Background
Peer physical examination (PPE) is widely used in health professional education programs to introduce learners to the physical examination skills required for practice in their chosen profession. PPE is the process where learners practice in pairs or in small groups of fellow learners to develop their skills in the physical examination of patients in preparation for clinical practice.
Much of the PPE literature has focused on medicine with limited literature in other professions including nursing [
1], physiotherapy [
2] and osteopathy [
3]. Numerous benefits for the use of PPE have been described including practising the application of clinical skills prior to patient exposure [
4,
5]; developing an appreciation for examining a patient, and being examined [
5,
6]; developing professionalism [
7]; allowing students to examine a range of body types [
6]; receiving peer feedback [
8]; and reinforcing anatomy knowledge [
5,
9]. Moreover PPE is easy to organise [
6] and less expensive than standardised or actual patients. Despite these benefits students can still feel uncomfortable or embarrassed [
8]. Their reluctance to participate has been associated with cultural/religious background [
8], poor body image [
10]; risk of inappropriate body contact [
11,
12]; and potential identification of pathologies [
6].
Osteopathy is a manual therapy profession that, within the Australian context, focuses on the management of musculoskeletal complaints [
13]. During their training, osteopathy students at both institutions participating in the present study learn and practise a range of physical examination skills related to the musculoskeletal system but do not examine intimate body regions [
9] beyond the femoral triangle, anterior hip region and chest (excluding breast tissue). They also learn screening examinations for the cardiovascular, respiratory, gastrointestinal and neurological systems, and practise a range of manual therapy techniques. All of these skills are practised in the classroom on fellow students before entering clinical practice with actual patients in the latter years of the program.
Developing clinical skills is an integral part of osteopathy programs [
14]. In the programs in the present study, students spend over 300 h learning clinical skills in practical classes over their 5 years of training, typically for between 2–4 h per week. This volume of PPE has yet to be reported in the literature, and may be higher than many non-manual therapy education programs (i.e. medicine, nursing) where PPE has been described. Therefore, understanding students’ perceptions of PPE in manual therapy education programs could be used to inform policies and procedures, not only for practising PPE in class but also for practising manual therapy techniques on their peers, an activity that has received little attention in the literature to date.
It may be possible to extrapolate the findings from PPE studies in medicine to osteopathy, however as Wearn et al. [
1] suggest students may ‘… begin their programme with a slightly different world view’ (p. 885). Consorti et al. [
3], in their study comparing PPE perceptions of Italian medical and osteopathy students, posited that the latter are likely to enter their program of study with a preconceived idea about body contact and
learning to touch as a part of their training. These authors compared the perceptions of PPE in Italian medical and osteopathy students, demonstrating that the latter students were more positive about their PPE experience, particularly the part-time students. Osteopathy students in the Consorti et al. [
3] study were either full-time or part time, with the part time students already having completed training as a health professional (typically medicine or physiotherapy) prior to entering the osteopathy program. In contrast, Australian osteopathy students complete their training in a full-time program, albeit they may enter with a previous health profession qualification. This difference, in part, limits the comparisons that can be drawn between the Australian and Italian training context.
PPE and practising manual therapy techniques on peers is a traditionally accepted part of training to be an osteopath, however there is very little literature that investigates student perceptions of these practices. The aim of the present study was to explore the perceptions of osteopathy students in two Australian teaching programs before and after their exposure to PPE activities over a 12-week teaching period to ascertain whether these perceptions are consistent with the literature on PPE in other health professions, and to inform curriculum development in osteopathy and other health professions.
Results
Responses rates at T1 were 86 % (
n = 114) and 91 % (
n = 41) from VU and SCU respectively. At T2, response rates were 76 % (
n = 101) and 67 % (
n = 29). Matched T1 and T2 data were available for 105 students, and it is this data set that is analysed here. Matched data from VU made up 81.9 % (
n = 86) of that analysed in the present study. Demographic data are presented in Table
1.
Table 1
Demographics by institution
Age | | |
Mean (SD) | 20 years (±3.17) | 27.5 years (±9.73) |
Range | 18–33 years | 18–52 years |
Biological gender | | |
Male | 46 (53.5 %) | 7 (36.8 %) |
Female | 39 (45.3 %) | 12 (63.2 %) |
Previous course involving PPE | | |
Yes | 12 (14 %) | 7 (36.8 %) |
No | 73 (84.9 %) | 12 (63.2 %) |
Born in Australia | | |
Yes | 82 (95.3 %) | 15 (78.9 %) |
No | 3 (3.5 %) | 4 (21.1 %) |
English as primary language at home | | |
Yes | 84 (97.7 %) | 18 (94.7 %) |
No | 1 (1.2 %) | 1 (5.3 %) |
Practice a religion | | |
Yes | 17 (19.8 %) | 1 (5.6 %) |
No | 68 (79.1 %) | 17 (89.5 %) |
Examining Fellow Students (EFS) questionnaire
EFS responses for all 105 students were not significantly different between T1 and T2 for both willingness to examine all body regions on a peer, or to be examined by a peer.
At T2, two SCU students indicated they were unwilling to have their chest examined by an opposite biological gender peer, and examine the pelvis of peers of either biological gender (Table
3). None of the demographic variables were significant in the regression model.
Table 3
Examining Fellow Students questionnaire responses at T2 by institution
| VU | SCU |
Examine a peer | Willing | Same gender | Different gender | Both same and different gender | Willing | Same gender | Different gender | Both same and different gender |
Head and neck | 86 (100 %) | | | | 100 % | | | |
Hands | 84 (97.7 %) | | 2 (2.3 %) | | 100 % | | | |
Arm and shoulder | 85 (98.8 %) | | 1 (1.2 %) | | 100 % | | | |
Upper body (no breast exposure) | 85 (98.8 %) | | 1 (1.2 %) | | 100 % | | | |
Abdomen | 85 (98.8 %) | | 1 (1.2 %) | | 100 % | | | |
Back | 85 (98.8 %) | | 1 (1.2 %) | | 100 % | | | |
Groin (without genital exposure) | 78 (91.0 %) | | 4 (4.5 %) | 4 (4.5 %) | 100 % | | | |
Feet | 84 (97.7 %) | | 1 (1.2 %) | 1 (1.2 %) | 100 % | | | |
Legs | 85 (98.8 %) | | 1 (1.2 %) | | 100 % | | | |
Hips | 85 (98.8 %) | | 1 (1.2 %) | | 100 % | | | |
Chest (no breast exposure) | 84 (97.7 %) | | 2 (2.3 %) | | 100 % | | | |
Pelvis (without genital exposure) | 83 (96.5 %) | | 1 (1.2 %) | 2 (2.3 %) | 100 % | | | |
Be examined by a peer | Willing | Same gender | Different gender | Both same and different gender | Willing | Same gender | Different gender | Both same and different gender |
Head and neck | 86 (100 %) | | | | 19 (100 %) | | | |
Hands | 86 (100 %) | | | | 19 (100 %) | | | |
Arm and shoulder | 86 (100 %) | | | | 19 (100 %) | | | |
Upper body (no breast exposure) | 86 (100 %) | | | | 19 (100 %) | | | |
Abdomen | 85 (98.8 %) | | 1 (1.2 %) | | 19 (100 %) | | | |
Back | 86 (100 %) | | | | 19 (100 %) | | | |
Groin (without genital exposure) | 84 (97.7 %) | | | 2 (2.3 %) | 19 (100 %) | | | |
Feet | 85 (98.8 %) | | | 1 (1.2 %) | 19 (100 %) | | | |
Legs | 86 (100 %) | | | | 19 (100 %) | | | |
Hips | 86 (100 %) | | | | 19 (100 %) | | | |
Chest (no breast exposure) | 85 (98.8 %) | | | 1 (1.2 %) | 18 (94.7 %) | | 1 (5.3 %) | |
Pelvis (without genital exposure) | 85 (98.8 %) | | | 1 (1.2 %) | 18 (94.7 %) | | | 1 (5.3 %) |
Peer Physical Examination Questionnaire (PPEQ)
Descriptive and inferential statistics for the PPEQ items are presented in Additional file
1. Median values for PPEQ items 1 through to 12 were all significantly different from T1 to T2 (
p < 0.02). Median values for these items either improved from T1 to T2 or were stable across the two administrations of the questionnaire, and effect sizes (r) ranged from 0.24 to 0.55. Items 13 to 16 were not significantly different from T1 to T2 (
p > 0.05).
Multiple items were significant at both T1 and T2. For item 5
I am concerned of being a possible object of sexual interest during PPE (OR 1.39 & OR 2.71,
small), those students aged between 20 and 25 years were more likely agree with this statement at both time points. In contrast, those 26 years or over were more likely to agree with this item at T1 (OR 21.11,
large), but less likely at T2 (3.63,
moderate). For item 7,
I am concerned of experiencing possible sexual interest for my teacher or tutor during PPE, students aged over 20 years were more likely to agree with this item at T1 and T2 (Additional file
2). Conversely for item 12, students aged over 20 years were less likely to agree with item 12
It is inappropriate to perform PPE on persons that will be my future colleagues (Additional file
2), that is, they see that PPE is appropriate to perform on future colleagues.
Internal consistency
Internal consistency of the PPEQ was acceptable at T1 (Cronbach’s alpha = 0.92, McDonald’s omega = 0.70). At T2 Cronbach’s alpha was acceptable (0.92). However, McDonald’s omega was slightly below an acceptable level (0.69). The Cronbach’s alpha scores for the PPEQ at T1 and T2 did not improve if an item was removed during the calculation.
Discussion
The aim of the present study was to explore perceptions of first year osteopathy students at two Australian universities about PPE. Overall, students in the present study were willing to examine, and have examined all body regions listed in the questionnaire. This is consistent with results of another study [
12] and within the 5 % range of students unwilling to participate in PPE identified by Power and Center [
26]. The only region where this value was larger was for students from VU who indicated an unwillingness to examine the groin of a peer, or have their groin examined, in some cases, regardless of peer biological gender. Students in the present study were less apprehensive about PPE and perceived it as a professional experience, as did those in the study reported by Consorti et al. [
3]. The findings of the present study, for the first time, reinforce the anecdotal experiences of the authors with the application of PPE in osteopathy.
The concept of PPE in osteopathy education extends beyond the rehearsal and development of physical examination skills to include the application of osteopathic manipulative therapy (OMT) and other manual therapy techniques. The World Health Organisation [
14]
Benchmarks for Training in Osteopathy requires programs to graduate students with:
-
competency in the palpatory and clinical skills necessary to diagnose dysfunction in the aforementioned systems and tissues of the body, with an emphasis on osteopathic diagnosis;
-
competency in a broad range of skills of OMT;
-
proficiency in physical examination and the interpretation of relevant tests and data, including diagnostic imaging and laboratory results.
Achieving these benchmarks requires substantial time practising these skills on peers in the classroom. In the context of the present study, over the 12-week teaching period, students spent approximately 50 h in a PPE environment. By the completion of their program of study they will have spent approximately 300 h developing their practical skills in the classroom and 1000 h with actual patients in a student teaching clinic. It is anticipated, as Rees et al. [
27] suggested, that the positive perceptions of PPE identified in this study will remain throughout the entire program. Exposure to the living body early in a students’ training is likely to have a significant influence on the relative ease that students will have with ‘therapeutically touching’ a patient in their clinical training years, and contribute to the development of professional attitudes towards patients [
28]. The practice of osteopathy in Australia is focused on the management of musculoskeletal complaints [
13]. Therefore there is little need to learn, or be able to practise, examination of sensitive areas like the breast and genitals [
29] which are beyond the scope of practice of osteopaths in Australia. Consequently, these regions were not included in the EFS questionnaire.
To be able to develop the manual therapy skills to become a registered osteopath in Australia, students undertake carefully scaffolded and supervised practice throughout their course. Students require full information about what is expected of them before they enrol and explanations about the benefits of participating in PPE need to be made clear [
4,
30]. However, some students may not wish to participate in a particular PPE activity, or may place conditions on their participation [
5]. Alternative learning pathways such as practising on standardised patients or on family members need to be made available [
16]. One of the challenges for educators is to design activities that meet the required learning outcomes while respecting the right of students to refrain from participating. In the history of both osteopathy teaching programs, few challenged have been reported, most being resolved by allowing students to practise initially with someone with whom they feel comfortable (e.g. a student of their own choosing, or a family member or friend), before practising with other students who can provide a wide variety of body types, and personal and medical histories.
No national or international guidelines could be located to guide good practice in PPE and practising treatment techniques on peers. The University of Queensland Medical School [
31] called for development of such guidelines in medicine. In osteopathy and other health sciences, guidelines for good practice are likely to include:
-
obtaining informed consent from students before they participate in PPE [
4,
30];
-
telling students what to expect in practical classes before they commence their courses [
6,
30,
32];
-
facilitating discussions about ethical, cultural and professional issues associated with PPE (e.g. therapeutic touch vs sexual touch; body image; age, gender, cultural influences on willingness to participate in PPE);
-
allowing students to choose who they practise with; and
-
offering alternatives to students who choose not to participate [
16].
Demographic influences on PPE
The EFS questionnaire asks students to indicate which areas of the body they would not be willing to examine on a peer or have examined by a peer. Numerous authors have reported that students are more willing to examine, rather than be examined by, a peer [
11,
33,
34], and this appeared to be consistent with the present study. Students entering an osteopathy program are likely to be aware that their course will include a substantial amount of time devoted to learning clinical assessments and manual therapy skills [
3]. Such an assertion is supported by the PPEQ responses in the present study where students were likely to
agree or
strongly agree with the items at T1, with either an increase in the median value, or at least with the value remaining high, at T2. Medium to large effect sizes were noted for PPEQ items 1 to 12. The changes in items 1 to 12 from T1 to T2 may reflect ‘reasoned or rationalized changes’ [
35] in the students’ perceptions following participation in PPE activities.
The last four PPEQ items relate to the application of PPE in osteopathy education. No significant difference between T1 and T2 was observed for these items (items 13 to 16). Students from both institutions potentially saw PPE as an integral part of their osteopathy education before entering the course, similar to the medical students reported by Chang and Power [
12]. Previous studies have found that students’ negative perceptions of PPE may be related to experiences with tutors and classmates. It is hypothesised that the tutors and lecturers of students in the present study may have created a supportive learning environment that contributed to the increase in median values for these items. Such supportive environments incorporate appropriate feedback from lecturers/tutors and peers. Chang and Power [
12] found that receiving feedback from peers was a key positive feature of PPE. In the present study, females were less likely to agree with item 15
In performing PPE I (will) get useful feedback from my colleagues about my skill at both T1 and T2, however, these OR’s were small.
Females were also more likely to feel uncomfortable with getting undressed for PPE activities at T1 and T2 although this influence of biological gender was reduced at T2. This result is consistent with the discussion by Rees [
32] who used a feminist theory lens to highlight the potential for body image issues to play a role in PPE. Of note is that females were still significantly more likely to feel embarrassed if disrobed in their practical skills class at T2, even though they had experienced 12 weeks of the learning environment and could arguably be more comfortable participating in it. This result highlights the ongoing need to consider body image wherever PPE is employed, including incorporating information about body image in the curriculum before and during the use of PPE, as well as reinforcing the need to demonstrate appropriate draping [
6,
36]. Discussions about body image could form part of students’ introduction to PPE.
The apparently conflicting results from our two questionnaires could be related to sample size: only a small number of people reported feeling uncomfortable examining, or having examined, most regions, most commonly the pelvis. Alternatively, the results may simply reflect the different purposes of the two questionnaires: the EFS targets students’ perceptions about PPE of specific body regions. The PPEQ on the other hand draws out responses to the wider learning environment for PPE and students’ level of comfort in it. This global willingness to engage in PPE is not elicited from the EFS.
A previous study [
5] suggested that practising a religion influenced willingness to examine the groin or feet of a peer - this was not the case in the present study, according to EFS data. The current data did not include details of particular religions practised by student(s) and did not explore whether specific religious beliefs accounted for the results [
27]. Further, it would be interesting to explore students’ understanding at T1 of what each of the EFS body regions meant to them given that a small number of students indicated this was a body region that they felt uncomfortable examining, having examined, or both. For example, examination of the groin and anterior hip are closely related in a musculoskeletal examination, and the use of the term ‘groin’ may have a particular meaning for an individual, albeit the EFS explicitly states ‘no genital exposure’. The femoral triangle, anterior hip, and chest (excluding breast tissue) are the only potentially sensitive regions of the body that are examined by students in Australian osteopathy programs.
Statistical considerations
The internal consistency of the PPEQ was evaluated using two approaches: Cronbach’s alpha and McDonald’s omega [
23]. Authors have argued that Cronbach’s alpha may not provide an accurate indication of internal consistency, and McDonald’s omega may be a better option [
24,
37,
38]. The PPEQ internal consistency was very good when using alpha, but borderline when using omega. Given the questionnaire has only been used in one other study [
3], further work to investigate the psychometric properties of the PPEQ is required. McLachlan et al. [
35] have asked authors investigating longitudinal changes in PPE perceptions to provide support for the pre-post differences obtained. In the present study this is provided by the reporting of effect sizes, something that the majority of PPE studies have not done. Many of the effect sizes in the present study are interpreted as medium [
19], suggesting that there is likely to be a change pre to post participation in PPE activities but larger participant numbers are required to confirm the results.
Limitations
The limitations of this study include its limited longitudinal nature (only a 12 week teaching period) and the fact that not all body regions had been examined by the students before the conclusion of the study period. Further, the study was conducted in two Australian teaching programs with a single cohort, therefore the generalisability to other non-United States osteopathy programs, and other Australian osteopathy student cohorts is limited. Matched data were only available for 105 students. It is possible that some students were not able to complete the questionnaire at either T1 or T2 due to an absence, or had withdrawn from the teaching program prior to completing the questionnaires at T2. The ratio of respondents was approximately 4.5:1 for VU and SCU and this may have influenced some of the results, however it would be difficult to control given the substantial differences in cohort sizes at the two institutions.
Only quantitative data were collected in the present study, and the addition of a qualitative component may shed further light on some of the issues faced by osteopathy students when entering a program of study that emphasises PPE. In particular, previous studies have highlighted the issue of harming, or being harmed by a peer during PPE [
5,
7,
33], something which is not captured in either questionnaire employed in the present study. The application of manual therapy techniques carries a very small risk of an adverse reaction [
39], so fear of harm may be a valid concern. How the results of the present study relate to the practice of OMT and other treatment techniques would require further investigation. This is particularly relevant as students in osteopathic programs in Australia will be required to practise manual techniques on some body areas that students in the present study were either unwilling to examine, or have examined on themselves. This is an avenue for further work in osteopathy and other manual therapy professions.
Direct comparisons with the Consorti et al. [
3] study at item level are not possible as detailed data from the previous study were not available. Such comparisons in future studies will enable a deeper understanding of the quantitative data derived from the PPEQ. The results of the present study also highlight a potential issue with the PPEQ in that it may be subject to a ceiling effect and not necessarily sensitive enough to detect a change in student perceptions. This may have been reinforced in the present study as the analysis was undertaken using the ordinal data generated by the responses to the PPEQ, rather than making the assumption that the underlying data were interval in nature, and subsequently using parametric inferential statistics [
18]. The use of these statistics may have yielded different results, however it may have also provided a less accurate indication about pre-post differences. Another factor that influences the interpretation of the PPEQ data is the large 95 % confidence intervals for some of the demographic variables (Additional file
2). In some cases these were quite substantial and suggest that further work is required to confirm if these demographic variables do in fact have a significant influence on the PPEQ responses.
Only one student reported not speaking English at home in the present study. Therefore it is not possible to describe its influence on perception of PPE. It is also possible that other unmeasured factors influence a students’ perception of PPE. The learning environment, interpersonal experiences with the class tutors and peers, learning approach, personality, body image, and motivations for learning could all influence students’ perceptions of PPE. These require exploration in future research. Rees [
32] also suggested that tutor biological gender is an avenue for further research and will be considered in future studies.
Conclusions
PPE is used extensively in Australian osteopathy teaching programs. This is the first study to explore students’ perceptions of PPE in this cohort. Australian osteopathy students are generally willing to participate in PPE. Students saw PPE as an important and relevant part of their training both before and after participation in classroom activities involving PPE. Students who had previously studied a course involving PPE were slightly more positive about PPE than those who had not. Willingness to participate in PPE was associated with biological gender: females were more likely to feel embarrassed when disrobed in practical classes. Being born outside Australia, and holding religious beliefs were also associated with reluctance to participate in PPE. Students over 20 years of age were initially more concerned about being of sexual interest and about performing PPE on a colleague than 18–19 year olds, and generally less likely to feel comfortable about performing PPE after exposure to the course. Further work is required to validate the results of the present study and ultimately to develop evidence-informed, safe, ethical and culturally-sensitive approaches to PPE in Australian osteopathy programs.
The present study adds to the PPE literature by evaluating the perceptions of osteopathy students who spend a substantial portion of their education practising PPE, evaluations that are likely to be common to all manual therapy students. Further, the study highlights a number of important considerations for curriculum development, such as incorporating discussions about body image, feedback skills training for educators, and providing detailed information to students about PPE before they commence their studies.