the active, engaging environment created by peer tutors. This aligns with findings by Riaz and Samra et al., who observed better MCQ performance amongst PAL participants.^[21,22] Importantly, PAL also empowered facilitators: Informal feedback revealed improvements in leadership, teaching ability and subject mastery-consistent with prior literature emphasising PAL’s bidirectional benefits.^[17,23]

CBL contribution

While PAL is well-studied, this intervention uniquely combined it with CBL, using a relatable scenario (‘The Exam Panic’) to simulate emotional and physiological stress responses. This helped contextualise complex physiological mechanisms and enhanced engagement, a hallmark strength of CBL. As Thistlethwaite et al. highlighted, CBL fosters deeper learning by promoting critical thinking, collaborative discussion and clinical reasoning.^[2,5] The case narrative addressed both cognitive and affective domains, allowing learners to empathise with the scenario while analysing the underlying mechanisms. This dual impact makes CBL a powerful pedagogical strategy, particularly when blended with PAL.

Student engagement and feedback

Student feedback underscored the relevance and impact of the PAL-CBL model. Beyond strong agreement on facilitator effectiveness and session content, qualitative responses revealed themes of relatability, practical coping strategies and peer bonding. Notably, a post-session WhatsApp-based Q and A feature saw active use, with 16 students engaging and all queries addressed within 24 h, enhancing the accessibility of the learning process. This aligns with Burgess et al. (2014), who concluded that peer tutoring benefits both learners and tutors by enhancing essential teaching and professional competencies.^[7]

Facilitator reflections

Peer facilitators reported that teaching their juniors greatly improved their own understanding of stress physiology, communication and facilitation skills. Preparing to anticipate peer questions required in-depth engagement with content, promoting metacognitive development. This aligns with Nestel and Kidd’s evaluation of peer tutoring in patient-centred interviewing, which demonstrated significant gains in facilitators’ teaching confidence and communication skills, even if the objective skills were similar to those taught by faculty.^[6]

Limitations

This study was limited to a single cohort of MBBS Phase I students at one institution, which may affect the generalisability of the findings. It did not include a control group receiving traditional instruction, which limits the comparative interpretation of the PAL-CBL method. Moreover, knowledge retention was measured only in the short term, immediately post-intervention, without follow-up to assess long-term learning outcomes. Finally, student feedback may have been subject to social desirability bias or influenced by positive rapport with peer facilitators, potentially inflating perceptions of effectiveness.

Data availability statement:

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.