This prospective controlled pre–post pilot study explored whether structured peer-evaluation training was associated with changes in clinical skills performance, observed professional behavior, and peer-assessment alignment among fourth-semester medical students. The peer-evaluation intervention was associated with statistically significant within-group improvements in faculty-assessed professional behavior and physical examination performance from pre-test to post-test. In contrast, the control group showed smaller, statistically non-significant changes. However, between-group comparisons of change scores were not statistically significant. Therefore, the findings should be interpreted as preliminary and hypothesis-generating rather than as definitive evidence of intervention effectiveness.

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The favorable trends observed within the experimental group are consistent with the broader educational rationale for peer assessment as a formative learning strategy. Structured peer evaluation requires students to actively observe performance, compare observed behaviors with explicit criteria, and provide feedback to colleagues. These processes may promote feedback literacy, self-regulated learning, and evaluative judgment, particularly when peer assessment is implemented using structured criteria and guided training. 8,9 In the present study, students in the experimental group were exposed not only to faculty assessment but also to peer-evaluation activities, which may have encouraged closer attention to checklist criteria and observable clinical behaviors.

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The favorable trend in faculty-assessed professional behavior is particularly relevant. Professional behavior in this study was assessed through observable actions, including communication clarity, permission-seeking, appropriate positioning, active listening, respectful interaction, avoidance of unnecessary patient discomfort, and maintenance of a calm and empathetic demeanor. These behaviors are visible during clinical encounters and may therefore be especially suitable for peer observation and feedback. Previous work has suggested that peer assessment may be useful in professionalism-related domains because peers can provide complementary perspectives on behaviors observed during educational activities. 10 However, professionalism assessment remains methodologically challenging because definitions, tools, and assessment approaches vary across medical education contexts. 11 Accordingly, the present findings support the feasibility of structured observation of professional behavior but do not validate the checklist as a comprehensive instrument for assessing professionalism.

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Faculty-assessed physical examination performance also improved in the experimental group from the midterm to the final OSCE. In this study design, the midterm OSCE served not only as a baseline assessment but also as a formative checkpoint, allowing students to receive feedback and identify areas for improvement before the final examination. Therefore, the observed improvement may reflect the educational value of intermediate feedback, checklist-guided peer observation, and opportunities for students to reflect on expected examination sequences and performance standards. Acting as a peer evaluator may have shifted students from passive participation to active analytical observation, helping them recognize both correct performance and common omissions and apply these insights to subsequent clinical skills performance. However, this interpretation should be approached with caution because the midterm and final OSCEs assessed different clinical stations. As a result, improvement may also reflect normal course progression, increased OSCE familiarity, differences in station difficulty, or repeated exposure to assessment criteria in addition to the peer-evaluation intervention.

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The peer-instructor comparison adds an important layer to the interpretation. After training, peer ratings of professional behavior showed a strong positive association with instructor ratings, suggesting that students may be able to judge observable professional behaviors more accurately after structured guidance and supervised peer-evaluation practice. This finding is consistent with previous work indicating that peer and near-peer feedback can be educationally valuable when students are prepared for the feedback role and when the process is structured and supportive. 12,13 In contrast, peer ratings of physical examination performance remained weakly correlated with instructor ratings. This contrast suggests that professional behavior, because it includes visible interpersonal and communication behaviors, may be more accessible to student raters than technical procedural performance, which requires procedural knowledge, correct sequencing, clinical accuracy, and recognition of missed examination steps.

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These findings highlight the importance of structured feedback training before implementing peer evaluation. The intervention introduced feedback principles and structured models, including the Situation-Behavior-Impact and feedback sandwich models. This aligns with recommendations that peer assessment should not be implemented as an informal activity; students need explicit preparation in how to observe, judge, phrase, and deliver feedback constructively. 14 Feedback literacy is increasingly recognized as an important component of health professions education because students need to understand, interpret, and use feedback for improvement. 15 In the present study, structured training may have contributed to improved peer calibration in the professional behavior domain, although the study design does not allow this mechanism to be confirmed.

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From a practical perspective, structured peer evaluation may offer an additional supervised formative learning opportunity in settings where faculty time and assessment resources are limited. Recent work on peer-feedback tools in clinical skills education has emphasized the potential scalability of structured peer feedback while also noting concerns about validity, variable engagement, and the need for supervision. 16 In the present study, peer scores did not affect official grades and were used only for educational and research purposes. This was appropriate given the pilot nature of the study and the limited evidence regarding the reliability of peer assessment, particularly for technical clinical skills.

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Limitations

Several limitations should be acknowledged. First, the sample size was small, which limited statistical power and increased the risk of unstable estimates. Second, students were allocated to existing tutorial groups rather than randomized individually, which may have introduced selection bias. Third, the experimental group had higher baseline scores than the control group, limiting causal interpretation of post-test differences. Therefore, the observed within-group improvements in the experimental group should be interpreted cautiously, and the findings should be considered preliminary. In addition, baseline demographic and educational characteristics were not collected, limiting the ability to assess baseline comparability between groups. Fourth, although the quality of peer feedback was assessed using a structured checklist, formal psychometric validation of the tool was not conducted. Finally, the study was conducted at a single institution, limiting generalizability.

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Strengths and future directions

Despite these limitations, the study has several strengths. It used a prospective pre-post design with a comparison group, incorporated structured peer-feedback training, used checklist-based assessment, separated faculty assessment from peer assessment, and examined both student performance and peer-assessment alignment. The study also included practical safeguards such as anonymized coding, non-friend peer assignment, faculty supervision, and non-summative use of peer scores. These features support the feasibility of implementing structured peer evaluation as a supervised formative activity in undergraduate clinical skills education.

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Future studies should include larger samples, randomized or matched group allocation where feasible, and comparable OSCE stations across pre- and post-assessments. Future research should also include formal peer-rater calibration, multiple faculty raters, inter-rater reliability analysis, and validation of peer-feedback quality tools. Qualitative analysis of written or oral peer feedback comments would also be valuable for examining whether students' feedback becomes more specific, constructive, balanced, and behavior-focused after training. Repeated peer-evaluation activities across several semesters may provide stronger evidence on whether peer assessment contributes to sustained development of clinical skills, professional behavior, and evaluative judgment.