Teaching physical examination skills is a fundamental component of medical education. In introductory clinical medicine courses, medical students often take turns practicing physical examination skills on each other. This helps familiarize them with examination techniques before they encounter patients in clinical settings. Peer physical examinations (PPEs) may also help develop student camaraderie, which has been identified as an important element of medical school learning.1
Despite their benefits, PPEs are an area of potential student discomfort or inappropriate behavior by classmates or tutors. In the past, many medical students were required to perform full examinations on each other, including female breast, male genital, and rectal examinations. Today standardized patients (SPs) are more commonly used for examinations of this type, and some educators have suggested replacing all PPEs with SP examinations to minimize the potential for student discomfort. Few published studies, however, provide information to guide faculty considering such changes in curriculum.
Several recent articles have focused on the broad issues of abuse among medical students and sexual harassment during medical training.2,3,4,5 Surveys have assessed medical students' attitudes,1,4,6 including comfort levels when taking sexual histories from different types of patients,7 but none has focused specifically on students' comfort with PPEs. Limited data are available on attitudes toward PPEs involving “sensitive areas”—defined by Metcalf and colleagues8 in 1982 as “the female breast, pelvic organs, external genitalia, rectum, anal canal, and anus, and the male external genitalia, inguinal region, rectum, prostate, anal canal, and anus.” In describing their living anatomy course for freshmen medical students, Metcalf and colleagues reported that all students believed that preclinical examination of the opposite sex was important and were strongly positive about the course. Further, the faculty believed that using medical students as models was “instructionally advantageous” in examining socially sensitive areas of the body. In a 1995 Australian study focusing on teaching methods of vaginal speculum examination, Abraham9 found that 25% of students would consider volunteering for female vaginal or male rectal examinations if the other students participating were of the same sex. Only 4% of these students preferred examining fellow student volunteers to the examination of paid models. In another publication describing students' preferred methods for learning pelvic exam skills, Abraham10 reported that students least favored examining medical student volunteers.
At the University of Minnesota Medical School in Minneapolis, PPEs occur during a nine-month, first-year introduction to clinical medicine course. Each tutorial group has eight students and a supervising faculty physician. The students, often in pairs, act alternately as examiner and examinee in clinic examination rooms. Using Metcalf's definition,8 the only “socially sensitive” elements of our PPEs are palpation of the chest wall for the point of maximal impulse (PMI) of the heart beat and examination of the groin area for the femoral pulse and inguinal lymph nodes. During this course, students are often asked to voluntarily remove some clothing to model examination technique by the tutor for the tutorial group. Students in this course occasionally have made requests that they not be examined at all or that a limit be placed on the extent to which their classmates examine them. Rarely, students have complained about their experiences during the course. Female breast/pelvic and male genital/rectal examination techniques are practiced on SPs during workshops supervised by faculty.
For this study, in 1998, we designed and administered a survey to 164 University of Minnesota medical students assessing their comfort with and attitudes about PPEs. Specifically, we investigated (1) comfort with various aspects of PPEs; (2) attitudes regarding the professionalism, appropriateness, and perceived value of PPEs; (3) attitudes toward and willingness to perform peer breast, genital, and rectal examinations; and (4) the effects of age and gender on responses.
The written survey instrument contained 29 questions (25 content, three demographic—age, gender, and year of graduation, and one open-ended comment section). Students responded to statements using a five-point Likert scale where 1 = strongly agree, 2 = agree, 3 = don't know, 4 = disagree, and 5 = strongly disagree.
Face validity of the survey instrument was evaluated by local experts and pilot tested with a convenience sample of 12 first- and second-year medical students. Following an explanation of the purpose of this anonymous survey, we administered it to 164 end-of-first-year medical students during a mandatory examination period when all students were present. The students were instructed that, unless otherwise indicated, the term “physical exam” did not include sensitive-area examinations (i.e., breast, genital, and rectal examinations) other than PMI palpation and inguinal examination. At the time, these students had already participated in the female breast/pelvic exam SP workshop, but not the male genital/rectal exam workshop.
We analyzed all results using standard descriptive statistics. Two categories of age (22 to 24 years old and 25 years old or older) were selected based on a median split. The effects of age and gender on response were analyzed using ANOVA. Interactions between age and gender were found for several questions and were compared further using threeway repeated-measures ANOVA, using same sex/opposite sex as the repeated measure.
Of the 124 students who responded (75.6% response rate), 50% were female (versus 46% of the entire class), and the average age was 25.7 years (range 22 to 42; age statistics are not kept by this medical school). Table 1 fully summarizes the students' responses.
Students' Comfort with PPEs
Ninety-seven percent of the respondents either agreed or strongly agreed that they were comfortable with both practicing examinations on other classmates and having physical examinations performed on them. Most (77%) felt comfortable with setting limits with classmates (e.g., “When you examine me, please don't examine this part”), but 12% did not and 11% were unsure. A large number (48%) felt exposed when they were undressed as a model to demonstrate examination technique in front of a group of peers.
Although the large majority of these students reported feeling comfortable examining their peers—including examination of the chest area (97% comfortable)—they became notably less comfortable performing inguinal examinations (77% comfortable). The students were more comfortable examining peers of the same gender (99% comfortable) than of the opposite gender (70% comfortable). For chest examinations, 99% of the respondents were comfortable examining peers of the same gender, compared with only 55% comfortable with opposite-gender exams. Similarly, for the inguinal exams, 78% of the students were comfortable with the same gender, 45% comfortable with the opposite gender.
Perceived Professionalism, Appropriateness, and Value of PPEs
Almost all respondents agreed or strongly agreed that PPEs are both an appropriate part of medical training (98%) and a valuable learning experience (97%). Most of the students (91%) did not feel that PPEs strain classmate relationships. No student indicated that PPEs were “unprofessional.” Fifty percent agreed that PPEs were preferable to using SPs, while 33% disagreed and 17% did not know.
Three students consistently reported that they were not comfortable with PPEs, that PPEs were not an appropriate part of medical education, and that they did not favor PPEs over examinations of SPs.
Breast, Genital, and Rectal Examinations
The majority (56%) agreed that performing peer breast, genital, and rectal examinations is not an appropriate part of medical training, and 68% would not consider volunteering for such examinations.
Age and Gender Differences
Age alone, as a continuous or categorical variable, did not influence response. Table 2 fully summarizes significant gender-related differences in responses. Women were somewhat less comfortable with PPEs with the opposite gender, thought peer breast, genital, and rectal examinations were less appropriate, and were much less likely to consider volunteering for peer breast, genital, and rectal examinations.
In addition, significant age/gender interactions were found for three items at p <.05. Older men (25 and over) and younger women (under 25) were the most comfortable setting limits with classmates, while older women (25 and over) and younger men (under 25) were the least comfortable groups (p =.036). This same age/gender pattern was repeated with inguinal-area examinations of same-gender peers (p =.026). Finally, older women were the least comfortable group being undressed in front of a group of peers, while older men were considerably more comfortable (p =.015).
Our results indicate that this sample of medical students was comfortable with PPEs of “non-sensitive areas” and willing to participate in such examinations as an appropriate and valuable part of the standard medical school curriculum. The students' responses were congruent with the assumed benefits of PPEs: getting valuable feedback on performance from classmates and having more time to learn techniques—without straining peer relationships. In the written comments, two students noted that PPEs are a beneficial experience that allows one to feel how a patient feels when examined by a doctor.
Although the majority of the respondents indicated a preference for examining their classmates over SPs, this particular group of students had had little curricular exposure to SPs at the time of the survey; thus, their responses may reflect a lack of familiarity with that type of examination. As was observed by Abraham,9,10 a sizable group of students expressed a willingness to perform sensitive peer examinations. This suggests a large divergence of opinion among medical students about what aspects of PPEs are considered appropriate.
Whereas overall the students valued and were willing to participate in PPEs, a small number of medical students (3%) did indicate discomfort with most aspects of PPEs. Thus, medical educators might consider creating mechanisms that allow students to express their concerns about PPEs and that provide these students with suitable learning alternatives, such as using SPs or practicing examinations on a friend or partner. Such refinements, however, would need to be carefully implemented and evaluated to avoid any real or perceived academic advantages (grading/evaluation scores) for students choosing these alternatives. Based on the overall comfort and positive attitudes of the respondents with PPEs, there is no suggestion that these students desired making extensive curricular changes such as replacing all PPEs with SP examinations.
Our findings suggest other ways in which peer examinations might be improved. One in four had difficulty setting limits with classmates. Direct attention to this issue in the tutorial setting might improve peer-group communication and minimize discomfort. Older women were particularly uncomfortable being models for group examinations. Older men may be less bothered by this. Most students were more comfortable examining classmates of the same gender, particularly for chest and inguinal examinations. Tutorial groups with equal numbers of student of both genders may facilitate comfortable pairings of examination partners. The students indicated that they had had uncomfortable experiences with both classmates and tutors. Clear, direct communication about expectations for behavior and concepts of professionalism may help improve classmate behavior. Faculty development and individualized tutor evaluations may help diminish uncomfortable experiences with tutors.
This study has limitations. The population was limited to one class at one institution. Although the survey instrument was pilot tested and reviewed by local experts, it has not been previously validated. To our knowledge, this is the first study of its kind; therefore, we limited demographic variables to age and gender. We had a high response rate, and there is no reason to believe that the respondents differed significantly from the remainder of the class. Cultural and religious beliefs, sexual orientation, sexual experience, and prior clinical training could have influenced the students' attitudes and comfort and confounded our results.
The results of this study must be replicated at other institutions. A followup study is in progress, surveying the attitudes of fourth-year medical students at this institution. Further, studies that address the origins of students' discomfort with PPEs may provide valuable insights to aid curriculum design.
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