Should medical students be examined by each other, or by Faculty?

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A few years ago, with Lynel Jackson’s capable assistance, I established a confidential portal on MedTech which allows students to submit commentary to me in a completely anonymous fashion.  Over the years, it’s proven to be a remarkably effective means for students to articulate concerns that are of a sensitive nature or which, for a variety of reasons, they are reluctant to express in person.  It has provided insights into issues which I’m sure would not have otherwise come to attention or, if they had, would have done so in much less effective ways.  One such issue was raised recently which has caused me to reflect and led to some conversations which I thought should be extended to the wider faculty and student body.  To quote our anonymous student:

“I have feedback regarding students being required to practice on each other in formal clinical skills sessions, such as the peripheral nerve exam the 2017s are learning tomorrow. This also relates to random students being called up to volunteer for clinical skills demonstrations in front of the class. This can (and has) caused exposure of students’ own medical problems. In one case this year a student’s disability was somewhat unwittingly revealed in front of all of the class of 2017. Some students are uncomfortable with/unable to comply with this for religious reasons. Others, such as myself, get anxious at the thought of potentially having private medical info disclosed in a public forum.”

I, like many of our teaching faculty, came through a medical school experience where “practicing” aspects of the physical examination on classmates was common practice and, in some instances, became informally incorporated into the curriculum.  It was also common practice for faculty to ask for student “volunteers” to demonstrate various aspects of the physical examination for small groups or even the class.  I’ve certainly been guilty of this in demonstrating the approach to cardiac examination and auscultation.  Over the years, our Clinical Skills program has placed boundaries on the peer-to-peer examination, limiting it to head, cranial nerves and peripheral limbs.  This has been in an attempt to avoid any potential embarrassment that might arise from exposure to even the abdomen and male thorax.

The note above, together with a brief review of the literature, would suggest attitudes are changing and deserve reconsideration, for a number of reasons:

  1. Students may have medical conditions, scars, or deformities they do not wish to reveal and do not wish exposed.
  2. Students may have personal or religious objection to exposure or touching
  3. Students may simply be shy or self-conscious about such contact

Although it’s easy to say that students can excuse themselves from such activities, doing so may be difficult for many and, in itself, essentially “expose” a concern.  This raises the issue of peer pressure to comply with the majority attitude of the group, and further raises the real concern as to whether faculty may be exerting a subtle form of coercion by even making a request.  We therefore seem to be confronted with an issue that affects a distinct minority of any class, but in a potentially very profound way that therefore deserves our attention.

To engage such an issue, I’ve found it’s always helpful to consult the students themselves early in the process and, wherever possible, involve them in developing solutions.  I therefore turned to Elizabeth Clement (Meds 2016), who is Vice-President (Academic) of the Aesculapian Society and student representative to our Curriculum Committee.  Liz engaged this with characteristic thoughtfulness and enthusiasm, reviewing the literature, conducting a student survey, and presenting this information in the form of a Briefing Note to the Curriculum Committee for consideration.  That note, in its entirety, is as follows:

Clinical and Communication Skills: peer teaching of the physical exam

Issue:

Recently, some Queen’s medical students have communicated their discomfort with respect to physical examination of peers or being examined by peers in clinical skills sessions. Reasons for discomfort include but are not limited to religious and cultural customs as well as gender modesty. It is also important to consider the impact that peer physical examination can have on the student who has real findings, both known and unknown.

Background:

Currently, Clinical and Communication Skills is run with Standardized Patients for specific and more invasive exams, including the cardiac, respiratory and abdominal exams; a practice that is both valuable and costly. Exams that are considered less invasive, such as lymph nodes, cranial and peripheral nerves and head & neck are learned and rehearsed using same-year classmates as patients.

In a survey of first and second year medical students:

  • 36% of students are comfortable with the current practices, where peer physical examination is only performed using specific exams, including vital signs, cranial nerves.
  • 58% of students stated they would be comfortable performing more invasive examinations on peers, with exceptions including the rectal, pelvic and genital examinations, while 4% of students said they would be comfortable with peer examination for any aspect of the physical exam.
  • 2% of students say that they are uncomfortable with any form of peer physical examination.

The survey also elucidated that 36% of students would be more comfortable with peer physical examination if they were working with individuals of the same gender; 61% said they would be neither more nor less comfortable.

Important elements of the Clinical and Communication Skills course go beyond routine examinations. The communication component of this course can intermingle with an individual’s personality and sense of self. The current structure at Queen’s allows for students to form meaningful relationships with one or two faculty members as well as nine colleagues as they explore how to optimize their communication for the practice of medicine. Any alterations to the structure and setup of this course need to take into account the impact that those changes could have of the value and strength of these important relationships.

Research and Analysis:

Other institutions are considering these same practices, but a clear solution has yet to surface. Many have evaluated attitudes toward using peers as ‘patients’, including a study conducted in Australia. This project used a Likert 5-point scale (1: not at all willing; 5: very willing) to evaluate overall willingness of students to participate in physical examination teaching using peers. The study’s trends suggest that students are more willing to participate when examining the extremities and typically unclothed areas (head and neck), and that both men and women are more willing to be examined by women.2

Another article, a response to a study of peer physical examination, stated that “students must be endowed with the same rights to which they are dutifully bound to grant patients, namely refusal of investigation, including examination.”1 The author concluded that the practice of peer examination is appropriate when students are able to pick their partner, but that the integrity of the physical examination as it is learned should be upheld with the use of simulated patients. For examinations of the pelvis, rectum and genitalia, the author recommends table-top models. A more moderate approach was elucidated in a letter to the editor of Academic Medicine, where the authors directly address the issue of consent – perhaps the crux of the issue of the Queen’s model of physical examination teaching. Their overarching comment suggests that schools should obtain consent from students, and that an important component of consent is to provide information about risks and benefits of peer examination in the learning of the physical exam.3

The data collected from students at Queen’s medicine demonstrates that most students are comfortable with our current practices, and, in fact, many would be willing to participate to a greater extent. However, in this instance, a minority of students expresses discomfort, and given the nature of this issue, it is important to consider whether alternatives could be made available so as to facilitate these students’ full participation in the learning of the physical exam.

Potential solutions

  • Consider no adaptation of the current model for physical exam teaching.
  • Consider a shift to physical exam teaching using solely standardized patients.
  • Consider a method of allowing students who are uncomfortable to self-identify, and manage them individually based on their concerns.

References

1Rizan CT, Shapcott L, Nicolson AE & Mason JD. (2012). PPE: A UK perspective, ‘All for one, NOT one for all’.  Medical Teacher, 34, 82; author reply 82-3.

2Reid KJ, Kgakololo M, Sutherland RM, Elliott SL & Dodds AE. (2012). First-year medical students’ willingness to participate in peer physical examination.  Teaching & Learning in Medicine, 24, 55-62.

3Delany C & Frawley H. (2011). We need a new model for obtaining students’ consent to conduct peer physical examinations.  Academic Medicine, 86, 539; author reply 539.

The Curriculum Committee had a preliminary discussion about this last week and have asked for a procedural approach to be drafted and presented to them, that will allow for student concerns to be addressed effectively while not eliminating the instructional value of peer examination completely.  In doing so, feedback from members of faculty and other students would be very much appreciated.  Please feel free to share your perspectives on this issue, either by responding to this post, or sending commentary to myself, Liz, Curriculum Committee chair, Michelle Gibson or Clinical Skills Director Cherie Jones.  My confidential portal is always available to students who wish to comment anonymously.

13 Responses to Should medical students be examined by each other, or by Faculty?

  1. Liz you are an absolute star. Thank you for representing students so professionally. Wow, this is a remarkable review. As always, it is wonderful to see the Qmed faculty listening to student concerns and diligently working with students to develop evidence-based and thoughtful solutions.

  2. Ray Viola says:

    I know that this blog concerns the School of Medicine alone, but similar learning practices occur in the Schools of Nursing and Rehabilitation Therapy in our faculty. I wonder if similar concerns have arisen in these other schools and whether a Faculty-wide approach should be considered?

    Ray Viola

  3. Brandon says:

    Sensitivity and possible reasonable accommodation should be given for those who feel uncomfortable with practicing on other students. This would amount to 1-2 students by the stats given above. It might be helpful to allow these people to privately declare themselves with each new class or be encouraged to use supportive, confidential channels to do so. Maybe this needs to be declared again by the UGME? If it is a gender issue, in past years we have often done female-female pairs to overcome this if someone has wanted it. I am not aware of problems resulting from matching gender when desired for the 4th years. Religious and other boundaries (e.g. cultural) are obviously different issues.

    For religious and other concerns:

    If it is one of these, in supportive discussion with the student I would be interested as to the boundaries they face and how this plays out in clinical practice. I wonder if the same applies to working with patients, standardized or not, or how the interaction goes in this setting. Is there something we can be doing to help them practice skills and in real life to overcome these boundaries? Perhaps we can also learn from these students to adjust our own clinical practice as some patients I have seen had similar physical examination concerns.

    Why I feel classmate practice is important:

    Student practicing was an extremely important tool in my medical education. Friends would give me good feedback that was non-threatening and most times easier to swallow than that which when a faculty member provided it. I am often harder on myself when it comes from those who I look up to as mentors. It also provided greater time in the CEC to practice than is ever possible with clinical skills in the pre-clerk years. It gives you a “muscle memory” you can rely on when you are on the wards late at night – knowing what to do and what manoeuvre to perform to find what you need to detect. I think the current system is a great one and will hopefully be able to address concerns within it as they arise.

    Findings in a classmate:

    I think the hardest issue here is having actual findings on a classmate. If someone has a disability and does not want that known they should be allowed to not volunteer themselves if called upon. In a small group or after hours, this concern could be alleviated by practicing with someone in their group they trust. Or if they do feel comfortable they could team up with a group of 3 and abstain from being a “patient”. I recognize this could create questions from classmates but the medical information would be protected and they would hopefully feel they have their decision to not participate as a patient respected in that setting.

    For unexpected findings, this is unfortunate to have this revealed to classmates as it would be distressing for the student. I am aware of a couple times this has happened. I am not sure if it can be avoided. My hope is that each class has become a family, like mine has. We are supportive of each other, and no one judges if something is found. We have tended to be there for each other, not only for these instances. Its whats great about our med school. The unexpected is the most difficult hurdle to get around. Even faculty or an SP could have this happen if they were used for that role. I am not sure if it would be any easier in either of those cases. SPs could be used exclusively to minimize student impact, but is likely resource intensive in some settings. I would advocate for support here and potentially SPs for all large/lecture hall settings if this is a widespread concern and feasible.

    Sorry for the long reply. I wanted to voice what I had thought after reading it. Thanks to Liz and Dr. Sanfilippo for taking this on and permitting discussion. Hope the above was a useful perspective in your discussions.

  4. Sophie says:

    Hi Dr. Sanfilippo,

    This is an interesting and relevant issue.
    My thoughts are that peer physical examination can be very valuable, both in terms of ensuring students have adequate opportunities to practice clinical skills, and providing students with the opportunity to subjectively experience how an examination feels.
    However, it is important that students feel safe participating in peer examination and that means there is an overarching context of consent and confidentiality with regards to practicing the physical exam on peers.
    Perhaps there could be a group session at the beginning of the year in clinical skills where the class develops “ground rules” for practicing the physical exam on peers? We have done similar “ground rules” sessions for developing expected behaviours in SGL with Dr. Allard in PF1A. In addition to any formal policies developed, this would be an opportunity for each class to think critically about issues of professionalism, consent, and confidentiality (as we are encouraged to do so in many other contexts), and allow each class to feel as though they have developed a valuable framework, decided upon as a group. This may also help to normalize the self-selection process later down the line for students that may not want to be examined by peers in a certain context, on a certain day, in certain clothing, etc. It could also allay some student concerns about confidentiality should expected or unexpected findings be discovered.
    Thank you for your time!
    Sophie (Meds 2017)

    • Hello Sophie,

      I think you raise a terrific point about experiencing the examination from the patient perspective. Must say, that’s a hidden benefit of peer examination I hadn’t considered until this conversation began and a good reason, in itself, to continue the process in a form that respects the personal issues that have been raised. Your suggestions are excellent and will certainly contribute to the development of our approach. Thanks for this and please continue to provide feedback on this or other issues.

  5. Kelly says:

    I’d like to echo my peers’ sentiments on this subject. I find practice of the physical exam on peers to be invaluable. Of the potential problems that accompany this practice, from my experience thus far, the majority of them arise in formal settings. This may include using a student as a demonstration in front of the class or having expanded clinical skills session in which you are divided into partners or small groups by administration.

    I think that students are generally protected from the latter as they can set up their own times to go into the CEC to practice and they can pick who they are doing this with. Often students just get a partner or two with whom they feel comfortable and this avoids any unwanted exchanges, such as explaining which exams they are or are not comfortable with. While I personally find changing who I practice with in order to be beneficial, I do understand the comfort in practicing with friends.

    In formal settings, as previously mentioned, there have been times when students have been ‘volun-told’ to be a demo. I know the majority of people see the awkwardness in this scenario due to the pressure students are under in the moment. They have to decide whether to deny a senior in front of all of their peers, or go to the front of the room and put on display their physical findings (or lack thereof). This has been avoided in other classes when formal requests went out before the lectures for someone to truly volunteer themselves as demos. I feel this is a more appropriate way to go about the process and do not think there will ever be a lack of volunteers.

    I agree with Sophie’s ideas on making ‘ground rules’ to establish behaviours surrounding clinical skills. Students should feel comfortable in their participation or rights of refusal and ‘ground rules’ may help with this. If there was a general understanding at the beginning of the year that peers may have findings, some of which they never even knew about, then some people may feel more comfortable in participating. As we know, there is a range of normal among the population and we are not exempt from this. Students should be educated on this matter and the concept of confidentiality in the context of peer examination should be raised. Furthermore, I think that the vulnerability often felt by students when examined by peers is a way to re-evaluate what it means to be a patient. We are incredibly lucky to have many volunteer or standardized patients that offer up their personal being to inexperienced hands as a learning tool. These people, and our peers, are extremely gracious and generous to offer this and it is easy to forget what a gift it is to be able to practice on ‘the real thing.’ Being a test subject yourself can serve as a reminder of the humility and vulnerability that accompanies being a patient, but also how a (soon to be) physician’s words and actions can comfort and support.

    I cannot stress enough how valuable I find the ability to practice the physical examination on peers. I think this conversation raises many excellent points and perspectives. Thank you!

    Kelly
    Meds 2017

    • Thanks Kelly, for this valuable feedback. I particularly appreciate your description of the student perspective on whole class demonstrations, which I think will be very revealing for faculty.

  6. Sheila Pinchin says:

    Hi Dr. Sanfilippo: There are many excellent ideas here. I would especially like to follow up on the Dr. Allard’s and Sophie’s and Kelly’s ideas about “ground rules”. It’s an excellent idea and would come from the tutors and the students themselves. What do you think?

    Sheila

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