Developing Early-Career Clinical Educators – A Qualitative Study of a Pedagogical Internship Track for Junior Doctors in Sweden   

Developing Early-Career Clinical Educators – A Qualitative Study of a Pedagogical Internship Track for Junior Doctors in Sweden | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Developing Early-Career Clinical Educators – A Qualitative Study of a Pedagogical Internship Track for Junior Doctors in Sweden Thomas Ramo, Paul Pålsson, Hanna Wallberg, Helena Vallo Hult This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8062096/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Near-peer teaching (NPT) and structured near-peer teaching programs (NPTPs) have been recognized as valuable approaches in medical education, yet relatively few studies have explored programs designed specifically for junior doctors. In response to a local shortage of clinical supervisors and educators at a non-university teaching hospital in Western Sweden, a voluntary pedagogical faculty development program was launched in 2018 as a part of the mandatory medical internship. The program engaged junior doctors with a documented interest in education to supervise medical students and peers. From the outset, the program was intended not only as a teaching initiative but also as an early form of faculty development, aiming to strengthen participants’ pedagogical skills and professional identity. This study aimed to explore how junior doctors participating in a pedagogical internship track experienced the development of their teaching skills and professional identity, as well as their experience of the program. Methods We conducted a qualitative study of the pedagogical internship track using semi-structured interviews with ten former participants, enrolled between 2018 and 2024. Interviews explored their experiences of the program and its influence on subsequent professional roles. Data were analyzed using qualitative content analysis. Results Three main themes were found: Support the development of a pedagogical toolbox, particularly in relation to feedback skills; to foster a sense of professional legitimacy during internship; and to contribute to the formation of an identity as clinical educators, carried into subsequent residency training. Participants also described that the program helped establish a broader pedagogical culture within the hospital. Conclusions Findings from this study suggest that structured near-peer teaching programs for junior doctors strengthen teaching skills, enhance professional identity, and promote continued engagement in clinical education. By embedding such programs within internship training, hospitals may not only support individual development but also foster a sustainable pedagogical culture. Neer peer teaching PAL Peer-assisted learning Health Professional Education Faculty Development Introduction Peer-assisted learning (PAL) and near-peer teaching (NPT) have been gaining increasing amount of attention and popularity as effective strategies in medical education, from undergraduate level to specialization training ( 1 ). PAL is defined as when individuals belonging to the same social group help each other to learn by teaching themselves, even though they are not trained professional educators ( 2 ). As for NPT, the widely agreed upon definition is a form of peer-education where the teacher is performing the same training as the student, but being at least one year ahead ( 3 ). Near-peer teaching programs (NPTPs) have been acknowledged across various academic disciplines ( 4 ) and have been proven to benefit both learners and those in teaching roles. Reported benefits for the tutors include consolidation of subject knowledge and clinical skills, development of communication and feedback competencies, improved organizational and planning abilities, and an enhanced understanding of educational theory and pedagogy. In addition, participation in NPTPs appears to cultivate positive attitudes toward teaching and may encourage future engagement in medical education ( 5 ). Quality clinical education is crucial for maintaining medical training ( 6 ). Even though there is a high level of motivation to teach among doctors ( 7 ), many health care systems still face challenges in recruiting and supporting clinicians as teachers ( 8 ). Reported barriers include a high level of clinical workload, lack of allocated time for teaching and lastly, the lack of formal pedagogical training, which seems to contribute to the ambivalent attitude toward teaching duties ( 9 ). Following the increasing interest in near-peer teaching programs in medical education, there has been a growing body of literature exploring the perspectives of senior medical students being tutors ( 10 , 11 ), including from Sweden ( 12 ). Yet, the data on the experience of junior doctors enrolled in such NPTPs within clinical settings is limited to a few studies ( 13 – 15 ). Moreover, faculty development tends to focus on residents ( 16 , 17 ). Interns, however, tend to work on different clinics within a hospital and are usually involved in teaching medical students and peers ( 18 ). Despite this, little is known about how structured pedagogical initiatives during internship shape teaching skills, professional identity, and opportunities for educational engagement. In this study, our aim was to explore how junior doctors who had participated in a pedagogical internship track experienced their development of teaching skills, professional identity and how they experienced the program. Methods Study setting Medical education in Sweden leading to an MD degree is provided at seven independent universities ( 19 ). Since the fall of 2021 the curriculum is comprised of six years leading to a medical license upon graduation ( 20 ). However, the previous curriculum considted of five and ahalf years, followed by a mandatory, structured clinical internship ranging from a minimum of 18 months up to 24 months – Allmäntjänstgöring (AT) – before being authorized to apply for a medical license from the National Board of Health and Welfare. During this internship, the junior doctor serves a minimum of 3 months within internal medicine and surgical specialties respectively (but a combined minimum of 9 months), 3 months in psychiatry and 6 months in primary care. Thus, AT serves as a transitional phase between undergraduate education and residency ( 19 , 21 ). The study setting is a regional, non-university hospital in Western Sweden, affiliated with the University of Gothenburg, where a voluntary pedagogical track within the internship program was introduced in the fall of 2018, designed as a NPT program. The purpose of the program was to engage junior doctors with a documented interest in teaching and education to supervise medical students during their clinical rotations. Each year, up to eight candidates with an interest in and merit for teaching are accepted into the program. The pedagogical internship track includes formal coursework in pedagogical skills and feedback, participation in simulation-based teaching activities, and opportunities to supervise both peers and medical students in clinical settings. In this way, the program incorporates elements of both peer-assisted learning and near-peer teaching, allowing participants to develop educational skills across different learner levels. Respondents and recruitment All 17 doctors who had completed the pedagogical internship track since its launch in 2018 were invited to participate in the study. They had been enrolled in the program between 2018 and 2024. Current participants were not invited, partly because the interviewer was enrolled in the same program at the time, and partly to allow reflections on how the pedagogical internship track had influenced subsequent career choices. Restricting inclusion to former participants also ensured that no personal or collegial relationship existed between the interviewer and respondents. A total of ten former participants agreed to take part in the study, six females and four males. Participants ranged in age from 29 to 46 years, and all had graduated from Swedish medical programs. At the time of the interviews, they were working within various medical specialties, as summarized in Table 1. Written and oral study information was provided to all respondents prior to the interviews, and all gave informed consent. The information included background to the study, study procedures, and details regarding the handling of personal data. Data collection A semi-structured interview guide was developed by the authors to explore respondents’ demographic background, current clinical roles and teaching responsibilities, experiences from the pedagogical internship track (including strengths and challenges), and their perspectives on peer- and near-peer teaching. The interview guide was piloted among current participants and underwent minor revisions (Appendix 1). All interviews were conducted by the first author between 17 October and 13 December 2024. Eight interviews were conducted online, via Microsoft Teams ( 22 ), while two were held in person at the hospital. All interviews were audio-recorded, using the Teams recording function. Interviews were carried out in Swedish, following the guide in a conversational style, with probing questions used to deepen and clarify responses. The duration of interviews ranged from 28 to 58 minutes. Data saturation was deemed to have been reached when no new themes emerged in later interviews. Analysis The interviews were transcribed verbatim. Only the first author and the transcriber had access to the recordings, which were deleted after transcription. Transcripts were pseudoanonymized prior to analysis. A full anonymization was not possible as the first author conducted the interviews. Qualitative content analysis was performed in accordance with Graneheim and Lundman ( 23 ). All authors initially read the transcripts several times to familiarize themselves with the material and ensure immersion in the data. Meaning units were identified, condensed, and coded. Codes were then grouped into subthemes and, through iterative discussions between the authors, further refined into overarching themes. Quotations have been translated from Swedish to English by the authors. Minor linguistic adjustments were made to improve readability while preserving core meaning. To enhance credibility, respondent validation was conducted after all interviews had been conducted and analyzed. A summary of the thematic framework was sent to participants, who confirmed that the findings reflected their experiences. Results Three prevailing themes emerged from the qualitative analysis: Building a Pedagogical Toolbox, Establishing Professional Legitimacy and Becoming a Clinical Teacher. Each theme is described in detail below, with illustrative quotes from the interviews (see Table 2 for a summary of themes and subthemes). Theme 1: Building a pedagogical toolbox Acquiring formal and practical education on medical simulations and feedback methods The opportunity to obtain formal and practical education on how to conduct medical simulations, along with theories underlying clinical supervision and feedback, was depicted as highly beneficial and educational. Several participants expressed their appreciation to the fact that they took formal coursework required at residency level, which in turn equipped them with tools to engage in their teaching activities and, importantly, to adopt a pedagogical approach even outside formal teaching contexts “Both the basic pedagogical course and the simulation instructor course give you a lot of tools to use when supervising and it feels like you can put more thought into it, even if you have a stressful everyday life. I think you got a lot of tips and tricks on how to think and how to do things… and I think that you have a baseline of a pedagogical mindset during your workday” (Respondent 1). “Having read extensively and received education in pedagogy and clinical supervision facilitates my daily clinical work.” (Respondent 10) Overall, receiving formal and practical training in medical simulation, leadership and feedback was perceived as a positive aspect of the pedagogical internship track, enhancing the participants' teaching abilities not only confined to formal teaching missions, but also to everyday, clinical practice. Emphasizing feedback Participation in the pedagogical internship track and the appurtenant teaching missions required the interns to regularly provide feedback to medical students and colleagues. Respondents described that this repeated practice not only improved their ability to deliver constructive feedback but also made them more available to receive feedback themselves. Several highlighted that they had become substantially more effective and confident in using feedback as a pedagogical tool. “ Well, I would say above all that I’ve become much better at giving feedback – really, much better. I would say that is the most clearly tangible thing I have improved after the program.” (Respondent 5). "If you practice how to give feedback, you also understand how to receive feedback when you need it, and then you make yourself more available. I feel that you learn so much more if you open yourself up to feedback" (Respondent 3) Developing feedback skills was described as a highly important and empowering aspect of the pedagogical internship track, improving the participants' openness to receiving feedback in their own careers and future roles as resident doctors and clinical educators. Orchestrating teaching events and activities on a logistical level Having the responsibility for different teaching activities within the hospital incentivized the participants to develop their ability to coordinate different logistical components, including booking lecture halls and finding suitable patients for the medical students to talk to. "What I have learned is a little bit about planning, how to plan and organize, partly a lecture and partly how to plan an educational day." (Respondent 6) “It was about booking it (student room) and then going around looking for these patients myself” (Respondent 2) Nevertheless, several respondents hinted to the fact that these secondary tasks were excessive and time-consuming. "In our case there was so much booking of student rooms and booking, i.e. administration all around." (Respondent 3) Taken together, taking responsibility for the organization of different teaching activities enabled participants to develop valuable logistical skills, essential to work as clinical supervisors, although some of these tasks were perceived as time-consuming and administratively burdensome. Theme 2: Establishing professional legitimacy Possibility to have influence Respondents emphasized the value of shaping both their own learning and the educational environment for their colleagues. Acting as pedagogical intern doctors allowed them to influence what and how other junior doctors learned, for example, by selecting scenarios and planning simulation days. This responsibility fostered engagement, ownership, and a sense of professional legitimacy, as they contributed directly to shaping the internship experience for their peers. “The strength during this time was that I got to reflect and be involved in shaping my own internship. Since I participated, I could influence how the other intern doctors experienced these simulation days. I chose scenarios based on what I felt I needed to learn more about.” (Respondent 4). Having the possibility to influence both personal learning and the learning conditions of colleagues enhanced participants’ professional agency and legitimacy, highlighting their role as active contributors to the broader educational environment within the medical internship. Pedagogical experience as career advantage Participants described pedagogical experience gained during the pedagogical internship track as an asset for their future careers. Being involved in teaching activities and formal pedagogical training was perceived to enhance their professional profile. Several participants highlighted that this experience gave them credibility in pedagogical contexts and was seen as an advantage when applying for residency positions. “It should really be said, I also think you will notice later when applying for jobs that it is a major merit, and everyone thinks, I mean, it sounds very good to know about pedagogy… people are very interested and curious, and it allows you to stand out in a way that is very advantageous” (Respondent 5). “It is definitely seen as a merit when applying for jobs…” (Respondent 4). In summary, Pedagogical experience during the medical internship was seen as a career-enhancing advantage, providing professional credibility in teaching situations, perceived as a way to help respondents distinguish themselves from peers in the job -market. Group credibility Participants highlighted that being part of a pedagogical group contributed to their credibility and legitimacy within the hospital setting and among peers. Belonging to a designated and structured team, supported by experienced supervisors being their employer, provided a “stamp of approval” that made it easier to initiate projects and be taken seriously by colleagues. Being in a group also facilitated mutual learning, inspiration, and professional development, as members could support and motivate each other. “I mean, our strength was that we were pedagogical and had, like, [name of chief of internship and head program director] behind us, and I think that is important. I think it is harder to just randomly start a project without some form of approval from someone.” (Respondent 1). “I think the strengths have also been that you are in a group, that you can develop, and you can get a bit of inspiration from each other.” (Respondent 7). Overall, being part of a pedagogical group enhanced participants’ credibility and confidence, while also providing opportunities for mutual support and professional growth. Having a local contact network within the hospital orworkplace The respondents, being former participants, emphasized the value of building a local professional network within the hospital. Engaging in pedagogical activities allowed them to establish connections with other supervisors and colleagues, providing both guidance and potential future support. Knowing key individuals personally, and having the opportunity to interact with them, were perceived as enhancing professional confidence and easing future collaboration. Establishing these contacts was also described as enjoyable and educational, contributing to both personal and professional development. “You get a very good foundation if you are interested in pedagogy and leadership, especially if you stay within the same hospital. You have contacts, you know, like [name of chief of internship and head program director], you know who they are and can email them, and hopefully they remember your name. That alone makes a big difference, I think” (Respondent 2). “You make contacts in this way, and it was very nice, fun, and educational.” (Respondent 4). Thus, participating in pedagogical activities provided participants with a valuable local contact network, enhancing both professional confidence and opportunities for future collaboration within the hospital. Theme 3: Becoming a clinical teacher Growing confidence as a clinical teacher Respondents described how involvement in the pedagogical internship track program increased their confidence and sense of credibility as clinical teachers. Being actively engaged in teaching tasks allowed them to gain experience, build expertise, and feel prepared for future pedagogical responsibilities. Several participants emphasized that early involvement provided both practical skills and legitimacy in educational matters, making them feel more capable of taking on formal teaching roles. “I probably wouldn’t have felt ready to become a program director (for current intern doctors) if I hadn’t already been somewhat involved myself as an intern doctor in these matters.” (Respondent 9). “I think it gives credibility in pedagogical matters.” (Respondent 3). Overall, participation in pedagogical activities during the internship seems to have fostered confidence and credibility as clinical teachers, supporting participants’ readiness to assume teaching responsibilities in the future. Developing a culture of peer teaching and learning Participants emphasized that the near-peer structure of pedagogical internship track facilitated effective teaching and learning among junior doctors. Working closely with colleagues at similar stages of training made it easier to understand each other’s perspectives, anticipate learning needs, and provide relevant, relatable feedback. This near-peer approach fostered a supportive and psychologically safe learning environment, enhancing both engagement and learning outcomes. “Being relatively close to each other academically and career-wise makes it easier to understand how the other person thinks and reasons; it can be harder if you have been a consultant for 30 years to sense the medical student’s needs” (Respondent 9). “There is a higher level of openness when doing peer-assisted learning; people are more humble about what they know and don’t know, and being in a safe group makes learning much more effective. You can see it with the students—those at the same level, friends, feeling safe to admit ‘I might not know this, you know it better,’ it creates a much better working environment” (Respondent 4). Ultimately, this near-peer teaching was seen as a way to strengthen both learning and professional collaboration, empowering participants to shape a supportive and responsive educational environment for their colleagues. Taking on new roles as clinical teachers As former participants, the respondents emphasized that the pedagogical skills gained during the pedagogical internship track had a lasting impact, enabling them to assume diverse educational roles after the program. In their subsequent positions as residents, they became actively involved in supervising medical students, mentoring new interns, and, in some cases, even taking on leadership roles such as program directors. Although these responsibilities were often demanding, they felt well-prepared and reassured by the pedagogical foundation established during their internship. “I am solely responsible for [the medical students’] education Monday to Friday full days, which is very tough but also very fun. I have faced many challenges in this, but it feels reassuring to have had a lot of pedagogical training behind me.” (Respondent 4). “I have had the clinical consultation skills course at the clinic, and with the new medical program (in Sweden), I have now had the same group two semesters in a row.” (Respondent 3). These accounts illustrate how the near-peer teaching experiences during the internship were perceived to create long-lasting pedagogical engagement, with participants continuing to contribute actively as clinical teachers in their new positions as residents. Discussion The aim of this study was to explore how junior doctors participating in a pedagogical internship track experienced thedevelopment of their teaching skills and professional identity, as well as how they perceived the program to have influenced their professional development. Our findings demonstrate that participation in the pedagogical internship track supported the development of a pedagogical toolbox, mainly improved feedback skills; fostered a sense of professional legitimacy during their time as intern junior doctors; and lastly contributed to the development of an identity of clinical educators, which participants carried into their subsequent roles as resident doctors. Several studies have documented the benefits of NPTPs in medical education, although most have focused on the undergraduate level ( 1 ). While some reports describe advantages for junior doctors, such as enhanced teaching ability, professional development, and improved knowledge and skills, few have addressed the internship period immediately following graduation. Our findings extend the existing literature by showing that structured NPTPs during internship can support both pedagogical skills and identity formation. This was particularly evident in themes one and three of our study, where participants highlighted feedback as a core competence and described a growing confidence as clinical teachers. The pedagogical internship track can also be understood as a faculty development initiative, aligning with several of the key features described by Steinert and colleagues ( 5 ), including experiential learning, relevant and applicable content, opportunities for feedback, intentional community building, and strong institutional support. Importantly, our findings resonate with established faculty development models that emphasize not only the acquisition of teaching skills and confidence but also professional identity formation, community building, and sustained engagement in educational roles. The outcomes illustrate well-documented benefits of faculty development programs, including enhanced credibility, legitimacy, and local networks within the workplace. We interpret these findings as evidence that the pedagogical internship track contributed to the development of a collaborative learning environment within the hospital, characterized by a strong sense of belonging, which facilitated future teaching initiatives as participants advanced to residency. O’Sullivan and Irby ( 24 ) distinguish between communities of practice that develop among program participants and those that manifest within the workplace. While the former is perhaps expected, our findings suggest that the pedagogical internship track also had a broader institutional impact. As interns rotate through multiple hospital departments, they can disseminate a “pedagogical culture,” as one respondent expressed it, thereby normalizing teaching and learning as valued professional activities. Such a culture may help strengthen the educational mission of the hospital. Medical educators are essential for sustaining the medical profession, as they play a central role in teaching medical students, junior doctors, residents, and in supporting continuing professional development ( 25 ). Although many physicians express strong motivation to teach, multiple challenges, including increasing clinical workload and limited protected time for education restrict their ability to engage in teaching. Estimates suggest that as few as 10% of clinicians can teach within their allocated time ( 26 ). One way to address these discrepancies is through faculty development initiatives for early-career doctors. Programs such as a pedagogical internship track strengthen participants’ professional profiles and encourage them to assume new roles as clinical educators, as illustrated by theme three of our study. Implications for practice Our findings suggest that structured near-peer teaching programs for junior doctors can have several practical implications. Although this program was developed within the Swedish internship system, the core elements of structured teaching opportunities, pedagogical training, and institutional support are transferable to other contexts and may help address the global shortage of clinical teachers ( 6 ). By equipping junior doctors with skills and confidence, such programs not only strengthen their professional development but also enhance the supervision and feedback provided to medical students and peers, thereby improving the quality of clinical learning environments. Importantly, as emphasized in previous research ( 15 ), sustained success requires strong institutional and organizational support. Several of our respondents likewise identified the need to optimize the administrative support system for participants as an area for improvement. In addition, initiatives such as the pedagogical faculty development program described in this study may be particularly valuable in non-university hospitals, where pedagogical infrastructures are often less developed ( 27 ). Embedding early faculty development tracks in these settings could help build a stronger teaching culture and ensure that clinical education remains a prioritized mission. Integrating programs like a pedagogical internship track into postgraduate training, while ensuring adequate organizational infrastructure, thus represents a sustainable strategy for health care systems that aligns workforce development with the educational mission of hospitals. Strengths and Limitations The strength of the current qualitative study lies in the inclusion of all former participants of the pedagogical internship track since its launch in 2018 with a good overall response rate. Furthermore, we performed respondent validation to ensure response credibility While the qualitative approach provided a valuable, in-depth, and contextualized understanding, future research could expand on our findings by including other roles or professions, such as nurses, multiple institutions, comparative studies of similar programs, or quantitative evaluation to enable broader generalization. The imitations, of this study also include its time-consuming character and the inherent risk for research bias ( 28 ). Furthermore, we investigated only the single perspective of former participants and did not include current interns. Finally, since the interviews were held in Swedish and later translated to English, we may risk potential loss of nuance. Conclusion Near-peer teaching and its application as near-peer teaching programs have long been recognized within the field of medical education although relatively few studies have explored and evaluated such programs intended för junior doctors. In line with recommendations from the field, this study evaluated, an ongoing near-peer teaching program (NPTP) for junior doctors in Western Sweden. Our findings demonstrate that the program supported the development of pedagogical skills, fostered professional legitimacy, and contributed to the formation of a clinical teacher identity among participants. These outcomes suggest that structured NPTPs can serve as an early form of faculty development, encouraging junior doctors to take on educational roles from the beginning of their careers. By strengthening teaching capacity during internship, programs like the one discussed in this article may help address the ongoing shortage of clinical educators and foster a stronger pedagogical culture within healthcare. Future research could explore long-term impacts on both participants and the students they supervise, as well as the transferability of this model to other settings. Declarations Acknowledgements We would like to express our great gratitude to all the respondents contributing to this study. Furthermore, we want to thank all the former and current interns of the pedagogical internship track. We are grateful to Nina Dereban for her valuable help and insights regarding the design and layout of the results tables. Author contributions TR, PP, HVH and HW contributed jointly to the design and implementation of the study. TR conducted the interviews. All the authors contributed to the analysis of the results and the writing of the manuscript. All authors reviewed the finished manuscript. Funding No funding was obtained for this study. Data availability The dataset from the study is available from the corresponding author upon reasonable request. Ethics approval and consent to participate The study protocol was reviewed by the Swedish Ethical Review Authority, Reference number 2024-04470-01. The Authority determined that the study did not involve any intervention or processing of sensitive personal data falling under the Swedish Act concerning the Ethical Review of Research Involving Humans and therefore did not require formal ethical approval. In an advisory opinion, the Authority raised no objections to the conduct of the study. The research was conducted in accordance with the principles of the Declaration of Helsinki. All participants received both written and oral information about the study and provided informed consent prior to participation. Clinical trial number: not applicable. Consent for publication Not applicable. Competing interests The authors have no conflicting interest to declare. Author details Thomas Ramo, M.D. Intern junior doctor and current participant in pedagogical internship track. E-mail: [email protected] ORCID iD: 0009-0003-4346-8674 Paul Pålsson (corresponding author) , M.D.Senior consultant in Anesthesia and Intensive Care, MSc in Medical Education. Program director for undergraduate and postgraduate medical education, NU hospital group. E-mail: [email protected] ORCID iD: 0000-0002-3494-3539 Hanna Wallberg, M.D.Specialist physician in Anesthesia and Intensive Care. Program director for undergraduate and postgraduate medical education, NU hospital group. ORCID iD: 0009-0009-3387-3370 Helena Vallo Hult Ph.D. Assistant Professor in Informatics with specialization in Work-Integrated Learning at University West, and Development Leader at NU Hospital Group ORCID iD: 0000-0002-0493-8974 Affiliation Region Västra Götaland, NU-hospital group, Department of Education, Trollhättan, Sweden School of Business, Economics and IT, Department of Informatics, University West, Trollhättan, Sweden References Feng H, Luo Z, Wu Z, Li X. Effectiveness of Peer-Assisted Learning in health professional education: a scoping review of systematic reviews. BMC Med Educ. 2024;24(1):1467. Topping KJ. The Effectiveness of Peer Tutoring in Further and Higher Education: A Typology and Review of the Literature. High Educ. 1996;32(3):321–45. Pintér Z, Kardos D, Varga P, Kopjár E, Kovács A, Than P, et al. Effectivity of near-peer teaching in training of basic surgical skills – a randomized controlled trial. BMC Med Educ. 2021;21(1):156. Stigmar M. 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Supplementary Files Table1Respondents.pdf Table2ResultsThemes.pdf Appendix1InterviewGuide.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 13 Apr, 2026 Reviews received at journal 03 Mar, 2026 Reviews received at journal 24 Feb, 2026 Reviews received at journal 12 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviewers agreed at journal 10 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers invited by journal 29 Jan, 2026 Editor assigned by journal 19 Nov, 2025 Submission checks completed at journal 19 Nov, 2025 First submitted to journal 08 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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PAL is defined as when individuals belonging to the same social group help each other to learn by teaching themselves, even though they are not trained professional educators (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). As for NPT, the widely agreed upon definition is a form of peer-education where the teacher is performing the same training as the student, but being at least one year ahead (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Near-peer teaching programs (NPTPs) have been acknowledged across various academic disciplines (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and have been proven to benefit both learners and those in teaching roles. Reported benefits for the tutors include consolidation of subject knowledge and clinical skills, development of communication and feedback competencies, improved organizational and planning abilities, and an enhanced understanding of educational theory and pedagogy. In addition, participation in NPTPs appears to cultivate positive attitudes toward teaching and may encourage future engagement in medical education (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eQuality clinical education is crucial for maintaining medical training (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Even though there is a high level of motivation to teach among doctors (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), many health care systems still face challenges in recruiting and supporting clinicians as teachers (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Reported barriers include a high level of clinical workload, lack of allocated time for teaching and lastly, the lack of formal pedagogical training, which seems to contribute to the ambivalent attitude toward teaching duties (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFollowing the increasing interest in near-peer teaching programs in medical education, there has been a growing body of literature exploring the perspectives of senior medical students being tutors (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), including from Sweden (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Yet, the data on the experience of junior doctors enrolled in such NPTPs within clinical settings is limited to a few studies (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Moreover, faculty development tends to focus on residents (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Interns, however, tend to work on different clinics within a hospital and are usually involved in teaching medical students and peers (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Despite this, little is known about how structured pedagogical initiatives during internship shape teaching skills, professional identity, and opportunities for educational engagement.\u003c/p\u003e \u003cp\u003eIn this study, our aim was to explore how junior doctors who had participated in a pedagogical internship track experienced their development of teaching skills, professional identity and how they experienced the program.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting\u003c/h2\u003e \u003cp\u003eMedical education in Sweden leading to an MD degree is provided at seven independent universities (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Since the fall of 2021 the curriculum is comprised of six years leading to a medical license upon graduation (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, the previous curriculum considted of five and ahalf years, followed by a mandatory, structured clinical internship ranging from a minimum of 18 months up to 24 months \u0026ndash; Allm\u0026auml;ntj\u0026auml;nstg\u0026ouml;ring (AT) \u0026ndash; before being authorized to apply for a medical license from the National Board of Health and Welfare. During this internship, the junior doctor serves a minimum of 3 months within internal medicine and surgical specialties respectively (but a combined minimum of 9 months), 3 months in psychiatry and 6 months in primary care. Thus, AT serves as a transitional phase between undergraduate education and residency (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The study setting is a regional, non-university hospital in Western Sweden, affiliated with the University of Gothenburg, where a voluntary pedagogical track within the internship program was introduced in the fall of 2018, designed as a NPT program. The purpose of the program was to engage junior doctors with a documented interest in teaching and education to supervise medical students during their clinical rotations. Each year, up to eight candidates with an interest in and merit for teaching are accepted into the program. The pedagogical internship track includes formal coursework in pedagogical skills and feedback, participation in simulation-based teaching activities, and opportunities to supervise both peers and medical students in clinical settings. In this way, the program incorporates elements of both peer-assisted learning and near-peer teaching, allowing participants to develop educational skills across different learner levels.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRespondents and recruitment\u003c/h3\u003e\n\u003cp\u003eAll 17 doctors who had completed the pedagogical internship track since its launch in 2018 were invited to participate in the study. They had been enrolled in the program between 2018 and 2024. Current participants were not invited, partly because the interviewer was enrolled in the same program at the time, and partly to allow reflections on how the pedagogical internship track had influenced subsequent career choices. Restricting inclusion to former participants also ensured that no personal or collegial relationship existed between the interviewer and respondents.\u003c/p\u003e \u003cp\u003eA total of ten former participants agreed to take part in the study, six females and four males. Participants ranged in age from 29 to 46 years, and all had graduated from Swedish medical programs. At the time of the interviews, they were working within various medical specialties, as summarized in Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003e Written and oral study information was provided to all respondents prior to the interviews, and all gave informed consent. The information included background to the study, study procedures, and details regarding the handling of personal data.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eA semi-structured interview guide was developed by the authors to explore respondents\u0026rsquo; demographic background, current clinical roles and teaching responsibilities, experiences from the pedagogical internship track (including strengths and challenges), and their perspectives on peer- and near-peer teaching. The interview guide was piloted among current participants and underwent minor revisions (Appendix 1).\u003c/p\u003e \u003cp\u003eAll interviews were conducted by the first author between 17 October and 13 December 2024. Eight interviews were conducted online, via Microsoft Teams (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), while two were held in person at the hospital. All interviews were audio-recorded, using the Teams recording function. Interviews were carried out in Swedish, following the guide in a conversational style, with probing questions used to deepen and clarify responses. The duration of interviews ranged from 28 to 58 minutes. Data saturation was deemed to have been reached when no new themes emerged in later interviews.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eThe interviews were transcribed verbatim. Only the first author and the transcriber had access to the recordings, which were deleted after transcription. Transcripts were pseudoanonymized prior to analysis. A full anonymization was not possible as the first author conducted the interviews.\u003c/p\u003e \u003cp\u003eQualitative content analysis was performed in accordance with Graneheim and Lundman (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). All authors initially read the transcripts several times to familiarize themselves with the material and ensure immersion in the data. Meaning units were identified, condensed, and coded. Codes were then grouped into subthemes and, through iterative discussions between the authors, further refined into overarching themes. Quotations have been translated from Swedish to English by the authors. Minor linguistic adjustments were made to improve readability while preserving core meaning.\u003c/p\u003e \u003cp\u003eTo enhance credibility, respondent validation was conducted after all interviews had been conducted and analyzed. A summary of the thematic framework was sent to participants, who confirmed that the findings reflected their experiences.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThree prevailing themes emerged from the qualitative analysis: Building a Pedagogical Toolbox, Establishing Professional Legitimacy and Becoming a Clinical Teacher. Each theme is described in detail below, with illustrative quotes from the interviews (see Table\u0026nbsp;2 for a summary of themes and subthemes).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Building a pedagogical toolbox\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eAcquiring formal and practical education on medical simulations and feedback methods\u003c/h2\u003e \u003cp\u003eThe opportunity to obtain formal and practical education on how to conduct medical simulations, along with theories underlying clinical supervision and feedback, was depicted as highly beneficial and educational. Several participants expressed their appreciation to the fact that they took formal coursework required at residency level, which in turn equipped them with tools to engage in their teaching activities and, importantly, to adopt a pedagogical approach even outside formal teaching contexts\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Both the basic pedagogical course and the simulation instructor course give you a lot of tools to use when supervising and it feels like you can put more thought into it, even if you have a stressful everyday life. I think you got a lot of tips and tricks on how to think and how to do things\u0026hellip; and I think that you have a baseline of a pedagogical mindset during your workday\u0026rdquo;\u003c/em\u003e (Respondent 1).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Having read extensively and received education in pedagogy and clinical supervision facilitates my daily clinical work.\u0026rdquo;\u003c/em\u003e (Respondent 10)\u003c/p\u003e \u003cp\u003e Overall, receiving formal and practical training in medical simulation, leadership and feedback was perceived as a positive aspect of the pedagogical internship track, enhancing the participants' teaching abilities not only confined to formal teaching missions, but also to everyday, clinical practice.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eEmphasizing feedback\u003c/h3\u003e\n\u003cp\u003e Participation in the pedagogical internship track and the appurtenant teaching missions required the interns to regularly provide feedback to medical students and colleagues. Respondents described that this repeated practice not only improved their ability to deliver constructive feedback but also made them more available to receive feedback themselves. Several highlighted that they had become substantially more effective and confident in using feedback as a pedagogical tool.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo; Well, I would say above all that I\u0026rsquo;ve become much better at giving feedback \u0026ndash; really, much better. I would say that is the most clearly tangible thing I have improved after the program.\u0026rdquo;\u003c/em\u003e (Respondent 5).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"If you practice how to give feedback, you also understand how to receive feedback when you need it, and then you make yourself more available. I feel that you learn so much more if you open yourself up to feedback\"\u003c/em\u003e (Respondent 3)\u003c/p\u003e \u003cp\u003e Developing feedback skills was described as a highly important and empowering aspect of the pedagogical internship track, improving the participants' openness to receiving feedback in their own careers and future roles as resident doctors and clinical educators.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOrchestrating teaching events and activities on a logistical level\u003c/h2\u003e \u003cp\u003eHaving the responsibility for different teaching activities within the hospital incentivized the participants to develop their ability to coordinate different logistical components, including booking lecture halls and finding suitable patients for the medical students to talk to.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"What I have learned is a little bit about planning, how to plan and organize, partly a lecture and partly how to plan an educational day.\"\u003c/em\u003e (Respondent 6)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It was about booking it (student room) and then going around looking for these patients myself\u0026rdquo;\u003c/em\u003e (Respondent 2)\u003c/p\u003e \u003cp\u003eNevertheless, several respondents hinted to the fact that these secondary tasks were excessive and time-consuming.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"In our case there was so much booking of student rooms and booking, i.e. administration all around.\"\u003c/em\u003e (Respondent 3)\u003c/p\u003e \u003cp\u003e Taken together, taking responsibility for the organization of different teaching activities enabled participants to develop valuable logistical skills, essential to work as clinical supervisors, although some of these tasks were perceived as time-consuming and administratively burdensome.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Establishing professional legitimacy\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003ePossibility to have influence\u003c/h2\u003e \u003cp\u003eRespondents emphasized the value of shaping both their own learning and the educational environment for their colleagues. Acting as pedagogical intern doctors allowed them to influence what and how other junior doctors learned, for example, by selecting scenarios and planning simulation days. This responsibility fostered engagement, ownership, and a sense of professional legitimacy, as they contributed directly to shaping the internship experience for their peers.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The strength during this time was that I got to reflect and be involved in shaping my own internship. Since I participated, I could influence how the other intern doctors experienced these simulation days. I chose scenarios based on what I felt I needed to learn more about.\u0026rdquo;\u003c/em\u003e (Respondent 4).\u003c/p\u003e \u003cp\u003eHaving the possibility to influence both personal learning and the learning conditions of colleagues enhanced participants\u0026rsquo; professional agency and legitimacy, highlighting their role as active contributors to the broader educational environment within the medical internship.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePedagogical experience as career advantage\u003c/h2\u003e \u003cp\u003eParticipants described pedagogical experience gained during the pedagogical internship track as an asset for their future careers. Being involved in teaching activities and formal pedagogical training was perceived to enhance their professional profile. Several participants highlighted that this experience gave them credibility in pedagogical contexts and was seen as an advantage when applying for residency positions.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It should really be said, I also think you will notice later when applying for jobs that it is a major merit, and everyone thinks, I mean, it sounds very good to know about pedagogy\u0026hellip; people are very interested and curious, and it allows you to stand out in a way that is very advantageous\u0026rdquo;\u003c/em\u003e (Respondent 5).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is definitely seen as a merit when applying for jobs\u0026hellip;\u0026rdquo;\u003c/em\u003e (Respondent 4).\u003c/p\u003e \u003cp\u003eIn summary, Pedagogical experience during the medical internship was seen as a career-enhancing advantage, providing professional credibility in teaching situations, perceived as a way to help respondents distinguish themselves from peers in the job -market.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eGroup credibility\u003c/h2\u003e \u003cp\u003eParticipants highlighted that being part of a pedagogical group contributed to their credibility and legitimacy within the hospital setting and among peers. Belonging to a designated and structured team, supported by experienced supervisors being their employer, provided a \u0026ldquo;stamp of approval\u0026rdquo; that made it easier to initiate projects and be taken seriously by colleagues. Being in a group also facilitated mutual learning, inspiration, and professional development, as members could support and motivate each other.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I mean, our strength was that we were pedagogical and had, like, [name of chief of internship and head program director] behind us, and I think that is important. I think it is harder to just randomly start a project without some form of approval from someone.\u0026rdquo;\u003c/em\u003e (Respondent 1).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think the strengths have also been that you are in a group, that you can develop, and you can get a bit of inspiration from each other.\u0026rdquo;\u003c/em\u003e (Respondent 7).\u003c/p\u003e \u003cp\u003e Overall, being part of a pedagogical group enhanced participants\u0026rsquo; credibility and confidence, while also providing opportunities for mutual support and professional growth.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eHaving a local contact network within the hospital orworkplace\u003c/h2\u003e \u003cp\u003eThe respondents, being former participants, emphasized the value of building a local professional network within the hospital. Engaging in pedagogical activities allowed them to establish connections with other supervisors and colleagues, providing both guidance and potential future support. Knowing key individuals personally, and having the opportunity to interact with them, were perceived as enhancing professional confidence and easing future collaboration. Establishing these contacts was also described as enjoyable and educational, contributing to both personal and professional development.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You get a very good foundation if you are interested in pedagogy and leadership, especially if you stay within the same hospital. You have contacts, you know, like [name of chief of internship and head program director], you know who they are and can email them, and hopefully they remember your name. That alone makes a big difference, I think\u0026rdquo;\u003c/em\u003e (Respondent 2).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You make contacts in this way, and it was very nice, fun, and educational.\u0026rdquo;\u003c/em\u003e (Respondent 4).\u003c/p\u003e \u003cp\u003eThus, participating in pedagogical activities provided participants with a valuable local contact network, enhancing both professional confidence and opportunities for future collaboration within the hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Becoming a clinical teacher\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eGrowing confidence as a clinical teacher\u003c/h2\u003e \u003cp\u003eRespondents described how involvement in the pedagogical internship track program increased their confidence and sense of credibility as clinical teachers. Being actively engaged in teaching tasks allowed them to gain experience, build expertise, and feel prepared for future pedagogical responsibilities. Several participants emphasized that early involvement provided both practical skills and legitimacy in educational matters, making them feel more capable of taking on formal teaching roles.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I probably wouldn\u0026rsquo;t have felt ready to become a program director (for current intern doctors) if I hadn\u0026rsquo;t already been somewhat involved myself as an intern doctor in these matters.\u0026rdquo;\u003c/em\u003e (Respondent 9).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think it gives credibility in pedagogical matters.\u0026rdquo;\u003c/em\u003e (Respondent 3).\u003c/p\u003e \u003cp\u003eOverall, participation in pedagogical activities during the internship seems to have fostered confidence and credibility as clinical teachers, supporting participants\u0026rsquo; readiness to assume teaching responsibilities in the future.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eDeveloping a culture of peer teaching and learning\u003c/h2\u003e \u003cp\u003eParticipants emphasized that the near-peer structure of pedagogical internship track facilitated effective teaching and learning among junior doctors. Working closely with colleagues at similar stages of training made it easier to understand each other\u0026rsquo;s perspectives, anticipate learning needs, and provide relevant, relatable feedback. This near-peer approach fostered a supportive and psychologically safe learning environment, enhancing both engagement and learning outcomes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Being relatively close to each other academically and career-wise makes it easier to understand how the other person thinks and reasons; it can be harder if you have been a consultant for 30 years to sense the medical student\u0026rsquo;s needs\u0026rdquo;\u003c/em\u003e (Respondent 9).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is a higher level of openness when doing peer-assisted learning; people are more humble about what they know and don\u0026rsquo;t know, and being in a safe group makes learning much more effective. You can see it with the students\u0026mdash;those at the same level, friends, feeling safe to admit \u0026lsquo;I might not know this, you know it better,\u0026rsquo; it creates a much better working environment\u0026rdquo;\u003c/em\u003e (Respondent 4).\u003c/p\u003e \u003cp\u003eUltimately, this near-peer teaching was seen as a way to strengthen both learning and professional collaboration, empowering participants to shape a supportive and responsive educational environment for their colleagues.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eTaking on new roles as clinical teachers\u003c/h2\u003e \u003cp\u003eAs former participants, the respondents emphasized that the pedagogical skills gained during the pedagogical internship track had a lasting impact, enabling them to assume diverse educational roles after the program. In their subsequent positions as residents, they became actively involved in supervising medical students, mentoring new interns, and, in some cases, even taking on leadership roles such as program directors. Although these responsibilities were often demanding, they felt well-prepared and reassured by the pedagogical foundation established during their internship.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I am solely responsible for [the medical students\u0026rsquo;] education Monday to Friday full days, which is very tough but also very fun. I have faced many challenges in this, but it feels reassuring to have had a lot of pedagogical training behind me.\u0026rdquo;\u003c/em\u003e (Respondent 4).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have had the clinical consultation skills course at the clinic, and with the new medical program (in Sweden), I have now had the same group two semesters in a row.\u0026rdquo;\u003c/em\u003e (Respondent 3).\u003c/p\u003e \u003cp\u003e These accounts illustrate how the near-peer teaching experiences during the internship were perceived to create long-lasting pedagogical engagement, with participants continuing to contribute actively as clinical teachers in their new positions as residents.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this study was to explore how junior doctors participating in a pedagogical internship track experienced thedevelopment of their teaching skills and professional identity, as well as how they perceived the program to have influenced their professional development. Our findings demonstrate that participation in the pedagogical internship track supported the development of a pedagogical toolbox, mainly improved feedback skills; fostered a sense of professional legitimacy during their time as intern junior doctors; and lastly contributed to the development of an identity of clinical educators, which participants carried into their subsequent roles as resident doctors.\u003c/p\u003e \u003cp\u003eSeveral studies have documented the benefits of NPTPs in medical education, although most have focused on the undergraduate level (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). While some reports describe advantages for junior doctors, such as enhanced teaching ability, professional development, and improved knowledge and skills, few have addressed the internship period immediately following graduation. Our findings extend the existing literature by showing that structured NPTPs during internship can support both pedagogical skills and identity formation. This was particularly evident in themes one and three of our study, where participants highlighted feedback as a core competence and described a growing confidence as clinical teachers. The pedagogical internship track can also be understood as a faculty development initiative, aligning with several of the key features described by Steinert and colleagues (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), including experiential learning, relevant and applicable content, opportunities for feedback, intentional community building, and strong institutional support. Importantly, our findings resonate with established faculty development models that emphasize not only the acquisition of teaching skills and confidence but also professional identity formation, community building, and sustained engagement in educational roles.\u003c/p\u003e \u003cp\u003eThe outcomes illustrate well-documented benefits of faculty development programs, including enhanced credibility, legitimacy, and local networks within the workplace. We interpret these findings as evidence that the pedagogical internship track contributed to the development of a collaborative learning environment within the hospital, characterized by a strong sense of belonging, which facilitated future teaching initiatives as participants advanced to residency. O\u0026rsquo;Sullivan and Irby (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) distinguish between communities of practice that develop among program participants and those that manifest within the workplace. While the former is perhaps expected, our findings suggest that the pedagogical internship track also had a broader institutional impact. As interns rotate through multiple hospital departments, they can disseminate a \u0026ldquo;pedagogical culture,\u0026rdquo; as one respondent expressed it, thereby normalizing teaching and learning as valued professional activities. Such a culture may help strengthen the educational mission of the hospital.\u003c/p\u003e \u003cp\u003eMedical educators are essential for sustaining the medical profession, as they play a central role in teaching medical students, junior doctors, residents, and in supporting continuing professional development (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Although many physicians express strong motivation to teach, multiple challenges, including increasing clinical workload and limited protected time for education restrict their ability to engage in teaching. Estimates suggest that as few as 10% of clinicians can teach within their allocated time (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). One way to address these discrepancies is through faculty development initiatives for early-career doctors. Programs such as a pedagogical internship track strengthen participants\u0026rsquo; professional profiles and encourage them to assume new roles as clinical educators, as illustrated by theme three of our study.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eImplications for practice\u003c/h2\u003e \u003cp\u003eOur findings suggest that structured near-peer teaching programs for junior doctors can have several practical implications. Although this program was developed within the Swedish internship system, the core elements of structured teaching opportunities, pedagogical training, and institutional support are transferable to other contexts and may help address the global shortage of clinical teachers (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). By equipping junior doctors with skills and confidence, such programs not only strengthen their professional development but also enhance the supervision and feedback provided to medical students and peers, thereby improving the quality of clinical learning environments. Importantly, as emphasized in previous research (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), sustained success requires strong institutional and organizational support. Several of our respondents likewise identified the need to optimize the administrative support system for participants as an area for improvement. In addition, initiatives such as the pedagogical faculty development program described in this study may be particularly valuable in non-university hospitals, where pedagogical infrastructures are often less developed (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Embedding early faculty development tracks in these settings could help build a stronger teaching culture and ensure that clinical education remains a prioritized mission. Integrating programs like a pedagogical internship track into postgraduate training, while ensuring adequate organizational infrastructure, thus represents a sustainable strategy for health care systems that aligns workforce development with the educational mission of hospitals.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThe strength of the current qualitative study lies in the inclusion of all former participants of the pedagogical internship track since its launch in 2018 with a good overall response rate. Furthermore, we performed respondent validation to ensure response credibility\u003c/p\u003e \u003cp\u003eWhile the qualitative approach provided a valuable, in-depth, and contextualized understanding, future research could expand on our findings by including other roles or professions, such as nurses, multiple institutions, comparative studies of similar programs, or quantitative evaluation to enable broader generalization. The imitations, of this study also include its time-consuming character and the inherent risk for research bias (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Furthermore, we investigated only the single perspective of former participants and did not include current interns. Finally, since the interviews were held in Swedish and later translated to English, we may risk potential loss of nuance.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNear-peer teaching and its application as near-peer teaching programs have long been recognized within the field of medical education although relatively few studies have explored and evaluated such programs intended f\u0026ouml;r junior doctors. In line with recommendations from the field, this study evaluated, an ongoing near-peer teaching program (NPTP) for junior doctors in Western Sweden. Our findings demonstrate that the program supported the development of pedagogical skills, fostered professional legitimacy, and contributed to the formation of a clinical teacher identity among participants. These outcomes suggest that structured NPTPs can serve as an early form of faculty development, encouraging junior doctors to take on educational roles from the beginning of their careers. By strengthening teaching capacity during internship, programs like the one discussed in this article may help address the ongoing shortage of clinical educators and foster a stronger pedagogical culture within healthcare. Future research could explore long-term impacts on both participants and the students they supervise, as well as the transferability of this model to other settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eWe would like to express our great gratitude to all the respondents contributing to this study. Furthermore, we want to thank all the former and current interns of the pedagogical internship track.\u003c/p\u003e\n\u003cp\u003eWe are grateful to Nina Dereban for her valuable help and insights regarding the design and layout of the results tables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eTR, PP, HVH and HW contributed jointly to the design and implementation of the study. TR conducted the interviews. All the authors contributed to the analysis of the results and the writing of the manuscript. All authors reviewed the finished manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eNo funding was obtained for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eThe dataset from the study is available from the corresponding author upon reasonable request.\u003cstrong\u003e\u003cem\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eThe study protocol was reviewed by the Swedish Ethical Review Authority, Reference number 2024-04470-01. The Authority determined that the study did not involve any intervention or processing of sensitive personal data falling under the Swedish Act concerning the Ethical Review of Research Involving Humans and therefore did not require formal ethical approval. In an advisory opinion, the Authority raised no objections to the conduct of the study. The research was conducted in accordance with the principles of the Declaration of Helsinki. All participants received both written and oral information about the study and provided informed consent prior to participation. Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eThe authors have no conflicting interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003cstrong\u003eThomas Ramo,\u0026nbsp;\u003c/strong\u003eM.D. Intern junior doctor and current participant in pedagogical internship track.\u0026nbsp;\u003cbr\u003e\u0026nbsp;E-mail: [email protected]\u0026nbsp;\u003cbr\u003e\u0026nbsp;ORCID iD: 0009-0003-4346-8674\u003cbr\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Paul P\u0026aring;lsson\u0026nbsp;\u003c/strong\u003e(corresponding author)\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003eM.D.Senior consultant in Anesthesia and Intensive Care, MSc in Medical Education. Program director for undergraduate and postgraduate medical education, NU hospital group.\u0026nbsp;\u003cbr\u003e E-mail: [email protected]\u0026nbsp;\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eORCID iD: 0000-0002-3494-3539\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHanna Wallberg,\u0026nbsp;\u003c/strong\u003eM.D.Specialist physician in Anesthesia and Intensive Care. Program director for undergraduate and postgraduate medical education, NU hospital group.\u003c/p\u003e\n\u003cp\u003eORCID iD: 0009-0009-3387-3370\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Helena Vallo Hult\u0026nbsp;\u003c/strong\u003ePh.D.\u0026nbsp;Assistant Professor in Informatics with specialization in Work-Integrated Learning at University West, and Development Leader at NU Hospital Group\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eORCID iD: 0000-0002-0493-8974\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAffiliation\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eRegion V\u0026auml;stra G\u0026ouml;taland, NU-hospital group, Department of Education, Trollh\u0026auml;ttan, Sweden\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSchool of Business, Economics and IT, Department of Informatics, University West, Trollh\u0026auml;ttan, Sweden\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFeng H, Luo Z, Wu Z, Li X. 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Med Teach. 2011;33(10):798\u0026ndash;803.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eP\u0026aring;lsson P, Cederborg A, Johansson M, Hult HV, Naredi S, Jood K. Clinical supervisors\u0026rsquo; experience of a first-time application of entrustable professional activities in clinical supervision of medical students: findings from a Swedish pilot study. BMC Med Educ. 2024;24(1):297.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLegitimation [Internet]. 2023 [cited 2025 Sept 6]. Medical internships (AT) in Sweden. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://legitimation.socialstyrelsen.se/en/medical-internships-at-in-sweden/\u003c/span\u003e\u003cspan address=\"https://legitimation.socialstyrelsen.se/en/medical-internships-at-in-sweden/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMicrosoft, Teams. Microsoft.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOʼSullivan PS, Irby DM. Reframing Research on Faculty Development. Acad Med. 2011;86(4):421\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGonz\u0026aacute;lez-Amarante P, Romero-Padr\u0026oacute;n MA. Motivations for a career in teaching: medical students\u0026rsquo; projections towards their future role. BMC Med Educ. 2025;25(1):117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQureshi Z, Gibson K, Ross M, Maxwell S. Perceived tutor benefits of teaching near peers: insights from two near peer teaching programmes in South East Scotland. Scott Med J. 2013;58(3):188\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuganlinskaya N, Detterline S, Fargahi F. Exploring faculty development opportunities and strategies in departments of medicine of U.S. community-based teaching hospitals. J Community Hosp Intern Med Perspect. 2019 Sept;9(3):410\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraneheim UH, Lindgren BM, Lundman B. Methodological challenges in qualitative content analysis: A discussion paper. Nurse Educ Today. 2017 Sept;56:29\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neer peer teaching, PAL, Peer-assisted learning, Health Professional Education, Faculty Development","lastPublishedDoi":"10.21203/rs.3.rs-8062096/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8062096/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Near-peer teaching (NPT) and structured near-peer teaching programs (NPTPs) have been recognized as valuable approaches in medical education, yet relatively few studies have explored programs designed specifically for junior doctors. In response to a local shortage of clinical supervisors and educators at a non-university teaching hospital in Western Sweden, a voluntary pedagogical faculty development program was launched in 2018 as a part of the mandatory medical internship. The program engaged junior doctors with a documented interest in education to supervise medical students and peers. From the outset, the program was intended not only as a teaching initiative but also as an early form of faculty development, aiming to strengthen participants\u0026rsquo; pedagogical skills and professional identity. This study aimed to explore how junior doctors participating in a pedagogical internship track experienced the development of their teaching skills and professional identity, as well as their experience of the program.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative study of the pedagogical internship track using semi-structured interviews with ten former participants, enrolled between 2018 and 2024. Interviews explored their experiences of the program and its influence on subsequent professional roles. Data were analyzed using qualitative content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree main themes were found: Support the development of a pedagogical toolbox, particularly in relation to feedback skills; to foster a sense of professional legitimacy during internship; and to contribute to the formation of an identity as clinical educators, carried into subsequent residency training. Participants also described that the program helped establish a broader pedagogical culture within the hospital.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFindings from this study suggest that structured near-peer teaching programs for junior doctors strengthen teaching skills, enhance professional identity, and promote continued engagement in clinical education. By embedding such programs within internship training, hospitals may not only support individual development but also foster a sustainable pedagogical culture.\u003c/p\u003e","manuscriptTitle":"Developing Early-Career Clinical Educators – A Qualitative Study of a Pedagogical Internship Track for Junior Doctors in Sweden ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 19:01:45","doi":"10.21203/rs.3.rs-8062096/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-13T16:14:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T02:56:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-24T08:08:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T03:35:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140514684306201134395062628996001728396","date":"2026-02-11T10:53:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38212900727233005201885477604506951983","date":"2026-02-11T09:36:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122763854586903376084394030663002004981","date":"2026-02-11T09:04:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206312847847813253915639542980175421020","date":"2026-02-10T08:00:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111362090064940771218702439758230277263","date":"2026-02-09T10:25:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T11:47:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-19T07:19:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-19T07:16:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-11-08T07:07:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3a0bce60-1636-40a1-b9f0-51576c9bcc44","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T11:38:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-02 19:01:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8062096","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8062096","identity":"rs-8062096","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}