Musculoskeletal examination teaching by patients versus physicians: How are they different? Neither better nor worse, but complementary

Figures & data

Table 1.  Summary of controlled patient educator studies to date

Citation	Intervention	Comparator	Results	Issues
Raj et al. (2006)	2 h patient educators n = 25	2 h rheumatologist with untrained patient n = 25	• No difference in scores on well validated 2 station OSCE • Structured interviews analyzed by grounded theory and showed students felt mostly positive toward teaching by patient educators though they were more positive about the physician teaching	• Qualitative assessment limited to structured interviews without direct observation of teaching
Humphrey-Murto et al. (2004)	9 h patient educators n = 30 Second year medical students	9 h rheumatologist with untrained patient n = 32	• No difference in teacher evaluations • No difference overall score of 9-station OSCE (2 weeks post) • More fails in patient educator group	• ↑ Duration of teaching and MSK specialist teachers not representative of most schools • No qualitative assessment
Smith et al. (2000)	Unclear duration patient educators n = 40? Second year medical students	Rheumatology fellows n = 40?	• Teacher evaluations show Fellow are superior for “interest” and clear demonstrations • No difference in 1-station OSCE score (end of semester)	• Unclear duration of teaching and number of students in patient versus fellow group • Single-station OSCE • Qualitative assessment limited to student responses to open-ended question on teacher evaluation
Schrieber et al. (2000)	80 min patient educators n = 25 First year medical students	Non-MSK physicians n = 12	• No difference in 1-station OSCE scores (1 week post) • 11/18 items of pre/post questionnaire by students significantly better in patient educator group	• Assessors not blinded • Single-station OSCE • No qualitative assessment
Hendry et al. (1999)	80 min patient educators n = 18 Fourth year medical students	Rheumatologist with untrained patient n = 18	• No difference in overall pre/post questionnaire scores • No difference in single-station OSCE scores (13 days post) • Many positive observations about patient educators in focus groups of patient educators and students although students describe physician as better at explaining theory/signs	• Single-station OSCE • Qualitative assessment by focus groups of patient educators and students without direct observation of teaching encounters
Branch & Lipsky (1998)	Video + 90 min 1 : 1 teaching with patient educator n = 88 Second year medical students	Video alone n = 93	• Pre/post questionnaire showed patient educators superior to physicians for facts and confidence but same for attitudes • Higher total scores on single-station OSCE for patient educator taught group	• Unequal duration of teaching • Single-station OSCE • No qualitative assessment
Bell (1997)	1 h MSK lecture + 90 min patient educator small group (1–2 trainees) n = 59 Medical students and residents	None	• Significant (33%) improvement immediately and 1 month post (25%) on patient educator observed assessment versus preteaching assessment • Responses to open-ended teacher evaluations showed all participants would attend again and recommend to their peers	• No comparison group • Qualitative assessment limited to student responses to open-ended comments on teacher evaluation
Gruppen et al. (1996)	Patient educators with circulating rheumatologists + 120 min full-class patient educator question and answer panel n = 68 and 97 Second year medical students	None	• On the pre/post written MSK exam, 3/5 knowledge questions were significantly better pre versus post and pre versus 1 year follow up • Self-rated confidence improved post teaching • Attitude improved less (small to moderate effect size) • No difference in interest in MSK career • Responses to open-ended teacher evaluations showed students liked seeing real patients	• No comparison group • No objective assessment of students • 44% response rate to assessments • Concurrent lectures may have improved knowledge score • Qualitative assessment limited to student responses to open-ended comments on teacher evaluation

Table

Practice points

PP®IA patient educators provide clear, structured, patient-centred MSK clinical skills teaching for preclinical medical students. Physician teachers provide more adaptable and opportunistic MSK clinical skills teaching for preclinical medical students. The integration of these two resources could provide a highly complementary teaching experience.

Table 2.  Themes identified, definitions, and illustrative examples

Theme	Definition of theme	PP®IA patient educator examples and quotations	Physician tutor examples and quotations
Topics covered	History taking? Physical exam? Investigations? Underlying theory? Functional assessment?	Briefly tells students her medical and surgical history “How do we ask about functions, like daily function?” Demonstrates using blood pressure cuff to quantify grip strength	Asks student to interview the patient Typical X-ray and lab findings discussed Mini-lectures on anatomy, mechanism of disease, differential diagnosis
Communication and professionalism	Discussion of how to communicate with patients and issues of professionalism	“How do we ask people about functions, like daily function?”	“What did you think of your interview?” Discussion on how to ask patient to move her joint a particular way. Discussion of how highly “medicalized” patient may lead you to wrong diagnosis
Joints covered	Session objectives: hand, wrist, elbow, shoulder, hip, knee, ankle, foot	See Appendix 6-A, Session objectives
Organization of joint exam	Suggested organization of how students should approach joint exam	Starts with introduction of the four aspects of MSK PE …	Starts with “Let's check for fluid on the knee … ”
Method of PE instruction	Verbal versus hands on instruction	Corrects mistakes both verbally and by pointing out by hand	Doctor examines patient, then asks student to follow him
Opportunities for all students to practice	Did all students have a chance to perform the PE with supervision?	One student examines patient while others form pairs and examine each other, then rotate	One student asked to examine patient while rest watch him
Comparison of normal and abnormal	Session objectives list “To interpret MSK findings as normal or abnormal”	Ask students to palpate for heat on her and then on each other	Asks students to compare mobility of their fingers and wrists to patient's
Comparison of inflammatory and degenerative	Session objectives list “To identify abnormal findings as more likely degenerative or inflammatory changes”	When looking at the hand asks “what is the difference between rheumatoid and osteoarthritis?”
Questions to students	Noted whenever instructor asked direct questions of the students	Questions used as sentence openers to draw attention “Why would you check active and passive motion?”	“Which nerve is involved in … ” “What is the mechanism of … ?” “What are erosions?”
Encourage verbalization of actions?	Noted whenever students asked to describe what they were seeing or doing	Asks students to verbalize what they see on inspection	“Tell me what you find at the MCP?” “What do you feel?”
Clarity of the presentation	Level of complexity at which the instructor began the session with and progressed to	Starts sessions with “today's teaching is about joint examination … ” goes on to introduce four aspects of MSK PE	Near start of session “As a rheumatologist you will do … ” Asks students to identify sites of atrophy of lumbricals
Responsiveness to events during session	Impact student questioning or comments had on course of session	Student asks when to do full exam versus focused exam. Patient answers briefly then group moves on to next joint	Patient mentions new biologic medication in history, so tutor initiates discussion of mechanisms of action of this medication
Patient feedback on student performance	Does the instructor ensure the students receive feedback from the patient?	(This is implicit to this teaching method.)	Doctor asks patient to give students some opinions on how to be a good doctor
Impact on the patient	Notations of direct comments on patient perspectives in disease such as functional assessment or psychosocial effects	Asks students to observe patient's reactions while they do the PE Asks how findings would affect patient's daily activities

Table 3.  Examples of similarities and differences between PP®IA patient educator and physician tutor groups

Theme	PP®IA patient educators (n = 2)	Physician tutors (n = 4)
Topics covered	0/2 History taking 2/2 Physical exam 0/2 Investigations 0/2 Theory 2/2 Functional assessment	4/4 History taking 4/4 Physical exam 2/4 Investigations 4/4 Theory 1/4 Functional assessment (NB: One doctor spent only 50/120 min on PE)
Communication and professionalism	1/2	2/4 (1 in regard to history, 1 in regard to patient instructions during PE)
Joints covered	2/2 did all of hand, wrist, elbow, shoulder, hip, knee, ankle, foot	1 only hand; 1 hand, elbow, and knee; 1 hand, wrist, shoulder, and knee; 1 hand, wrist, elbow, shoulder, neck, spine, knee
Organization of joint exam	2/2 same components and order: Inspection, then palpation, then ROM, then functional assessment	Each doctor uses different components and order: 2/4 Inspection 4/4 Palpation 2/4 ROM 1/4 Functional assessment NB: 3/4 started with palpation
Method of PE instruction	2/2 Both verbal and hands on	1/4 Verbal only 3/4 Both verbal and hands on
Opportunities for all students to practice	2/2	3/4
Comparison of normal and abnormal	All did this	All did this
Comparison of inflammatory and degenerative	All did this	All did this
Questions to students	Used mainly to highlight points of interest, 1–2 per session	4/4 used to test students’ knowledge 5 or more per session 1/4 used to create learning issues
Encourage verbalization of actions?	Requested for inspection only	Requested throughout session
Clarity of the presentation	Consistent presentation style starting with basic components of MSK PE and working up	Presentation styles very variable
Responsiveness to events during session	Correct problems but continue with task at hand	Often change direction in response to questions or problems
Patient feedback on student performance	2/2 gave feedback throughout session	1/4 doctors requested patient feedback on student performance
Impact on the patient	2/2 discussed patient function and impact of arthritis on patients’ lives	1/4 Doctors emphasized patient function 1/4 Discussed psychosocial effects of disease

Figure 1. Spectrum of teaching structure.

Table A1.  Session objectives provided to students, physician tutors, and PP®IA

Aim	Objective	Have I done this?
A. Technical aspects of MSK Examination including: → Inspection (erythema, swelling, and deformity) → Active ROM → Passive ROM → Palpation (temperature, soft tissue and bony structures, effusions) → Common “Special Tests” (=physical maneuvers to help Dx-specific problems)	To perform PE of the upper extremity joints (hand, wrist, elbow, and shoulder)	___ Hand? ___ Wrist? ___ Elbow? ___ Shoulder?
	To perform PE of the lower extremity joints (foot, ankle, knee, and hip)	___ Foot? ___ Ankle? ___ Knee? ___ Hip?
B. Use of clinical reasoning in MSK exam	To interpret MSK findings as normal or abnormal	___
	To identify abnormal findings as more likely degenerative or inflammatory changes	___
	To identify when additional physical maneuvers needed	___
C. Communication, attitude and empathy behaviors in MSK PE	To demonstrate proficiency in communicating with patients with MSK concerns	___
	To demonstrate knowledge of how the lives of patients with MSK problems may be affected by these changes	___
	To demonstrate concern for patients’ comfort during examination	___

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