Student attitudes to peer physical examination: A qualitative study of changes in expressed willingness to participate

Abstract

Background: A number of studies have explored student attitudes to examining each other (peer physical examination: PPE). Differences have emerged in whether students prefer to be examined by friends or strangers. Changes have been reported in how students feel about PPE if asked before or after the PPE programme commences.

Research intention: Since a Grounded Theory paradigm was employed, there was no formal research hypothesis: the research intention was to explore factors which might underlie changes in student willingness to undertake PPE following familiarity with the process.

Methods: Students who had completed an Examining Fellow Students Questionnaire at the beginning and end of the academic year, and who had indicated a change in willingness to participate, were invited to attend focus groups. Four focus groups were convened and transcripts were analysed for common themes.

Results: Surprisingly, students downplayed the significance of changes. Also unexpectedly, dichotomous views emerged on familiarity, with some students preferring friends for examination and others preferring strangers. Staff embarrassment also emerged as a factor inhibiting student participation.

Conclusions: The significance of reported changes in attitudes to PPE may have been exaggerated. Proposals for increasing the willingness of students to participate in PPE are developed from the emergent themes.

Introduction

The process by which students examine each other as part of their learning process in anatomy and clinical skills is known as peer physical examination (PPE) (McLachlan et al. 2004). While the use of the living body in anatomy teaching can be deduced from references in the eighteenth and nineteenth century (McLachlan & Patten 2006), the earliest modern reference we know is found in the preface to Eisendrath's (1903) Text-book of Clinical Anatomy, in which he stated ‘An especial attempt has been made to encourage both practitioners and students to examine the human body during life’. Subsequently, Waterston, in Anatomy in the Living Model (1931), indicated ‘It is now several years since the study of the living model was introduced into anatomy schools as a means of supplementing the training in anatomy obtained by the dissection of the cadaver’. He also mentioned a General Medical Council (GMC) recommendation that ‘the demonstration of structure and function in the living should form an integral part of medical students’ professional training’. There is however no reference for this, and the GMC have no records of it. Barrows et al. (1968) recommended the use of living models, which in turn influenced Stillman et al. (1978). However, the earliest explicit recommendation of the use of student peer examination (as opposed to the use of professional models) we know of is by Metcalf et al. (1982). Use of professional models continues to prove of value (Collett et al. 2009).

A number of recent studies have focussed on the acceptability of peer examination. In 1998, O’Neill et al. found good acceptance of the idea of PPE, with some unwillingness to have examined (in order of reluctance) the inguinal region, female chest and male genital region. Chang and Power (2000) explored the influence of demographics on willingness to participate, concluding that females were more reluctant to be examined by males, and that older males and younger females were more likely to be comfortable with the concept. Rees et al. (2004) reported that at least 93% of students were comfortable participating in PPE for regions other than the breast and groin region, with females more reluctant to be examined than males. Rees et al. (2005) extended these findings to show that males were generally more comfortable than females with PPE, younger students were more comfortable than older students and students declaring a religious faith were less comfortable than students not declaring a religious faith. Power and Center (2005) found that 95% of the fourth-year students valued peer examination, but that the remainder were significantly uncomfortable with it, and for these students the use of simulated patients was recommended. Wearn and Bhoopatkar (2006) again found high levels of acceptance and noted that their students preferred to work with ‘friends’ rather than strangers, in contrast to the findings of Barnette et al. (2000) who concluded that students preferred examining a stranger.

Since there is evidence that cultural factors have an influence (Das et al. 1998), a large international and longitudinal study has been conducted (Rees et al. 2009). In particular, they found that student attitudes to PPE were reasonably stable between being surveyed prior to encountering PPE and being surveyed subsequent to experiencing PPE in practice. However, where changes were observed, they included a decline in willingness to examine and an increase in willingness to be examined, with females more likely than males to report a change in willingness (in both directions). Qualitative data was gathered in Rees et al. (2009) by open-ended questions, but it is preferable to use a study method (such as focus groups) in which respondents can expand on and clarify their responses. Since changes in views in the light of experience are of significance, we therefore carried out a qualitative exploration, using focus groups, of reasons behind such changes in view. We concentrated largely, but not wholly, on female students, since females were more likely to have issues about participation in peer examination.

Since a Grounded Theory Approach was adopted, we do not have a formal research question or hypothesis: the research intention was to explore factors, which might underlie changes in student willingness in PPE following familiarity with the process.

Table

Practice points

Students should be allowed to select their PPE environment where possible, including working with friends or unknown classmates. Students perceive PPE as being valuable in terms of clinical skills and future clinical practice. Staff, particularly occasional teachers, may benefit from induction outlining PPE intentions. Reported attitude changes to PPE should be explored through qualitative methods.

Methods

We invited Durham students who had participated in the Rees et al. (2009) study, had completed an Examining Fellow Students (EFS) Questionnaire (Rees et al. 2004) and had reported a changed willingness to participate in focus groups. The EFS instrument categorizes willingness to examine, or have examined, a variety of body regions. Questionnaires were administered at the beginning of the academic year, before students had taken part in PPE, and again at the end of the academic year, when all students had participated in PPE sessions. Ethical approval for the study was granted by the Ethics Committee of the School for Health, University of Durham. Although the current study involved the Rees et al. (2009) study cohort, this particular data was collected independently of that study and has not been published previously in any form.

A total of four focus groups were held (n = 5, n = 4, n = 3 and n = 3). Fifteen students therefore participated, with 11 females and 4 males. All students had indicated a change in views over the course of the year involving willingness to participate in PPE with regard to sensitive body regions, with 10 changing from willing to unwilling and 4 changing in the opposite direction. Participation in PPE had been by written consent following the circulation of information sheets and completion of the EFS Questionnaire. (In the class as a whole, most students had agreed to have most regions examined: exceptions were sensitive regions such as breast in females and buttocks and groin in both sexes).

The methodology drew upon the Grounded Theory paradigm (Glaser & Strauss 1967). We employed a semi-structured approach in the focus groups. The themes raised by the interviewer were: (i) ideas and expectations in advance; (ii) reasons for change; (iii) ways to improve the learning experience and (iv) any other comments. We tape-recorded the groups, with participants’ individual and explicit permission before and after the session to taping, transcription and subsequent publication of anonymised data. Tapes were transcribed by an independent party and anonymised by participant number. Open codings were identified by two researchers independently. These were compared and contrasted through a process of iterated discussion and negotiation until a consensus was reached. Subsequently, axial codings were derived first independently and then by negotiation in a similar manner.

Extracts were selected on the basis of being illustrative of a particular theme, conflicting or diverse views and succinctness. In view of the small size of the project, analytic software was not used: a combination of normal word processing facilities and hard copy material was used during the analysis.

Eight themes emerged from the analysis, which were grouped into three super categories (environmental factors, positive themes and negative themes). Several themes had identifiable subthemes.

Environmental themes

Willing to participate but pre-empted by staff or fellow students

One very interesting theme related to female students who were keen to participate but were pre-empted or discouraged. This could be by male classmates.

Extract 1. ‘So I think even if you were on the verge of offering, the lads just get in there first, so you’re like ‘oh right well I don’t have to offer now’

But staff expectations and prejudices could also prove inhibitory, and subvert the intentions of the programme. This was an informative quote.

Extract 2. ‘a lot of the tutors were like ‘ah, don’t worry girls, we won’t ask’, I think their response influenced me by thinking, I was thinking ‘oh it must be bad’. Do you know what I mean? It must be embarrassing if they’re having, if the tutors are having to reassure us constantly as a year group then there must be something wrong with it … and I thought ‘ah well, there must be a problem then.’ I don’t know, I think it's, tutors’ attitudes can influence the way we feel as well’.

Working with friendship groups as opposed to strangers

We allowed peer examination groups to self-select, so students could choose to work with friends or with relative strangers. This was a particularly interesting category because clearly dichotomous views were expressed, often with vigour.

Extract 3. ‘I’ve only been examined by close friends of mine, so that was fine’

Extract 4. ‘If you expect to examine the patient then you’ve got to be prepared to do it yourself, especially with people you know rather than someone you don’t know’

Extract 5. ‘Everybody was quite happy, maybe it was because we’ve all lived with each other for a year and were quite comfortable and happy to share’

This contrasted with:

Extract 6. ‘To me it's a bit easier to do it with somebody you have less of a relationship with.’

Extract 7. ‘I think I would have been more comfortable with not knowing the person’

Effect of group size

There were three issues raised within this theme. The first concerned the opportunities to practice skills.

Extract 8. ‘A negative would be the big groups, sometimes there's only one person … so it's really hard to get a skill and practice it over and over again’

The second related to access to tutors.

Extract 9. ‘Sometimes … I wasn’t entirely sure what I was doing all the time and there were not many people to kind of ask so you’re kind of just left to find out’

The third related to privacy.

Extract 10. ‘I wouldn’t have been comfortable in the Skills Lab because it's all open plan and it wouldn’t have been just one person examining you, the entire class could have been looking at yer …’

Cultural expectations of students and staff

While this could be a promoter of participation, it also had the possibility of being, or seeming, slightly coercive.

Extract 11. ‘Initially you think ‘oh yeah, I’ve just got to, everyone else around me is probably happy to do it’‘

Positive themes

Positive anticipation and enthusiasm, along with ‘open mindedness’

Many comments expressed the view that students had looked forward to the experience.

Extract 12. ‘Yeah, enthusiastic to get on with it …’

This can be contrasted with the theme of apprehension described below. Often, however, a student would describe both positive anticipation and a degree of apprehension.

Positive learning experience

A number of comments related to the pedagogic virtue of the approach, both in assessments and in later clinical practice.

Extract 13. ‘Because it helps, helps you remember things like that when you come to the exam’

Extract 14. ‘It has been a very useful experience, the knowledge that we were taught through the class to apply to the job we will end up doing’

This matches other comments we have received outside the context of this study, which identified learning styles as important, with students who describe themselves as visual or kinaesthetic learners expressing particular satisfaction with the process.

Negative themes

Apprehension

Extract 15 ‘I was a little bit apprehensive …’

Extract 16 ‘I guess before going into medical education I had a different view of professionalism. I didn’t think it would be so much expressed in education, about being professional so I was a bit scared about it’

This was often expanded into a subtheme, such as not knowing what to expect or what was expected of them.

Extract 17. ‘I was a little bit apprehensive not knowing what to expect’

Extract 18. ‘I was worried that we wouldn’t be given enough information about what it is ….’

Extract 19. ‘I was not very comfortable in class because again it was strange and I have never done it. I didn’t feel very comfortable’

Another ‘Apprehension’ subtheme was the possibility of discovery of circumstances, requiring further investigation.

Extract 20. ‘I think I was more apprehensive because I was scared someone might find something’

Extract 21. ‘I think later on my feelings changed because what if something is discovered in that session’

Embarrassment

Comments about embarrassment are often related directly to body image.

Extract 22. ‘I just think I’m embarrassed about my body image, my body and people seeing it’.

In other comments, this also is related to not wishing to seem incompetent.

Themes which did not emerge

Despite being the original research intention, and therefore raised by the interviewers during the group sessions, responses addressing reasons behind change were rather few and low key in nature. One student who had become more positive about peer examination over the year commented:

Extract 23. ‘I think we’ve grown up a little bit and are more confident’

More frequently, students represented the view that they could not remember what they had put previously. Some students felt that they had not adequately represented their views on the first occasion or that they had not understood the issues.

Extract 24. ‘I don’t know why I put that’

Extract 25. ‘Maybe we got confused’

Changes did not emerge as profound responses to the experience.

Discussion

Our research intention had been to explore reasons why students had changed their minds about willingness to participate in peer examination, whether it was in the direction of increased or reduced willingness. This was reflected not only in our structure for the focus groups, but also in the sampling strategy. But in accordance with the principals of grounded theory, this did not emerge as a significant theme even in this selected group of students who had chosen different options on the two occasions. Rather, the responses were casual and low key (Extracts 24 and 25). They seemed to indicate that students had neither reflected deeply as a result of their experiences, nor undergone reasoned or rationalized changes. Associated with this was the observation that some students could not recall what they had put previously. If their views had been equipoised between participation and non-participation, then minor factors might lead them to select one option rather than another on any given occasion. A ‘change’ might therefore be much less significant than had previously been thought. Together, these two observations suggest that the quantitative interpretation of ‘changes’ in longitudinal studies such as those of Rees et al. (2009) should be approached with due caution, and efforts should be made to identify, quantify and control for these themes when students record different views on different time occasions.

Another interesting and unexpected finding that also emerged clearly was the role of tutors in promoting embarrassment. There were clear indications that staff embarrassment and unwillingness to endorse the peer examination agenda were significant. In other words, it was staff barriers rather than student barriers that were significant in inhibiting participation in PPE. There is an interesting parallel, made explicit by several students, with the infectiousness of embarrassment in a clinical setting – that if the student felt embarrassed, so would the patient. PPE was seen as a way to overcome embarrassment about examining others and therefore of significant clinical value. This can be viewed as an example of symbolic interactionism (Blumer 1969), in which the meaning of acts arises out of the social interaction that the actor has with others: more particularly, it can be seen as an emotional contagion (Hatfield et al. 1994), with the person acting as ‘tutor’ influencing the actions of others in accordance with the tutor's expectations.

The third interesting finding, on which dichotomous views were expressed, was that of group composition. Some students were plainly more comfortable with friendship groups, while others preferred being examined by relative strangers. This is an extremely interesting issue, because it indicates that there may not be a single successful strategy that promotes willingness to take part in peer examination. This particular study was not designed with the intention of exploring this issue, which emerged from the analysis of transcripts, but it would make a worthy subject for future studies. It may be that it is possible to identify groups or categories of students who have a preference for one approach rather than the other and to customize the peer examination environment accordingly.

The identification of two categories of students, one more comfortable with examining friends and the other more comfortable with examining strangers, would explain the differences in findings reported by Wearn and Bhoopatkar (2006) and Barnette et al. (2000). This kind of information emerges best from qualitative studies, where the reasons behind decisions can be explored.

Other emergent themes shed clear light on factors that would make use of the peer examination more acceptable. Plainly, aspects of the setting exerted a significant influence, particularly with regard to the use of an open space where other groups were simultaneously visible. Provision of screens or partitions is therefore likely to have a significant impact on willingness to participate. This will be explored in further studies.

Another issue was group size and tutor presence, with a clear indication that if there had been more tutors present, there would have been more participation.

Plainly then, some of the barriers to peer examination, and the frequently recorded slight decrease in willingness to participate after experience, could be related to environmental factors such as group size, setting, self selection of preferred group composition and tutor ratio. But another factor is ‘noise’: non-intentional changes caused by having selected the wrong response on a previous occasion or by being almost equipoised between the two possibilities. Further studies addressing environmental variables are required to establish the impact of attention to these issues. Reports which ask students about their ‘reluctance’ to examine particular body areas may semantically convey the idea of negativity. It is important to recognize that student levels of comfort with participation may be higher than expected (and higher than staff are comfortable with).

Limitations of this study

This study was carried out within a single, culturally relatively homogenous organization, with a relatively small number of students. Moreover, the findings did not fulfil the expectations of the original research intention, and therefore the semi-structured approach to interviewing did not perfectly match the student views that subsequently emerged. As always with qualitative research, other researchers might have coded the transcripts in different ways.

Implications for future research

The suggestion clearly emerges from this work that longitudinal studies of willingness to participate in peer examination should rule out the possibility of some recorded differences from time point to time point being non-significant; caused, for instance, by students not remembering what they had put previously and being close to equipoise on the degree of willingness, or by students not having properly understood the options on one occasion. In addition, the possible presence of dichotomous views on whether or not PPE is best conducted with friends or with strangers should be taken into account in study design, since otherwise, these two factors might cancel each other out. Finally, the role of staff in inducing embarrassment in students, particularly female students, during PPE seems deserving of further investigation.

Acknowledgements

We are grateful to Charlotte Rees for reading and commenting on this article. This does not, of course, indicate agreement on her part with the conclusions. Thanks also to Mrs Helen Taylor for transcribing the tapes.

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

Additional information

Notes on contributors

J.C. McLachlan

JOHN MCLACHLAN, PhD, is the Associate Dean for Undergraduate Medicine and professor of medical education at Durham University. He is a National Teaching Fellow. His interests lie in assessment theory and practice and in novel methods of teaching anatomy.

P. White

PAMELA WHITE, is a Teaching Fellow in Anatomy at Durham University. Her research interests include medical education and widening participation.

L. Donnelly

LEO DONNELLY, PhD, is a lecturer in Anatomy at Durham University. His research interests are in the development and evaluation of anatomy teaching methods and learning resources, and in the use of personal digital assistants by undergraduates.

D. Patten

DEBRA PATTEN, PhD, is a lecturer in Anatomy and Medical Education at Durham University. Her research interests are in the development and evaluation of anatomy teaching methods and learning resources.