Students’ views on the impact of peer physical examination and palpation as a pedagogic tool for teaching and learning living human anatomy

Abstract

Background: Modern medical education teaching and learning approaches now lay emphasis on students acquiring knowledge, skills and attitudes relevant to medical practice.

Aims: To explore students’ perceived impacts of using hands-on approaches involving peer/life model physical examination and palpation in teaching and learning living human anatomy on their practice of physical examination of real patients.

Methods: This study used exploratory focus groups and a questionnaire survey of years 3–5 medical students.

Results: The focus group discussions revealed new insights into the positive impacts of the hands-on approaches on students’ clinical skills and professional attitudes when dealing with patients. Students’ exposure to the hands-on approaches helped them to feel comfortable with therapeutically touching unclothed patients’ bodies and physically examining them in the clinical environment. At least 60% of the questionnaire survey respondents agreed with the focus group participants on this view. Over 75% also agreed that the hands-on experiences helped them develop good professional attitudes in their encounter with patients.

Conclusions: This study highlights the perceived educational value of the hands-on approaches as a pedagogic tool with a positive impact on students’ clinical skills and professional attitudes that helps in easing their transition into clinical practice.

Introduction

Anatomy curricula in many universities have been subjected to review and significant changes in approaches to teaching and learning human anatomy have been placed within wider developments in medical education (Jones et al. 2001). There is now a shift in emphasis away from absorbing factual information to acquiring the knowledge, skills and attitudes thought to be desirable for modern medical practice (Towle 1991). Our new generation of students learn differently. Their learning approach is multi-modal and stimulus dependent (Reidenberg & Laitman 2002). These have evoked new thinking in innovative ways of teaching and learning in medical schools.

Anatomy is one of the core medical science subjects and its teaching and learning is essential to medicine (Pabst & Rothkotter 1997; Patel & Moxham 2006; Moxham & Plaisant 2007; Fitzgerald et al. 2008). It is generally taught by the dissection of human cadavers (Persuad 1984; Richardson 1988; Patel & Moxham 2008). This is mostly seen as a defining experience in the early years of medical doctors’ training (McLachlan et al. 2004). Dissection of human cadavers has been described in the past as the most universal and universally recognisable step and a right of passage in becoming a doctor (Dyer & Thorndike 2000).

However, the teaching and learning of human anatomy is now undergoing changes across the world. In the United Kingdom and North America there is a huge transformation in the teaching of human anatomy to undergraduate medical students due to changes in thinking about how to best prepare doctors for medical practice in the twenty-first century (Dangerfield et al. 2000; de Barros et al. 2001; Fitzpatrick et al. 2001; Johnson 2002; Miller et al. 2002; Op Den Akker et al. 2002; Prideaux & Bligh 2002; Reidenberg & Laitman 2002; McLachlan et al. 2004; Patel & Moxham 2006; Gogalniceanu et al. 2009). Opinions are shifting away from continued use and students’ dissection of cadaveric materials in medical education, partly as a result of changes in society's expectations of good ethical practice, cost and availability (Prideaux & Bligh 2002; McLachlan et al. 2004). Furthermore, because of the prominence in modern educational thinking given to the relevance of learning in context and to the use of appropriate learning materials, it has also been argued that anatomy ought to be taught in the context of how it is encountered in clinical practice (General Medical Council 2003; McLachlan & Regan de Bere 2004; McLachlan et al. 2004).

The Peninsula Medical School (PMS) uses innovative methods of teaching living and clinical human anatomy to reflect the way anatomy and the use of its knowledge is encountered and applied in clinical practice during patients’ contacts. These methods include life human models/peer physical examination and palpation, plastic anatomical teaching models and various human anatomical imaging techniques including live ultrasound (McLachlan & Regan de Bere 2004; McLachlan et al. 2004). Living and clinical anatomy teaching are delivered through small group sessions, using hands-on approaches which involve peer/life model physical examination and palpation, anatomical drawing or painting and image projections on the living body (for more details, see McLachlan & Regan de Bere 2004; McLachlan et al. 2004).

There have been studies on the use of peer physical examination for teaching and learning living human anatomy and clinical skills in medical schools (O’Neill et al. 1998; Chang & Power 2000; Rees et al. 2004, 2005). These studies have found that the majority of medical students are comfortable with participating in peer physical examination. Rees et al. (2004, 2005) explored year 1 students’ attitudes towards peer physical examination. The result showed that 97% of the students were comfortable with participating in peer physical examination of all body parts except the breast and inguinal regions including genitals. O’Neill et al. (1998) reported a similar level of acceptance with medical students in Manchester. At the University of Minneapolis, USA, 97% of students were reported to be comfortable with examination of the body of peers and being examined (Chang & Power 2000). In general, students expressed reluctance in peer examination of inguinal region including genital and female breast.

The above studies have mainly focused on medical students’ attitudes towards peer physical examination and the effects of demographic factors on their willingness to participate in or volunteer for peer physical examination. While the findings of these studies are informative, there have been little or no follow-up studies on the impact of students’ early exposure to these hands-on approaches. In particular, how do these hands-on methods assist them with developing and practicing their clinical skills and professional attitudes in the clinical years? This study aims to understand students’ perceived impact of using these innovative hands-on approaches to teaching and learning living anatomy on their learning and practice of physical examination on and encounters with real patients in the clinical environment.

Table

Practice points

Most PMS medical students feel that the hands-on approaches to teaching and learning functional living anatomy involving peer/life model physical examination and palpation are clinically relevant and have direct application to medical practice. Students’ early exposure to peer/life model physical examination and palpation as pedagogic tools for teaching and learning human anatomy was perceived to have positive impact on improving their clinical skills and professional attitudes when dealing with real patients. The ease with which students are comfortable with therapeutically touching real patients’ bodies (or body parts) for physical examination may be influenced by their early exposure to simulated examiner/examinee roles through peer/life model physical examination and palpation. Using innovative human anatomy teaching and learning approaches such as peer/life model physical examination, palpation and body painting of anatomical image help students develop a mental picture of the positions and locations of underlying deep structures beneath the skin of the living body during physical examination of real patients. Peer/life model physical examination and palpation used as a teaching tool in a clinically integrated curriculum could be one example of how pedagogic approaches may help students with a ‘seamless’ transition from theory/practical simulation to real clinical practice.

Methods

This study was part of a larger study designed to explore students’ experiences and perceptions of PMS innovative approaches to teaching and learning human anatomy in years 1 and 2 of the medical curriculum. Mixed qualitative and quantitative methods were used. This involved exploratory focus group interviews of samples of the PMS years 3–5 undergraduate medical students and a questionnaire survey based on the focus group findings of the whole population of these cohorts of students. These groups of students have already had the experiences of using the hands-on approaches. The quantitative questionnaire survey data were used not to generalise about the representativeness of opinions, but rather to tap into the opinions of a wider set of students, to add substance to the smaller focus group samples.

Focus group interviews

The focus group interviews were conducted in order to generate issues relating to students’ experiences and their perceived impact of their exposure to the hands-on approaches on their practice of physical examination on real patients. This was followed by a self-completion questionnaire survey to determine how widely the expressed views were held by the focus group participants among the larger student population of the cohorts under study.

The students were contacted via e-mail with an information sheet and invited to volunteer for the research. Students who volunteered to participate in the focus group interview discussions were offered the opportunity to formally express their willingness to take part in the project and give permission for their data to be used for research purposes by signing a consent form. Two focus group interviews were conducted at two different locations of the PMS medical students. The Truro focus group consisted of 12 students and the Plymouth group consisted of eight students. There was at least one representative from each of the cohort year under study in each focus group with a male and female gender mix. The interview was semi-structured with a flexible topic guide, which covered issues relating to the students’ views and opinions on the impact of their exposure to the hands-on approaches on their clinical skills and professional attitudes. The focus group interview discussions were recorded using a tape recorder and transcribed verbatim.

Analysis of focus group data

The transcripts of the focus group data were analysed using the thematic framework content analysis method (Ritchie & Spencer 1994). Each focus group discussion represented one case in a qualitative data matrix. And each case was framed against the identified themes. To reduce the complexity of the coding system used for the data analysis, only the participants’ identity codes were reflected against the participants’ quotes presented in the “Results” section.

Questionnaire survey

After the analysis of the focus group interviews transcripts, a self-completion questionnaire was developed based on the emerging key issues from the focus group interview discussions for survey a month later. The questionnaire asked for information on demographic characteristics of responders such as level/year of study, age, gender and ethnicity. It also contained structured question statements based on the emerging key issues from the focus group with response rating on 5-point Likert scale. Participants were requested to put a tick in one of the 5-point Likert scale boxes for the statement that most appropriately described their views (where 1, Strongly disagree; 2, Disagree; 3, Neutral; 4, Agree; and 5, Strongly agree). The questionnaire was sent to the students electronically via e-mail and responders were requested to submit their completed questionnaires via e-mail within 1 week of receipt.

Analysis of questionnaire data

Answers provided by respondents in the questionnaires were numerically coded and entered onto a spreadsheet for quantitative statistical analysis using the statistical analysis package, SPSS. The analyses included frequency tests on the numerical data to provide descriptive statistics relating to prevalence of held views and cross tabulations to examine the relationship between the views held and other variables such as gender, age, year of study, ethnicity and the question statements.

Results

Demographic characteristics of the questionnaire survey participants

The PMS students’ population were made up of a heterogeneous group of students with varying demographic characteristics including level/year of study, age, gender and ethnicity. Data on these demographic characteristics presented in Table 1 were collected in order to assess how they influenced students’ views on the perceived impact of their exposure to the innovative hands-on approaches on their clinical skills and professional attitudes. The responders were predominantly white (86.8%, n = 99). As shown in Table 1, the response rate was 23% (114 out of 495), of these, 32.5% (n = 37) were year 3, 52.6% (n = 60) were year 4 and 14.9% (n = 17) were year 5. The majority of the students were aged between 20 and 23 (67.5%, n = 77) and 11.4% of them were above 30 (n = 13). Among them 43.9% (n = 50) were males and 56.1% (n = 64) were females.

Table 1.  Demographic characteristics of questionnaire responders

Age, sex and year distributions of the questionnaire responders
Male						Female					Total (%)
	16–20	20–23	23–25	25–30	>30	16–20	20–23	23–25	25–30	>30
Year 3	0	11	0	0	3	9	13	1	0	0	37
Year 4	1	17	4	1	5	0	28	1	2	1	60
Year 5	0	3	2	0	3	0	5	2	1	1	17
Total	1	31	6	1	11	9	46	4	3	2	114
(%)	50					64					(23)

The responders’ demographic characteristics are representative of the whole student cohorts under study, as evidenced by the available records in the medical school data base. The whole cohorts were made of 77.6% of students from a white ethnic origin. Their gender distribution includes 54.5% females and 45.5% males with a median age range of between 20 and 23. As such there was no reason to believe that the demographic characteristics of the non-responders’ were different from the students who participated in this study or that the responders were typical.

Cross-tabulation analysis between the views held on each of the questionnaire question statements against each variable which include gender, age, year of study and ethnicity did not show any significant relationship. This suggested that the views and opinions of these students about the impact of their exposure to the living human anatomy teaching and learning hands-on approaches on their clinical skills and professional attitudes were not significantly influenced by any one of these demographic characteristics.

The impact of using living human anatomy teaching and learning hands-on approaches

The key points that emerged from the focus group interview discussions include the following:

• The ease with which students generally felt at therapeutically touching patients’ bodies and physically examining unclothed or half-clothed patients.

• The perceived impact of students’ early exposure to the hands-on approaches on how they felt with touching and examining real patients.

• The impact of the hands-on approaches on their professional attitudes and the perceived value of the hands-on approaches as a pedagogic tool.

Touching the body of patients

The students were of the view that they generally feel very comfortable with touching and examining patients’ bodies or body parts including unclothed or half-clothed patients without embarrassment or awkwardness. However, the ease with which they felt in therapeutically touching these patients’ bodies (or body parts) and carrying out physical examination may have been influenced by their experiences of early exposure to the hands-on approaches of teaching and learning the anatomy of the living body. It may also have helped them in the clinical environment in dealing professionally with examining unclothed or half-clothed patients and to identify anatomical landmarks with precision. These views were expressed in the quotes from participants in the focus group presented below to which most of the other participants agreed and echoed.

Participant T3: … one thing I really enjoyed right from the start, and having a life model made me very comfortable with the human body and it also helped my examination technique because … you know, … I am not that comfortable doing that, … em … I have found that really useful because it helped me during my clinical years dealing with you know half naked people (background murmuring of mmm in agreement by other members of the group) … examining to find out … that was really good …

Participant T2: … that I found really useful … the clinically oriented anatomy sessions because not only did they teach us the anatomy, but they gave us a relevance, the relevance which I think helps even further … I still use now on the ward …

These opinions were also widely held by the majority of the students who responded to the general questionnaire survey. Figures 1–3 show that the majority of the students surveyed agreed that the hands-on approaches had a positive impact on their clinical skills when it came to therapeutically touching patients’ bodies (or body parts) for a physical examination in the clinical environment. About 60.5% of the students agreed that it helped them to feel very comfortable with touching nude or half-naked patients for carrying out a physically examination.

Figure 1. Students views on touching patients’ body or body parts.

Figure 2. Students views on examining unclothed or half-clothed patients.

Figure 3. Students views on the perceived impact of their early exposure to peer/life model physical examination and palpation on how they feel about touching and examining nude or naked patients’ body.

Developing mental pictures and precise location of anatomical landmarks

As expressed in the quote below, students were also of the view that adopting the PMS living human anatomy teaching and learning hands-on approaches enabled them to develop a mental picture of the positions or locations of some of the underlying deep organs or structures beneath the skin of the living body and helped with physical examinations of real patients in their clinical environment.

Participant P4:  … em I found that using each other actually like physical examination and palpation and drawing on each other during the life sciences living anatomy sessions was really good for learning where all the major anatomy is and that became really useful when you then go to like physical examination in the ward, because you can really picture in your mind where all the underlying organs are (background murmuring of mmm in agreement by other members of the group). Em and that I think was really the best thing about life sciences sessions …

Professional attitudes

Some of the students felt that palpating and or physically examining life models and fellow students’ bodies (or body parts) during living anatomy teaching and learning sessions helped them to improve on their professional attitudes towards real patients. Professional attitudes were described as the ability to win a patient's trust and consent, maintain patient confidentiality, treat patients with dignity and care, have respect for their physical and psychological comfort, and use appropriate language to describe body structures and patients in human context rather than as objects or disease exhibits. This view was also held by the majority of the students surveyed, as shown in Figure 4. About 75.5% of the responders agreed with the focus group participants that the hands-on approaches helped them to develop good professional attitudes in their contacts with real patients in their later years of study in the clinical environment.

Figure 4. Students views on the perceived impact of their early exposure to peer/life model physical examination and palpation on their professional attitudes towards patients.

The value of the hands-on approaches as a pedagogic tool

In addition to the perceived positive impact, the students also expressed what they felt were the perceived value of the hands-on approaches as a teaching and learning tool. They felt that the approaches were an effective pedagogic tool for teaching and learning functional living human anatomy because of their clinical orientation and contextualisation and practical clinical application. The students said that the approaches were of value in acquiring anatomy knowledge that is clinically relevant and has direct applications to clinical practice. These views were reflected in the quotes from some of the focus group participants presented below.

Participant T7: I think one of the first approaches that I remember using was surface anatomy. Yeh we … use various methods for example … on each other in order to try and look at the surface anatomy and surface landmarks. … I found that very effective way of learning, its’ very hands on, its’ very practical …

Participant P2:  … Em I remember just being impressed with how hands-on the course was … I think the life models were really very useful actually em in the first couple of years and … I find them still quite useful … we’re going into surgery just to get your head around the idea …

Participant P5: I would agree with em … , the life models were very useful in the majority of the anatomy that I’ve sort of had from 1st and 2nd year … on each other, the surface anatomy and things like that, that was really useful for me and for my way of learning … physical examination of each other and also on life models where you can … was very useful as well …

The students generally appreciated the perceived value of the hands-on approaches in terms of their clinical relevance and application to clinical practice. However, there was a view that the hands-on approaches were very time consuming and inefficient and not a realistic way of learning anatomy in later years of their study considering how little is learned when compared with the time it takes to demonstrate the landmarks and outline the locations of structures. This view was expressed in the quote below by one of the focus group participants.

Participant T5: I mean … going back to what … was saying about … I think that was useful to an extent but I do feel that … It will take you 20 or 25 minutes to do something … to find out where the spleen is, … I think that's an excessive amount of time to spend on such a small or limited thing … em … I think it is a useful thing to may be do in the first year or two … I think to continue em … in the fourth or fifth year … on each other is kind of unrealistic …

The questionnaire survey shows that whilst some students might feel that the hands-on approaches are inefficient and costly in terms of time and knowledge gained, caution must be exercised about generalising to all students. Figure 5 shows that about 38% of the students disagreed with the view that the hands-on approaches were very time consuming and about 27% neither agreed nor disagreed. Also Figure 6 shows that the majority of the students (over 73%) agreed with the focus group participants that the hands-on approaches were of value in impacting anatomy knowledge and skills that were very clinically relevant. The view that may have been held by some of the students, that the hands-on approaches are time consuming and inefficient could be because they now consider these approaches as very rudimentary tools for learning living human anatomy particularly in their clinical years. This could be a reflection of their maturity and advancing knowledge/skills as they progressed through their studies over the years. However, it does not suggest detraction from the importance and value of the approaches as useful pedagogical tool during their formative years in learning anatomy of the living body.

Figure 5. Students’ views on the efficiency of the hands-on approaches.

Figure 6. Students’ views on the value of the hands-on approaches.

Discussion

Dealing with the human body poses a lot of challenges to medical students as the body demands a culturally defined respect and provokes deep feelings (Mudd & Siegel 1969). Routine physical examination of patients requires a physical intimacy that could evoke strong feelings in a personal context that are regarded as unprofessional in medical practice. Smith III and Kleinman (1989) reported that as medical students encounter the human body, they experience a variety of uncomfortable feelings including embarrassment, disgust and arousal. Medical students often struggle with knowing how to deal with these feelings in their initial encounters with patients (Haas & Shaffir 1982).

Peer physical examination and palpation have been used as a pedagogic tool in formal medical education curricula to facilitate students’ learning of clinical skills and functional living human anatomy for several decades (Metcalf et al. 1982). It takes different forms and involves students examining the bodies (or body parts) of their peers or life models; and being examined themselves by their peers. Students therefore play the roles of examiner and examinee. The ‘students’ examiner’ role has been likened to those of the doctor; and the examinee role to those of the patient (Metcalf et al. 1982; Wearn et al. 2008). Peer/life model physical examination and palpation are always conducted in a manner that respects gender, religious and cultural sensitivities. However, not all students consent to participate in the role of examinee for a number of reasons. It has been reported that ‘the students’ examinee’ role helps students develop empathy with the patients’ perspective as it puts them in a position to understand or appreciate what it feels like to undress in front of and be examined by a ‘stranger’ (Rees et al. 2004).

Past quantitative and qualitative studies have mainly explored factors influencing medical students’ attitudes towards and willingness to participate in or volunteer for peer physical examination (Metcalf et al. 1982; Chang & Power 2000; Rees et al. 2004, 2005; Wearn et al. 2008). Rees et al. (2004, 2005) reported that the PMS students were comfortable with participating in peer physical examination. A similar finding was also reported by Chang and Power (2000) for students in the University of Minneapolis, USA and O’Neill et al. (1998) in Manchester. Wearn et al. (2008) in a qualitative multi-site study of views of year 1 medical students, examined the complexities of students’ relationships in peer physical examination using activity theory.

This study examined years 3–5 medical students’ views on the impact of their early exposure to simulated examiner/examinee roles of the hands-on approaches to facilitating the learning of functional living human anatomy. The study added insight on the perceived influence of the innovative methods on the students’ professionalism and clinical skills. It showed that the majority of the PMS students felt that the anatomy knowledge they learned through the approaches was clinically very relevant. They also agreed that the hands-on approaches may have had a positive impact on their professional attitudes towards patient care and clinical skills for real patient's physical examination. According to the majority of the students, early exposure to the hands-on approaches helped them feel very comfortable with therapeutically touching patients’ bodies (or body parts) and physically examine nude or half-naked patients without embarrassment or awkwardness during their later years of study in the clinical environment. It may have also made it easy for the students to internalise and create a mental picture of their knowledge of the positions and locations of underlying deep organs or structures beneath the skin on the living body.

Their early exposure to peer/life model physical examination and palpation may also act as a confidence booster for the students when it comes to real patient's physical examination and or carrying out other clinical procedures. The students require such internalised visual memory and comfort with touching patients’ naked or half-naked bodies in order to accurately identify the landmarks for the location of underlying anatomical structures beneath the skin on the living body. These findings resonate with earlier reports that students perceived peer/life model physical examination as a means for practicing and developing clinical skills and professionalism in addition to learning basic functional human anatomy of the living body (Wearn et al. 2008).

Although reports of studies on peer physical examination with students in their first year of study show that students find learning situations they consider artificial or lack realism unhelpful (Nestel & Tierney 2007; Wearn et al. 2008). The findings of this study suggest that medical students may change their perception in later (clinical) years of their study when they have realised the practical need for the application of their skills and knowledge. The change in perceptions during clinical years emphasises the acknowledgement of the relevance and the long-term benefits of using simulated hands-on approaches that may have been considered artificial. The results show that the year's 3–5 medical students appreciated the clinical relevance and applications or usefulness of their early exposure to simulated examiner/examinee roles through peer/life model physical examination and palpation towards the development of clinical skills and good professional attitudes. This is consonant with the report that early patient contact which is similar to exposure to peer/life model physical examination and palpation, enhances medical students learning and the integration of theory and practice (Dornan & Bundy 2004; Littlewood et al. 2005; Diemers et al. 2007; Smithson et al. 2010). This helps students to develop appropriate attitudes and skills for clinical practice (Littlewood et al. 2005), and makes for a smoother transition into the clinical environment in the later years of their training (Radcliffe & Lester 2003) because of early exposure to professional socialisation (Dornan & Bundy 2004; Goldie et al. 2007).

So far the debate around peer/life model physical examination has focused on the students’ attitudes, willingness to participate and its acceptance as a pedagogic tool for teaching and learning living human anatomy (Metcalf et al. 1982; Chang & Power 2000; Rees et al. 2004, 2005; Nestel & Tierney 2007; Wearn et al. 2008). However, this study which set out to explore anatomy teaching and learning experiences in general uncovered an important aspect to peer/life model physical examination that has not been articulated in the previous literature.

There is no evidence on how medical students who are not exposed to this pedagogic tool of peer/life model physical examination and palpation overcome their emotional challenges of dealing with physical contacts with patients. However, this study suggests that as a teaching tool, the hands-on approaches may contribute in enabling students adapt to the skills and professional attitudes required to deal with physical contacts with patients in their clinical years with some ease. In an integrated curriculum where time is at a premium, teaching methods in medical education need to be carefully considered in terms of their impact and relevance to clinical practice. Peer/life model physical examination and palpation like early patient contacts as teaching tools, seem to do away with the need for a ‘gear change’ of a sort whereby students have to spend time reorienting to new environments and methods of practical skills learning. Peer/life model physical examination and palpation employed as a teaching tool in the context of a clinically focused curriculum could be one example of how pedagogic approaches may help students with a ‘seamless’ transition from theory/practical simulation to real clinical practice.

To date much of the literature around new curricular teaching and learning approaches has focused on ‘subject content’ (Older 2004; Patel & Moxham 2006, 2008; Raftery 2006); however, this study gives rise to the question of process and relevant pedagogic tools in integrated medical curricula and perhaps suggests that this might be one of the new ways to go amongst a range of other innovative approaches in modern medical education curriculum design and delivery.

Conclusion

This study may have progressed our understanding of the use of peer/life model physical examination and palpation as a pedagogic tool in medical education. This study has highlighted the enduring nature of the learning that is gained from early exposure to peer/life model physical examination and palpation as tools for facilitating learning of living human anatomy in the first 2 years of the PMS undergraduate medical curriculum. It suggests a perceived positive impact of the hands-on approaches on students’ clinical skills and professional attitudes when it came to physical examination of and encounters with real patients. The early exposure of students to simulated examiner/examinee roles through these hands-on approaches may contribute in helping students to feel comfortable with therapeutically touching the bodies (or body parts) of patients and physically examine them in the clinical environment even when patients are in the nude or half-naked without embarrassment or awkwardness. This suggests that pedagogic approaches with emphasis on clinical relevance and applicability of acquired knowledge, skills and attitudes may be what are required for the delivery of an integrated curriculum in modern medical education to help students with a ‘seamless’ transition from theory/practical simulation to real clinical practice.

Limitations

The extent to which the findings from this study are generalisable is doubtful as the study was confined to the experiences and perceptions of students in one medical school in UK. Also there was a low response rate for the questionnaire survey. However, this study was primarily about students’ perceptions of the impact of their experience of the hands-on approaches on their clinical skills and professional attitudes rather than a quantitative measure of their views. The choice of this triangulation approach was not aimed at validating the findings of the focus group data. The questionnaire survey was used to further explore issues related to shared experiences and perceptions of the educational interventions following the focus group interviews on wider samples of the students’ populations. It was not intended to be used to generalise about the representativeness of the students’ opinions. A future study might be to compare the findings presented here with those of other medical schools in the UK with similar or different approaches.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.