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:
- Students may have medical conditions, scars, or deformities they do not wish to reveal and do not wish exposed.
- Students may have personal or religious objection to exposure or touching
- 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
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.
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.
- 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.
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.