Abstract
Background: Musculoskeletal (MSK) complaints comprise 12–20% of primary healthcare; however, practicing physicians’ MSK physical examination (PE) skills are weak. Further, there is a shortage of specialists able to effectively teach this subject. Previous evaluations of patient educators have yielded mixed results.
Aims: The aim of this study is to document how teaching by patient educators and physician tutors in MSK PE skills differs.
Methods: A qualitative researcher observed, video-recorded, and took notes during preclerkship MSK PE teaching sessions given by patient educators or physician tutors. The researcher identified themes which were evaluated by collective case study methods.
Results: Two patient educator and four physician groups were evaluated. The patient educators were more consistent regarding content and style than the physicians. There appeared to be a continuum in teaching organization from patient educator to novice physician tutors to experienced physician tutors. The patient educators consistently covered all major joints (physicians did not); physicians were more likely to request verbalization of actions, relate findings to history, receive questions, and use opportunistic teaching moments.
Conclusions: Understanding preclerkship MSK teaching by patient educators compared to physician tutors is necessary for appropriate targeting of the existing Patient Partners® in Arthritis patient educator program and to guide the development of future MSK teaching initiatives.
Introduction
Musculoskeletal (MSK) complaints make up 12–20% of primary healthcare visits (Badley et al. Citation1994, Citation1995). Previous studies and recent documents from the American Association of Medical Colleges and the Collège des Médecins du Québec have identified MSK clinical skills as an area of weakness in medical school curricula and in practicing physicians (McClure Citation1985; Anonymous Citation1993; Glazier et al. Citation1996a, b, 1998; Davis et al. Citation1997; College des Medecins du Quebec Practice Enhancement Division Citation1999; Association of American Medical Colleges Citation2005). Further, there is a shortage of faculty able to effectively teach this subject due to a combination of declining number of practitioners in MSK-related specialties and low comfort level by generalists (McClure et al. Citation1985; Glazier et al. Citation1996a, b, 1998; Davis et al. Citation1997).
Patient educators have been used successfully in teaching non-MSK subjects; for example, through the Pelvic Exam Program (Leserman & Luke Citation1982; Kleinman et al. Citation1996). The Patient Partners® in Arthritis (PP®IA) program is a centrally coordinated, standardized national volunteer program that trains patients with arthritis to teach and evaluate MSK clinical examination skills (The Arthritis Society 2008). Teaching by PP®IA patient educators was introduced at the preclerkship level at McGill University in 2004 as an integral part of the teaching program. To date, student evaluations of this teaching have been uniformly strongly positive.
Previous qualitative research on MSK teaching, and specifically on the PP®IA patient educator program, has primarily been limited to reports of participants’ experiences. The previous MSK patient educator studies are summarized in . For example, a pilot study using open-ended qualitative comments on evaluation forms of patient educator teaching reported that participants would recommend the program to colleagues and would like to participate again (Bell et al. Citation1997). Another study reporting written responses to open-ended questions by students on their experience of patient educator teaching found that students enjoyed the chance to see real patients and felt they had a better understanding of the impact of arthritis on patients’ lives. They also felt that the patient educators had good ability to explain how to do an MSK exam (Gruppen et al. Citation1996). In a final study's description of written responses to open-ended questions, students suggested that exposure to MSK patient educators “increased their empathy with the arthritis sufferer and improved their awareness of the disability resulting from arthritis”; however, students also indicated that they believed that rheumatology fellows were more likely to teach “correct” techniques (Smith et al. Citation2000).
Table 1. Summary of controlled patient educator studies to date
There are two mixed methods studies of PP®IA patient educators that include qualitative methods. The first held focus groups of both patient educators and students to determine their impressions of the patient educators versus physician-led teaching sessions (Hendry et al. Citation1999). The authors report that the students liked that the patient educators could describe what students should be perceiving, that they felt less “intimidated” and that they had greater responsibility for establishing rapport with the patient. The students also found the patient educator sessions to be more systematic and thorough and they appreciated the immediate and specific feedback. The students described frustration with theoretical discussions given by the physician teachers, as they did not feel this was an appropriate use of the PE teaching time; however, they did feel that the questions the physicians asked regarding the importance of certain signs did improve their learning.
The second qualitative study used semi-structured interviews of both patient educators and students after the study to explore their experiences (Raj et al. Citation2006). The interviews were audio-recorded, transcribed, and coded according to the grounded theory approach. Additional focus groups of medical students were also held. Overall, the qualitative analysis found that students felt that they benefited from seeing how arthritis affects individuals and that they felt that the patient educators put the skills they were learning in context. The students felt mostly positive toward teaching by patient educators though they were more positive about the physician teaching. They felt it was reasonable to be taught by patient educators alone, provided they had access to a physician teacher later in their training. The interviews of patient educators revealed that they found the experience “less daunting than they had first envisaged” and they described a feeling of “self-worth and confidence and being able to finally use their illness in a positive manner”.
There are no reported studies of direct observation of PP®IA patient educator teaching sessions. This study uses a different qualitative methodology, within site collective case study with embedded analysis through direct observation and video recording of teaching, to further elucidate the important features, similarities, and differences between patient educator and non-MSK specialist physician MSK physical examination (PE) teaching.
In addition, there are no reported qualitative assessments of patient educators compared to non-MSK specialist physicians. A recent study by this group has shown that the majority of MSK teaching in Canada is performed by non-MSK specialist physicians and the average duration of small-group MSK teaching is 3–5 h in preclinical medical students (Oswald et al. Citation2008). Thus, this study is the first study to qualitatively evaluate a more realistic duration of teaching.
The research question for this study is: how do MSK PE skills teaching sessions led by PP®IA patient educators compare qualitatively to those led by non-MSK specialist clinicians? There are two important subquestions: What are the important features and themes that emerge from these sessions? Can we identify similarities and differences within and between the themes in the two groups? For the purpose of this study, patient educators are defined as lay people with a chronic MSK condition who undertake formal training in teaching MSK PE skills.
Methods
Preclerkship second year medical students at McGill University in the first two of three 7-week cohorts of the Introduction to Internal Medicine (IIM) course at two McGill teaching hospital sites were eligible for this study. As part of a larger research program, students were randomly assigned to small groups of four to six students using a computer program. In rare circumstances, student hospital site was changed for personal reasons. Each group was taught by an internal medicine clinician educator. None of the physician tutors who taught the course in the year of this study were specialists in MSK medicine such as rheumatology, orthopedic surgery or physiatry. All but one of the observed physician tutors had been teaching in this course for over 10 years and were considered experienced. One physician tutor started teaching in the course in the year of the study and was considered more inexperienced.
At hospital site 2, for the first of two 7-week cohorts of the course, one of the usual tutor-led 2-h small-group sessions was replaced by a PP®IA patient educator led small-group session of equal duration. The physician tutors were instructed not to attend the patient educator led sessions. Concurrently at hospital site 1, an untrained arthritis patient from the community attended one of the physician tutor small-group sessions as a volunteer subject. At both sites, the remaining 11 teaching sessions were dedicated to non-MSK teaching topics as per this course's usual curricular outline. Students were not permitted to switch from one hospital site to the other.
During the second cohort of the IIM course, a new group of students went through the IIM course. For this cohort, the patient educators actively led sessions for the hospital site 1 groups and untrained community arthritis patients were present for the usual tutor-led small-group sessions at hospital site 2. Again, at both sites, the remaining 11 teaching sessions were dedicated to non-MSK teaching topics as per this course's usual curricular outline. None of the students in the second cohort had experienced the IIM course before and again switching between hospital sites was not permitted.
Prior to the beginning of the IIM course, a group briefing session was held where each patient educator was given a copy of the student IIM MSK supplementary handout which explained the reasons for designating one of the IIM sessions to MSK, and a written copy of the specific objectives was reviewed to ensure that the objectives were clear and they were given the opportunity to ask questions. A briefing for the physician tutors was given individually by one of the study authors (AO). Each received the identical copy of the student IIM MSK supplementary handout and the identical written objectives document was reviewed to ensure that the objectives were clear and they were given the opportunity to ask questions. Both groups were also given an abstract that outlined the general purpose and nature of the research project.
This study was set up as a within-site collective case study according to Creswell's qualitative methodology in order to give an in-depth view of the salient details of PE teaching sessions that might be missed by standard quantitative objective structured physical exam (OSCE) and questionnaire methods (Creswell Citation2007).
An independent non-participant qualitative researcher silently observed, video-recorded, and took hand-written notes during all four of the physician tutor MSK small-group clinical exam sessions in the first cohort and two of the three PP®IA patient educator sessions in the second cohort. This sample was chosen to maximize observations despite overlaps in the teaching schedules during the study period and falls fairly close to Creswell's recommended case number of four to five cases for collective case studies. The authors expected less variability in the patient educator group as they received identical and limited training. Thus, when schedules overlapped, the authors instructed the observer to maximize observations of the physician tutor group as variability was expected to be higher.
The notes and video recordings were reviewed by the qualitative observer and one of the authors (AO) by a process of embedded analysis to identify emerging teaching related themes including, but not limited to, topics of discussion and the nature of the group interaction (Haggarty Citation1996; Meyrick Citation2006). The categories were not predetermined other than the decision that the focus would relate to teaching behaviors. After the independent qualitative researcher drafted initial notes and reflections regarding themes, the author confirmed these themes by comparing video recordings of the sessions and hand-written notes to the observer's summaries to ensure that key themes were not missed. The themes were then compared within and across intervention groups by the independent observer and three of the authors (AO, LS, and JW) using within-case and cross-case analyses. Hypotheses were generated based on these emerging themes.
For the purpose of data collection, analysis, and presentation, information that could identify specific individuals was not included. While attendance and participation in the small-group teaching was mandatory, participation in the study, including agreeing to be video-recorded during the sessions, was voluntary. Consent was obtained from all 89 potential student participants at the introductory session for each IIM block. The patient educator and physician tutor consents were obtained at a separate briefing session before the course as described above. This study was funded by an unrestricted educational grant from Pfizer and ethics approval was obtained from the McGill University Institutional Review Board.
Results
Six small groups were evaluated, of which two were led by PP®IA patient educators and four by physician tutors. The 14 main themes identified in the within-case analysis, definitions of themes, and examples are listed in . Some of these themes related directly to session objectives; for example, themes such as which joints were covered and if there was discussion of inflammatory versus degenerative findings. Other themes emerged independent of the session objectives such as organization of the joint exam, degree to which students were encouraged to verbalize actions, and responsiveness to events during the sessions.
Table 2. Themes identified, definitions, and illustrative examples
A summary of major similarities and differences between the two groups from the cross-case analysis can be found in . In terms of differences, we found that the two patient educators were more consistent in regard to their teaching content and style than the four physician tutors. For example, the patient educators both gave equal distribution of time to all major joints and used a standard approach to the examination of each joint, which consisted of inspection, palpation, range of motion (ROM), and functional assessment. Despite reviewing objectives indicating the need to cover all major joints ( in Appendix) both verbally and in writing with all group leaders, only one physician tutor covered all major joints. In fact, one physician spent the entire session on the examination of the hand. Further, the physician tutors did not present a standard approach to joint examination.
Table 3. Examples of similarities and differences between PP®IA patient educator and physician tutor groups
Although the objectives of the teaching session did not include history taking skills, nearly all physician tutors included significant time teaching history taking skills in the session whereas patient educators did not. As such, physician tutors were more likely to relate physical findings to historical features elucidated in the session. The patient educators limited their discussions of historical features to the assessment of patient function and occasionally to their own personal medical history. Physician tutors inconsistently addressed patients’ functional status.
Physician tutors were more likely than patient educators to interrupt students and to present mini-lectures on knowledge-based topics during the sessions. For example, several tutors gave mini-lectures on the anatomy of the hand or on mechanisms of disease. The patient educators tended only to interrupt when the students were performing part of the examination incorrectly.
The patient educators’ sessions were more consistently patient-centred whereas the physician tutor sessions were more variable in regard to patient-centeredness. For example, physician tutors inconsistently addressed patients’ functional status or asked for patient feedback. Further, in sessions where tutors were more likely to dominate the session with mini-lectures, the sessions became not only less student-centred but also less patient-centred.
Physician tutors asked more knowledge-based questions of the students and also received more questions from the students. On the other hand, the patient educators used questioning of students more as a tool to draw attention to important points without insisting that students answer the questions as a test of knowledge.
Physician tutors were more likely to give a summary at the end of the session and some tutors reviewed issues of professional conduct and communication skills at that time. The patient educators did not overtly discuss these issues. One of the physician tutors generated learning issues for the students to follow up on after the session whereas none of the patient educators did this.
In terms of areas of similarities, both physician tutors and patient educators ensured that students compared normal findings on each other to actual or expected abnormal findings on the patients. Further, both patient educators and physician tutors spent time highlighting features of inflammatory versus degenerative disease.
However, there was variability within the two PP®IA patient educators and the four physician tutors in regard to the ability to ensure each student had equal supervision time while practicing the techniques. In addition, physician tutors were more likely to request verbalization of actions by the students although the patient educators did request verbalization of findings of inspection.
Discussion
This study demonstrated that MSK PE teaching sessions by PP®IA patient educators were more structured and uniform than those given by usual physician tutors in that they used a standard approach to the session and to the joint examination itself, covered all major joints in same depth, and consistently provided a more patient-centred approach.
The findings also indicated that physician tutors placed more emphasis on history taking skills, asked and were asked more knowledge-based questions, and were more likely to provide mini-lectures on knowledge-based topics. The coordination of history taking skills and PE was not part of the objectives of this session and is taught elsewhere in the curriculum. Although these are important skills to review, one may question the appropriateness of using significant amounts of the limited PE teaching time for this purpose.
Previous qualitative research on MSK teaching, and specifically on PP®IA patient educators, has primarily been limited to reports of participants’ experiences (Gruppen et al. Citation1996; Bell et al. Citation1997; Hendry et al. Citation1999). This study is the first to compare patient educators to physician tutor teaching by directly observing and analysing the teaching sessions through a collective case study approach. Interestingly, there are many similarities between the findings of the previous studies and our findings, despite the differences in methodology, adding validity, and credibility to the results.
Examples of findings in our study that are consistent with those of the Hendry, Schrieber, and Bryce focus group study include the finding that patient educators provide more systematic and thorough teaching, give immediate and specific feedback, ensure each student has a turn to practice, and provided a less direct knowledge-based questioning (Hendry et al. Citation1999). We also report that the patient educators started at a basic level and then elaborated compared to the physician tutors who sometimes pitched their sessions too high. Like this study, the Hendry, Schrieber, and Bryce study found that the physician tutors gave more explanations regarding underlying theory and that patient educators asked fewer questions of students regarding the importance of different findings. They also commented that the physician tutors highlighted important and unusual features of disease. In their study, the students reported missing these questions as they felt they helped with their learning. However, the students in their study felt frustrated when this occurred extensively as they felt that this time was not meant for topics that could be easily covered in lectures or by reading textbooks.
Raj et al. (Citation2006) used structured interview and focus groups in a grounded theory qualitative methodology, yet they also found that students felt that they benefited from seeing how arthritis affects individuals and that they felt that the patient educators put the skills they were learning in context. Unlike this study, the students in the Raj et al.'s study were less confident of the skills they learned in the MSK patient educator led sessions. Although they felt mostly positive of teaching by patient educators, they were more positive about the physician teaching. They felt it was reasonable to be taught by patient educators alone, provided they had access to a physician teacher later in their training.
There are also several unique assertions that can be made from this study. Although previous studies have described the PP®IA patient educator program as providing more patient-centred teaching, few have explored how the program achieves this, other than by obvious observations that patients are present and directing the students. This study revealed that the patient educators placed significantly more emphasis on the determination of function and the impact abnormal findings may have on patients’ daily lives, giving a more patient-centred focus. These techniques could be incorporated into future teaching innovations that wish to emphasize patient-centeredness.
Another unique aspect of this study is how it highlights the give-and-take relationship between the clarity gained by a more structured teaching style versus the adaptability gained by a more opportunistic teaching style. It is critical to determine the best timing for each of these styles as both have merit when applied appropriately. One might consider that in the earlier stages of the curriculum, a more structured approach may be most effective as students are struggling to master basic skills, while more experienced students are more likely to benefit from the richer and more fluid nature of a more opportunistic teaching style (ten Cate et al. 2004).
A third unique finding was that physician tutors were more likely to request verbalization of PE findings by the students. This finding is extremely important as it may be hypothesized that practicing verbalization during PE sessions may improve students’ ability to perform well on OSCEs (Ericsson Citation2004). As many previously reported works on the efficacy of PP®IA patient educators are based on OSCE outcomes, this raises concerns regarding bias of positive results toward physician-led groups in these studies.
An interesting trend that emerged in the thematic analysis was the appearance of an overlapping teaching structure between the patient educators, the novice physician tutor, and the experienced physician tutor. The PP®IA patient educators groups used a very structured approach to both the session as a whole and to the individual joint examinations. The more novice physician tutor had an intermediate approach that shared more in terms of structure of the session and uniform approach to each joint with the patient educator group than it did with the experienced physician tutors, who were least structured in their teaching style (). Although the patient educators were felt to have a more clear approach than the experienced physician tutors, the experienced physicians appeared to be more able to change the direction and emphasis of the session in response to issues that came up during the session, enabling them to take advantage of “teaching moments”.
Figure 1. Spectrum of teaching structure.
The finding that the novice physician tutor's teaching style has the most features in common with both the patient educators and the experienced tutors raises the hypothesis that teaching style becomes less structured and more able to incorporate opportunistic teaching as clinical teaching experience increases. It may suggest that the novice physician's style bridges the differences that are described between patient educator and physician teaching.
There are several limitations of this study. First, physicians who agreed to participate in the observation and video recording of their teaching session may have been different than those who did not, raising questions regarding the internal validity or in qualitative terms, credibility of the study. For example, the participating non-MSK physicians could be more comfortable with their ability to teach MSK PE than average non-MSK physician tutors. This may give an overly positive view of the nature of the physician tutors’ teaching. However, all who were asked to participate agreed. As part of the criteria for the study, none of these physicians practiced MSK specialties such as rheumatology, orthopedic surgery, or physiatry. Further, two of the four tutors had not taught MSK PE when they taught this course in the past and expressed discomfort with this skill despite it being part of the course objectives. Finally, had these tutors been more comfortable with MSK than average tutors, they would have only made the standards to which the patient educators were compared more rigorous.
This question may also be raised for the PP®IA patient educators. The patient educators who agreed to give the teaching sessions had to give three to four sessions each over the 5-month course. Patient educators who are available for this kind of time commitment may be more dedicated to the program and thus motivated more to give a high-quality session than the general pool of available participants. However, this type of commitment would likely also be necessary for patient educators who agree to participate in future preclinical PE teaching. Thus, their performance would likely be representative of those patient educators who would be used for this purpose in the future.
It is also possible that the knowledge that an observer would be present for the session and that there would be video recording might cause the patient educators and physician tutors to prepare and conduct themselves differently; though research has not necessarily supported this claim (Koetting Citation1985). In attempts to lessen the potential Hawthorne effect, we made it clear to all patient educators and tutors that the notes and video tapes would be kept confidential and would not be released to the undergraduate course coordinator or to the PP®IA patient educators coordinator. Although this kind of extra preparation is likely to affect the content of the material covered, it is less likely to affect the nature of the teacher's structure, style, and teaching environment. Fortunately, it is likely that all teachers were more conscientious of their behavior during the sessions, preventing this factor from introducing bias.
For students, the observer was present for both the patient educators and the physician tutors, so differences noted should not be affected by this presence. Further, the same observer was used for all the sessions to avoid differences based on unique behaviors of the person observing.
The early introduction of patients into the undergraduate medical curriculum is desirable as it may improve the authenticity of the teaching experience by making the context of the learning environment more similar to what students will experience in their future clinical roles. The patient educators give students experience on how to conduct themselves in front of real patients and give them more responsibility to develop a rapport with patients in the absence of supervising physicians. Furthermore, the patient educators provide students with explicit opportunities to learn from patients, appreciate patients as knowledgeable partners, and incorporate the patient's perspective as part of the educational messages.
All too frequently, educational activities are added to rather than integrated into current curricula and educational systems. PP®IA patient educators provide teaching that is partly additive to and highly complementary with those of experienced clinician teachers. One possible way to blend these two resources would involve having the patient educators give introductory MSK PE sessions and then have physician tutors give later sessions on how to incorporate these skills with information gained from history, other parts of the PE, and from information gained in prior knowledge-based courses. This would allow physicians’ teaching time to be used more efficiently once students have had the chance to become comfortable with an approach to basic skills of joint exam.
In conclusion, the themes and assertions identified in this study suggest that creative integration of complementary aspects of the PP®IA patient educator and clinical tutor methods would be better than simple addition of one to the other. This would allow for the creation of an “educational win-win” situation that would maximize both students’ learning experience and physician tutors’ use of limited teaching time. The complementary aspects that will require the most consideration relate to balancing those resources that provide clarity through structured teaching with those that provide adaptability through opportunistic teaching.
Acknowledgments
This study was funded by an unrestricted educational research grant from Pfizer. The authors would also like to thank and acknowledge Ms Susan Lu for her role as the independent observer of the sessions, Dr Tim Lymberiou for his assistance in video recording the sessions, tutors from the Department of Medicine at McGill University and from the PP®IA patient educator group for agreeing to teach MSK sessions and participate in our study, Dr Michael Starr for providing the untrained community arthritis patients, and the Division of Rheumatology at McGill University, for all their support.
Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of the article.
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Appendix
Table A1. Session objectives provided to students, physician tutors, and PP®IA